Northrise Wellness & Rehabilitation

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 2 (R #31 and R #59) of 2 (R #31 and R #59) 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 meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: R #31 A. Record review of R #31's admission Record, no date, revealed an admission date of 04/04/26. B. On 04/29/26 at 10:25 AM, during an interview, R #31 stated there were not any activities that she was interested in. R #31 stated that there were not any church services at all. C. Record review of R #31's Annual MDS assessment dated [DATE] revealed the following activity preferences are very important: 1. Having books, newspapers and magazines. 2. Having music. 3. Being around animals. 4. Keeping up with…

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

Based on interview and record review the facility failed to have a qualified activity professional to direct an ongoing program of activities for 2 (R #31 and R #59) of 2 (R #31 and R #59) residents sampled for activities, when staff failed to ensure the Activities Director (AD) had the qualifications necessary to perform the duties of an AD. This deficient practice could lead to a less engaging and beneficial program for residents and could negatively impact residents' well-being and quality of life. The findings are: A. Record review of AD personnel file revealed the following:1. A hire date of 11/06/25. 2. Her Resume did not include the following: a. A license or registration as a therapeutic recreation specialist or if she was eligible to become licensed or accredited as a therapeutic recreation specialist. b. Two years of experience in a social or recreational program within the last five years. c. Qualifications of an occupational therapist or occupational therapy assistant. d. Completion of a training course for activities professionals that was approved by the State. 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 record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #13, R #38 and R #57) of 5 (R #13, R #20, R #38, R #54 and R #57) residents reviewed for accuracy of documentation, when staff failed to: 1. Document information when R #13 left the facility to have a Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) tube placed and after she returned from having a PEG tube inserted. 2. Document administration of R #13's enteral feedings and residual amounts.3. Thoroughly document information for circumstances leading R #38 to be transferred to the hospital on [DATE].4. Document information regarding R #57's discharge from the facility. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: R #13A. Record review of R #13's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program for 4 (R #13, R #30, R #49, and R #54) of 5 (R #13, R #28, R #30, R #49, and R #54) residents reviewed for Transmission Based Precautions (additional infection control measures used in healthcare settings alongside Standard Precautions. They prevent the spread of known or suspected pathogens) when staff failed to:EBP A. Record Review of the [Name of Federal Agency] Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 03/20/24, revealed the following: 1. MDRO transmission is common in long term care (LTC) facilities. 2. EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. a. Examples of high-contact care activities include: i. Dressing ii. Bathing/showering iii. Transferring iv. Changing linens v. Providing…

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 residents were aware of the process to file a grievance for 1 (R #30) or 1 (R #30) resident sampled for missing items. If the facility does not ensure that residents know how to file grievances, then residents are likely to feel that their issues and/or concerns are not taken seriously. The findings are: A. On 04/29/26 at 12:38 PM, during an interview, R #30 stated staff did not tell her how to file a grievance. B. On 05/01/26 at 10:06 AM, during an interview with the Administrator, he stated the grievance process is gone over during resident council meetings. The Administrator stated if residents do not go to resident counsel that SSD will go over how to file a grievance with the resident. The Administrator stated the facility does not currently have an SSD. The Administrator stated if a resident tells staff they are missing items, he would talk to the resident and file a grievance for them. C. On 05/01/26 at 10:23 AM, during an interview, the AD stated she thought she was supposed to file grievances for the…

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

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 2 (R #28 and R #54) of 5 (R #13, R #15, R #28, R 46, and R #54) residents reviewed for unnecessary medications, when staff failed to ensure PRN psychotropic medications were not prescribed for longer than 14 days without a written rationale from the provider. This deficient practice could likely result in residents receiving medications longer than needed without a rationale from the provider causing a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #28A. Record review of R #28's admission Record, no date, revealed R #28 was admitted to the facility on [DATE]. B. Record review of R #28's physician's order, dated 04/27/26, revealed an order for alprazolam (a psychotropic medication used to treat anxiety disorder) 1 mg every 8 hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement an effective discharge planning process for 2 (R #40 and R #57) of 6 (R #15, R #30, R #31, R #40, R #47, and R #57) residents reviewed for discharge, when staff failed to: 1. Conduct IDT discharge planning for R #40 and R #57. 2. Update comprehensive care plans and discharge plans with treatment preferences and needs for R #40 and R #57.3. Document a discharge plan of care that included treatment preferences and needs for R #57. These failures have the potential for unsafe discharge and an increased risk of resident harm. The findings are: R #40 A. Record review of R #40's admission Record, no date, revealed R #40 was admitted to the facility on [DATE] and discharged on 03/14/26. B. Record review of R #40's progress note, dated 03/14/26, revealed R #40 was insistent on going home. The provider was notified and gave approval for R #40 to be discharged . C. Record review of R #40's care plan, dated 03/03/26, revealed staff did not document a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #28) of 3 (R #15, R #28, and R #41) residents reviewed for pressure ulcers. This deficient practice could likely result in residents' needs not being met. The findings are: A. Record review of R #28's admission Record, no date, revealed R #28 was admitted to the facility on [DATE]. B. Record review of R #28's admission MDS Assessment, dated 03/31/26, revealed staff completed the MDS on 04/14/26 (not within 14 days of resident's admission on [DATE]). C. On 05/04/26 at 2:48 PM, during a joint interview, the DON and Regional Clinical Nurse confirmed R #28's admission MDS Assessment was not completed within 14 days of his admission on [DATE]. Staff were expected to complete admission MDS Assessments within 14 days of admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete and transmit an MDS assessment after discharge for 1 (R #4) of 1 (R #4) residents reviewed for MDS assessment. This failed practice could lead to the facility not reporting information in a timely manner (within 14 days) to the Federal Agency. The findings are: A. Record review of R #4's admission Record, no date, revealed R #4 was admitted to the facility on [DATE] and discharged from the facility on 12/06/25. B. Record review of R #4's medical record, no date, revealed staff did not document a Discharge MDS Assessment after R #4 discharged from the facility on 12/06/25. C. On 05/04/26 at 2:55 PM, during a joint interview, the DON and Regional Clinical Nurse confirmed the following:1. R #4 was discharged from the facility on 12/06/25.2. R #4's medical record did not have a Discharge MDS Assessment. 3. Staff were expected to complete a Discharge MDS Assessment after residents were discharged from the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the MDS was accurate for 1 (R #15) of 7 (R #13, R #15, R #28, R #30, R #31, R #41 and R #57) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #15's admission Record, no date, revealed she was admitted to the facility on [DATE]. B. Record review of R #15's physician orders revealed an order dated 03/31/26: Lantus (long-lasting insulin designed to provide a steady 24-hour release of the medication to help regulate blood sugar levels) inject 15 units subcutaneously (medication given by injection just below the skin) one time daily for diabetes mellitus. D. Record review of R #15's admission MDS assessment dated [DATE] revealed the following: 1. Under the insulin section of the MDS, staff documented R #15 received insulin for the previous two days since her admission to the facility. 2. Under…

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 services that meet professional standards of practice for 2 (R #30 and R #31) of 2 (R #30 and R #31) residents randomly reviewed, when staff failed to monitor R #30's and R #31's weight as ordered. This deficient practice could likely result in staff being unaware of weight gain/loss. The findings are: R #30 A. Record review of R # 30's admission Record, no date, revealed R #30 was admitted to the facility on [DATE]. B. Record review of R #30's physician's orders revealed R #30 was at risk for malnutrition (a condition that occurs when your body does not get the right balance of nutrients, calories, or energy to function properly), weigh weekly for four weeks, and monthly after that. C. Record review of R #30's weight summary, no date, revealed R #30 was weighed on 03/30/26 and 04/19/26. Staff did not document any other weights for R #30. D. On 05/04/26 at 12:38 PM, during an interview, the DON confirmed staff did not perform weekly weights for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received quality treatment and care for 1 (R #48) of 5 (R #15, R #28, R #41, R #48, and R #49) residents reviewed for edema and wound care, when staff failed to identify edema (swelling caused by excess fluid trapped in body tissues, commonly affecting the legs, feet, ankles, hands, or abdomen. It is often a symptom of underlying issues like heart failure, kidney disease, liver cirrhosis, or venous insufficiency) in R #48's legs. This deficient practice could likely lead to resident's needs not being met and/or a worsening of their medical condition and prognosis. The findings are: A. Record review of R #48's admission Record, no date, revealed the following R #48 was admitted to the facility on [DATE]. B. On 04/29/26 at 11:21 AM, during an observation and interview with R #48, the following was revealed:1. R #48's legs appeared to be swollen.2. R #48 stated he had had swelling in both of his legs since he was in the hospital prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #13) of 1 (R #13) residents sampled for tube feeding (enteral nutrition, delivers essential nutrients, fluids, and medications directly into the stomach or small intestine for individuals unable to take adequate nutrition by mouth), when staff failed to:1. Monitor R #13's weight as ordered.2. Monitor R #13's enteral feedings as ordered.3. Monitor R #13's residual volume (the amount of formula, water, and digestive secretions remaining in the stomach, often checked to assess tube feeding tolerance and aspiration risk) as ordered. These deficient practices could likely result in residents losing weight without the facility being aware and causing worsening of medical conditions. The findings are:A. Record review of R #13's admission Record, no date, revealed R #13 was admitted to the facility on [DATE]. B. On 04/30/26 at 11:59 AM, during an interview, R #13 stated the following:1. She had her…

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 respiratory care in accordance with professional standards for 1 (R #54) of 3 (R #54) residents reviewed for respiratory care when the staff failed to ensure R #54 had an order for oxygen therapy. This deficient practice is likely to result in staff not being aware of residents' respiratory status and worsening of their condition. The findings are: A. Record review of R #54's admission Record, no date, revealed R #54 was admitted to the facility on [DATE]. B. On 04/29/26 at 11:01 AM, during an observation and interview, the following was revealed:1. An oxygen concentrator (a medical device that filters ambient air, providing a 90%-95% concentrated oxygen supply for patients with low oxygen levels) was sitting next to R #54's bed.2. R #54 stated she used oxygen when she lays down in bed. C. Record review of R #54's Convalescent Care Orders (CCOs, written orders for admission to a nursing facility, detailing necessary therapies (e.g., physical…

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, interview, and observation the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 2 (R #20 and R #46) of 2 (R #20 and R #46) residents reviewed for pain, when the facility failed to assess and monitor pain levels for R #20 and 46. This deficient practice could likely result in residents experiencing unnecessary or uncontrolled pain causing residents to experience a decline in physical and emotional health. The findings are: R #20 A. Record review of R #20's admission Record, no date, revealed the following:1. R #20 was admitted to the facility on [DATE].2. R #20's diagnoses include: wedge compression fracture of the third lumbar vertebra (a type of compression fracture where one side of the vertebra [series of small bones forming the backbone] collapses, resulting in a wedge shape. Most common in the lumbar region [lower back] of the spine, particularly in older adults with weakened…

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 ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) center for 1 (R #59) of 1 (R #59) residents reviewed for dialysis, when staff failed to: 1. Obtain orders for dialysis treatment. 2. Monitor R #59 for complications before and after dialysis treatments. 3. Provide ongoing communication, coordination, and collaboration between the facility and dialysis staff. If the facility is unaware of the status, condition or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need. The findings are: A. Record review of R #59's admission Record, no date, revealed an admission date of 04/26/26 with a diagnosis of end stage renal disease (the final, permanent stage of kidney failure where kidney function declines to below 10-15%, making it impossible for the body to filter waste and fluid). B. On 04/29/26 at 10:52 AM, during an interview with R #59, he stated he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure drug records were in order and account of all controlled drugs for 1 (R #54) of 1 (R #54) residents randomly reviewed for medication storage, when staff failed to document dispensed narcotics. This deficient practice could likely result in an inaccurate accounting of resident narcotics. The findings are: A. Record review of R #54's admission Record, no date, R #54 was admitted to the facility on [DATE]. B. Record review of R #54's physician's order, dated 04/22/26, revealed an order for oxycodone (used to treat moderate to severe pain) 5 mg, give one tablet every 4 hours. C. On 05/04/26 at 2:32 PM, during an observation, R #54 control substance log for oxycodone 5 mg, showed staff documented that there should be 50 capsules. Observation of the medication card revealed there were only 48 capsules. D. On 05/04/26 at 2:32 PM, during an interview, LPN #8 stated that she had given R #54 two doses of oxycodone 5 mg before her appointment…

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 staff implemented comprehensive antibiotic stewardship practices (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for 1(R #15) of 1 (R #15) resident's reviewed for antibiotic use when they failed to provide an end date for R #15's antibiotics. This deficient practice could likely result in the inappropriate use of antibiotics that can lead to antibiotic resistance (significant risk associated with long-term antibiotic use when bacteria change to resist antibiotics that used to effectively treat them) and multi-drug resistant organisms (pathogens, primarily bacteria, that have developed resistance to multiple antibiotics, making them less susceptible to standard treatments) The findings are: A. Record review of R #15's physician's orders revealed the following:1. an order dated 04/14/26 for amoxicillin 500 mg by mouth three times daily for tooth infection. The order was end-date was entered as indefinite (no date to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was a functional system in place to ensure staff could initiate/not initiate CPR (Cardiopulmonary Resuscitation lifesaving technique, aims to blood and oxygen flowing through the body) during an emergency for 1 (R #1) of 2 (R #1 and R #2) resident reviewed for hospitalization, when staff failed to honor the code status (type of emergency treatment a person would or would not receive if their heart or breathing were to stop) wishes of R #1's POA. This deficient practice could likely cause confusion among the nursing staff who may not be aware of which residents are Full-Code (if the person's heart stopped beating, or stopped breathing, all resuscitation procedures will be provided to keep them alive) and those residents who wish to be a DNR (Do Not Resuscitate) (No code, allow natural death), then residents are likely to receive the incorrect initiation of CPR (Cardio Pulmonary Resuscitation, lifesaving technique, aims to blood and oxygen…

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 upon their admission to the facility) within 48 hours of admission for 1 (R #2) of 2 (R #2 and R #4) 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 #2's admission Record, no date, revealed he was admitted into the facility on [DATE]. B. Record review of R #2's Admission MDS, dated [DATE], revealed the following: 1. Staff documented R #2 had one unstageable pressure ulcer (not stageable due to coverage of wound bed by slough [dead tissue in a wound, typically soft, yellow or white,…

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 plans for 2 (R #1 and R #3) of 2 (R #1 and R #3) residents reviewed for care plans when staff failed to document pressure ulcers and the need for wound care. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents and worsening of the pressure ulcers. The findings are: R #1 A. Record review of R #1's admission record, no date, revealed she was admitted into the facility on [DATE]. B. Record review of R #1's Admission MDS, dated 01/15/26, revealed the following: 1. Staff documented R #1 had one unstageable pressure ulcer (not stageable due to coverage of wound bed by slough [dead tissue in a wound, typically soft, yellow or white, that can impede healing if not properly managed] and/or eschar [hardened, dry, black or brown dead tissue that forms a scab-like covering over deep wounds]) present upon admission. 2. Staff documented…

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 medical records were complete and accurate for 1 (R #1 and R #3) of 3 (R #1, R #2, and R #3) residents reviewed accuracy of documentation when staff failed to accurately document the completion of wound care. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: R #1A. Record review of R #1's admission record, no date, revealed she was admitted into the facility on [DATE]. B. Record review of R #1's physician order, dated 01/15/26, revealed an order for wound care to the right buttocks. Cleanse site with normal saline (NS; solution similar to salt concentration in human blood making it ideal for cleaning wounds) and pat dry, Medihoney (medical grade honey often used in wound dressings) to the wound bed. Cover with calcium alginate gauze (highly absorbent wound dressings designed to manage drainage and promote a moist healing…

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 that nursing staff had the appropriate competencies and skill sets to provide nursing services for all 121 residents that were in the building between 06/25/24-08/23/24 (residents were identified by the Census Report from 06/25/24-08/23/24 provided by the DON 12/11/25) when the facility employed Staff Member (SM) #1 as LPN when she did not have a license or skill set to provide nursing services to residents. This deficient practice could result in residents receiving inappropriate care and interventions for both routine and emergency situations. The findings are: A. Record review of the facility's investigation report dated 08/29/24 revealed R #1 needed to go to the restroom. SM #1 went to assist R #1. R #1 had foley catheter. The urine collection bag was attached to bed. When SM #1 went to assist R #1 she did not take the bag off the bed, and this resulted in R #1 foley catheter tubing to pull on his penis and cause him pain. R #1 was assessed…

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 report allegations of neglect for 1 (R #2) of 121 residents that were in the building between 06/25/24-08/23/24 (residents were identified by the Census Report from 06/25/24-08/23/24 provided by the DON 12/11/25), when they failed to report missed medications and medications left at the bedside of R #2 by Staff Member (SM) #1. If the facility fails to report allegations of neglect, then residents could be subjected to continued neglect resulting in a worsening condition of health and life. The findings are: A. Record review of the facility's investigation report dated 11/03/25 revealed that SM #1 was working at the facility from 06/10/24 to 08/28/24 using false credentials and posing as an LPN. B. Record review of SM #1 disciplinary actions revealed the following: 1. On 07/08/24 Residents have expressed concern regarding a nurse presenting him with medications that he did not recognize as his own. He also stated that she attempted blood sugar checks…

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, sanitary and comfortable environment 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 (27) residents who live in the facility (residents were identified by the Resident Matrix provided by the Administrator on 01/15/25). 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.…

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 designate a qualified, trained, or certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP.) This failure could affect all 27 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 01/08/24). This deficient practice could likely result in residents being at greater risk of infectious disease. The findings are: A. On 01/29/24 at 3:33 PM, during an interview, the DON stated the following: 1. The IP had some issues with her nursing license. 2. The IP has been on leave due to the issues with her nursing license since 01/10/25. 3. She is now performing IP duties. 4. She is working to obtain her IP certification. B. Record review of the former IP's time sheet, no date, confirmed she last worked at the facility on 01/10/25.

Based on record review and interview, the facility failed to notify the resident and the resident's representative(s) of the transfer in writing for 5 (R #184, R #185, R #186, R #187 and R #188) of 6 (R #32, R #184, R #185, R #186, R #187, and R #188) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the resident and resident's representative(s) of the plan to discharge the resident from the facility in writing and in a language and manner they understand for R #184. 2. Notify the resident and resident's representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R #185, R #186, R #187, and R #188. 3. Include in the discharge or transfer notices a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 4. Include in the transfer or discharge notices the name,…

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

Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 4 (R #185, R #186, R #187, and R #188) of 4 (R #185, R #186, R #187, and R #188) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #185 A. Record review of R #185's medical record revealed the following: 1. On 12/27/24, R #185 was sent to the hospital for altered mental status (a change in a person's level of consciousness, awareness, and cognitive function). 2. The record did not contain any documentation of a written bed hold notice. R #186 B. Record review of R #186's medical record revealed the following: 1. On 09/06/24, R #186 was sent to the hospital for gastrointestinal bleeding (bleeding that occurs in the digestive tract). 2. On 09/23/24, R #186 was sent to the hospital for abdominal pain and distention…

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 4 (R #4, R #7, R #11, and R #184) of 5 (R #4, R #7, R #8, R #11, and R #184) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the resident's needs. The findings are: R#4 A. Record review of R #4's admission record revealed R #4 was admitted on [DATE]. B. Record review of R #4's wound care consultation dated 12/25/24 revealed the following: 1. Stage II (shallow, open ulcer with a red-pink wound bed, without slough [non-viable tissue composed of dead cells accumulating on the wound surface. Can appear as a moist, yellow, tan, or white layer and is often fibrous or stringy in texture]) coccyx (tailbone, is a small triangle-shaped bone at the end of the spinal column) pressure ulcer a.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 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 3 (R #11, R #184, and #R #185) of 3 (R #11, R #184, and #R #185) 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: R #11 A. Record review of R #11's admission record revealed the following: 1. admission date of 12/27/24. 2. Diagnoses included the following: a. Cellulitis (a common bacterial infection of the skin and underlying tissues) of Left Lower Limb (left leg). b. Cellulitis of Right Lower Limb c. Sepsis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 3 (R #7, R #8, and R #184) of 5 (R #4, R #7, R #8, R #184, and R #191) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #7 A. Record review of R #7's admission record (no date) revealed the following: 1. R #7 was admitted to the facility on [DATE]. 2. Diagnosis: unspecified retinal detachment (serious eye condition where the retina [a light sensitive layer of tissue in the back of the eye] is pulled away from its normal position) with retinal break (when vitreous [clear jelly-like substance that fills the middle of the eye] pulls on the retina and causes a split) of the left eye. B. Record review of R #7's admission Minimum Data Set (MDS, federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) Assessment,…

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 plan requirements were met for 4 (R #4, R #7, R #8, and R #19) of 6 (R #2, R #4, R #7, R #8, R #18, and R #19) residents reviewed for care plans when staff 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 #7, R #8, and R #19. 2. Revise the care plan with the most current resident information for R #4. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions due to lack of participation of the entire IDT, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: IDT Team R #7 A. Record review of the Post admission…

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 keep the residents free from accidents for all 14 residents on the East Unit (Residents were identified by the resident Census provided by the Administrator on 01/14/25), when they failed to keep treatment carts (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) locked when not supervised by staff. This deficient practice could likely result in injury to residents obtaining medical equipment which can cause injury/death:. The findings are: A. On 01/15/25 at 9:12 AM, during an observation of the East Unit, the IV (intravenous, within vein) treatment cart was unlocked and opened, the cart had sterile needles, and intravenous catheters (a thin, flexible tube inserted into a vein to deliver fluids). Staff were not present. B. On 01/15/25 at 9:14 AM, during an interview, RN #8 confirmed the IV treatment cart was unlocked and opened. She said the treatment cart should be locked when not in their sight or control. C. On 01/15/25 at 9:16 AM, during an…

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

Based on observation and interview, the facility failed to properly store medications, when staff failed to ensure medications were not expired in medication cart for all 14 residents on the East Unit (Residents were identified by the resident matrix provided by the Administrator on 01/15/25). This deficient practice could likely result in residents obtaining medications that are no longer effective, resulting in adverse side effects. The findings are: A. On 01/21/25 at 3:25 PM, an observation of the medication cart on the East Unit revealed fish oil supplement (a supplement used to help reduce pain, improve morning stiffness and relieve joint tenderness in people with rheumatoid arthritis), 1000 mg, expired on 12/2024. B. On 01/21/25 at 3:27 PM, during an interview with RN #16, she confirmed the bottle of Fish Oil 1000 mg was expired and should not have been in the medication cart. C. On 01/21/25 at 3:35 PM, during an interview with the DON, she confirmed expired medications should not be in the medication carts. Nurses should check for expired medications in the medication carts…

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 ensure the call light pull cords in resident's rooms were adequately equipped to allow residents to call for help using the call light system for 3 (R #4, R #8, and R #15) of 3 (R #4, R #8, and R #15) when the facility failed to have proper pull cords on the call light system in the resident's rooms when they could not be reached if the resident was not in bed. This deficient practice could likely result in residents being unable to call for assistance. The findings are: R #4 A. 01/15/25 3:48 PM, during an interview, R #4's wife said that R #4 was not cognizant (not having knowledge or being aware of) enough to pull the cord on the call light. R #4 had no other option for the calling for help. R #8 B. On 01/15/25 at 11:01 AM, during an interview and observation of R #8's room revealed a trash bag was tied to the end of the call light. R #8 said that the cord on his call light is too short and he can't reach the call light. R #8 said he didn't know why the trash bag was tied to the cord except to maybe make it longer. R #15…

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

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 2 (R #11 and R #184) of 2 (R #11 and R #184) residents when staff failed to: 1. Implement convalescent care orders (physician's orders that admit a patient to a nursing facility after a hospital stay) for R #11 wounds. 2. Assess R #11's wounds upon admission. 3. Notify the provider when R #184 developed Moisture Associated Skin Damage (MASD, a condition where prolonged exposure to moisture, such as urine, sweat, wound exudate, or saliva, leads to skin damage). Failure to implement convalescent care orders and notify the provider about changes in resident conditions could likely lead to facility staff and the physician being unaware of changes in resident condition and could likely lead to worsening of resident's condition. The findings are: R #11 A. Record review of R #11's admission record revealed the following: 1. admission date of 12/27/24. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure wound care orders were obtained and implemented and wound care was completed for 1 (R #4) of 3 (R #4, R #11, and R #28) 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 #4's admission record (no date) revealed R #4 was admitted to the facility on [DATE]. B. Record review of the wound care consultation (outside wound care provider) note dated 12/25/24 revealed the following: 1. Stage II (shallow, open ulcer with a red-pink wound bed, without slough [non-viable tissue composed of dead cells accumulating on the wound surface. Can appear as a moist, yellow, tan, or white layer and is often fibrous or stringy in texture]) coccyx (tailbone, is a small…

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

Based on observation, record review and interview, the facility failed to ensure a resident with a condom catheter (an external urinary device that collects urine from men with urinary incontinence or difficulty urinating) had an order and clinical condition that demonstrated that a condom catheter was necessary for 1 (R #191) of 1 (R #191) residents reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of a urinary tract infection (bacteria in the urinary tract). A. On 01/15/25 at 1:53 PM, during an interview, R #191 said he had a catheter to streamline the process of elimination. R #191 said that he is continent of bowel and bladder. B. On 01/15/25 at 1:54 PM, during an observation of R #191, revealed R #191 had a catheter. C. Record review of R #191's physicians orders revealed R #191 did not have an order for a condom catheter. D. Record review of R #191's medical record revealed the record did not contain any documentation of a clinical condition for the need of a condom catheter. E. On 01/17/25 at 2:30 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, interview, and record review, the facility failed to provide respiratory care (health care discipline specializing in the promotion of optimum cardiopulmonary function, health and wellness) that was consistent with professional standards of practice for 1 (R #2) of 1 (R #2) resident sampled for respiratory care when staff failed to change R #2's nasal cannula (medical device to provide supplemental oxygen therapy to through the nose) within 7 days of the previous change. This deficient practice could likely cause the nasal cannula to become obstructed, non-functional, and unsanitary and not provide the resident with the oxygen needed. The findings are: A. On 01/15/25 at 11:03 AM, during an observation of R #2 revealed R #2 had a portable oxygen tank and nasal cannulas. The nasal cannulas were not dated with a date indicating the date they had been changed. B. Record review of R #2's Physicians Orders dated 12/18/24 revealed Oxygen at 2 Liters to be administer via nasal cannula continuously. C. On 01/16/25 at 1:51 PM, during an interview, the DON stated 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 did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 1 (R #198) of 5 (R #2, R #7, R #19, R #28, and R #198) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason or when the medication is no longer necessary, placing these residents at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #198's admission record, no date, revealed the following: 1. R #198 was admitted to the facility on [DATE]. 2. R #198 had the following diagnoses: a. Cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes). b. Other symbolic dysfunctions (language impairments caused by an underlying medical condition). c.…

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

Based on interview and record review, the facility failed to develop a care plan on the resident's individualized discharge goals and needs for 3 (R #11, R #12, and R #13) of 3 (R #11, R #12, and R #13) residents reviewed for discharge planning. This deficient practice is likely to prevent a safe transition from the facility to the resident's post-discharge setting. The findings are: A. Record review of R #11's care plan, dated 01/19/24, revealed staff did not care plan R #11's discharge goals and needs. B. Record review of R #12's care plan, dated 03/06/24, revealed staff did not care plan R #12's discharge goals and needs. C. Record review of R #13's care plan, dated 04/01/24, revealed staff did not care plan R #13's discharge goals and needs. D. On 05/01/24 at 2:39 PM, during an interview, Social Services (SS) confirmed she did not document the residents' discharge goals or needs in the care plans. SS confirmed she did not have documentation of the residents' discharge goals or needs in the residents' charts.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents, their representatives, or the Ombudsman received a written notice of transfer as soon as practicable for 2 (R #19 and R #122) of 2 (R #19, and R #122) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged . The findings are: R #19 A. Record review of R #19's medical record revealed the following: 1) R #19 was sent to the hospital on [DATE]. 2) No written transfer notice was found. B. On 11/03/23 at 11:03 AM, during an interview, the Social Services Director confirmed the facility did not provide R #19 a transfer notice. The Social Services Director also confirmed she did not provide the copies of written transfer notices to the ombudsman. R #122 C. Record review of R #122's medical record revealed the following: 1) R #122 was sent to the hospital on [DATE]. 2) No written transfer notice was found. D.…

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

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #128) of 2 (R #125 and R #128) residents reviewed for care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: A. On 10/31/23 at 11:56 AM, during an observation, R #128 had a foley catheter. B. Record review of R #128's care plan, dated 10/31/23, revealed staff did not include R #128's foley catheter in the care plan. C. On 11/02/23 at 2:25 PM, during an interview with the Administrator, she confirmed staff did not include R #128's foley catheter in the resident's care plan, and they should have.

Based on observation, interview, and record review, the facility failed to provide proper care for pressure ulcers (an injury that breaks down the skin and underlying tissue), for 1 (R #125) of 3 (R #125, R #126, and R #128) residents sampled for pressure ulcers, when they failed to have the prescribed air mattress for R #125. This deficient practice could likely result in the development and/or worsening of pressure ulcers. The findings are: A. Record review of R #125's Skin Assessment, dated 10/27/23, revealed R #125 had a stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle). B. Record review of R #125's Physician's Orders, dated 10/2/23, revealed an order for a pressure-redistribution mattress (Designed to prevent, treat, and heal pressure ulcers in the home or long term care setting) to bed. C. On 10/31/23 at 11:34 AM, during an interview with R #125, he said he had a pressure ulcer on his buttocks, and it hurt. D. On 10/31/23 at 11:36 AM, during an observation of R #125's room there was no air mattress on his bed. E. On 11/01/23 at 12:42 PM,…

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

Based on observation and interview, the facility failed to keep residents free from accidents for all 10 residents in the East Unit of the facility (residents were identified by the Census Report provided by the Administrator on 10/31/23), when they failed to secure a treatment cart. This deficient practice could likely result in residents obtaining medical equipment that could be harmful to them resulting in injury. The findings are: A. On 10/31/23 at 9:54 AM, an observation of the nurse's station area revealed a treatment cart unlocked. No staff were present. B. On 10/31/23 at 9:56 AM, during an interview, LPN #32 confirmed the treatment cart was unlocked. LPN # 32 also confirmed the expectation was for the treatment cart to be locked when unattended. C. On 11/03/23 at 8:54 AM, an interview with the interim DON confirmed that treatment carts should be locked when nurses do not have line of sight of the cart.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for Foley catheter (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #128) of 2 (R #128 and R #126) residents sampled for urinary catheter, when they failed to: 1. Keep R #128's Foley catheter tubing and collecting bag off the floor, and 2. Have a current order for R #128's Foley catheter. This deficient practice could likely result in residents getting infections and having the Foley catheter longer than needed. The findings are: A. On 10/31/23 at 11:56 AM, during an observation, R #128's catheter tubing and collecting bag was on the floor while he sat in his wheelchair. B. On 10/31/23 at 11:59 AM, during an interview, LPN #31 confirmed R #128's foley tubing and collection bag was on the floor. She also confirmed they should not be on the floor. C. On 11/02/23 at 9:41 AM, during an interview, the Administrator confirmed the catheter tubing and collection bags should not be on the floor.…

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

Based on record review and interview, the facility failed to ensure that nursing staff demonstrated competency in skills and techniques necessary to weigh residents safely and correctly for 3 (CNA #4, CNA #5, and CNA #6) of 3 (CNA #4, CNA #5, and CNA #6) employees sampled for training. This deficient practice could likely result in staff working who are not competent to weigh residents. The findings are: A. On 11/03/23 at 11:59 AM, during an interview with the Dietician, he confirmed he had concerns about resident weights being accurate. The Dietician stated he had informed the facility of the concerns. The Dietician stated that if there was a question on the weights then he would request for a re-weigh to confirm. B. Record review of employee files revealed the following: 1. No competency for weighing residents for CNA #4. 2. No competency for weighing residents for CNA #5. 3. No competency for weighing residents for CNA #6. C. On 11/03/23 at 3:07 PM, during an interview, the Executive Director confirmed the facility had not done competencies or training for staff regarding…

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 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 undertrained and providing inadequate care. The findings are: A. Record review of employee files revealed the following: 1. No performance evaluations for CNA #4. 2. No performance evaluations for CNA #5. 3. No performance evaluations for CNA #6. B. On 11/03/23 at 12:38 PM, during an interview, the Executive Director confirmed the facility had not done the performance evaluations for CNA #4, CNA #5, and CNA #6.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to properly store medications in the medication storage room for all 19 residents (residents were identified by the resident matrix provided by the Administrator on [DATE]) that were randomly sampled, when they failed to dispose of expired Shingrix (A zoster vaccine is a vaccine that reduces the incidence of herpes zoster, a disease caused by reactivation of the varicella zoster virus, which is also responsible for chickenpox) in the medication refrigerator. This deficient practice could result in residents obtaining vaccinations that are expired resulting in adverse side effects. The findings are: A. On [DATE] at 10:53 AM, during an observation, the medication storage room refrigerator revealed eight vials of Shingrix with an expiration date of [DATE]. B. On [DATE] at 10:53 AM, during an interview, the ADON confirmed the eight vials of Shingrix were expired. The ADON confirmed staff should have discarded the expired Shingrix.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 18 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 10/31/23), when they failed to: 1. Keep the dry storage area floors clean, 2. Ensure that spices in the kitchen were labeled and dated, 3. Stored a plunger in the dry storage area. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 10/31/23 at 10:18 AM, an observation of the main kitchen revealed: 1. There was dark liquid on the floor in the dry storage area. 2. There was a plunger that looked dirty and dusty next to the door in the dry storage area. There was a box of bananas next to this door. B. On 11/03/23 at 10:36 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 observation and interview, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 2 (R #126 and R #173) of 3 (R #126, R #127 and R #173) residents reviewed for call lights. If the facility does not have a functioning call light system then residents are unlikely to get their immediate needs met by facility staff. The findings are: A. On 10/31/23 at 3:10 PM, during an interview with R #126, he said he did not have a call light. B. On 10/31/23 at 3:11 PM, an observation of R #126's room revealed his room did not have a call light, and wires stuck out from the wall where the call light used to be. C. On 10/31/23 at 3:12 PM during interview, LPN #11 confirmed a call light was not attached to the wall of R #126's room, and the light had not worked for at least a year. She further stated the call lights in room [ROOM NUMBER] A and B did not work. D. On 10/31/23 at 3:14, during observation of R #73's call light, the light did not function when…

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

Based on record review and interview, the facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) to 1 (R #24) of 3 (R #22, R #23, and R #24) residents sampled for beneficiary notices. If residents are not provided with the beneficiary notices, then they may not make an informed decision about the services provided to them and could likely result in a decline in health and function. The findings are: A. Record review of R #24's medical record revealed R #24 was discharged from the facility on 09/25/23. B. Record review of the NOMNC dated 09/22/23 revealed the NOMNC delivered telephonically not written. C. On 11/03/23 at 12:15 PM, during an interview, the Administrator in Training confirmed the facility did not provide a written NOMNC to R #24 or their respresentative.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have the physician document the required discharge information in the resident's medical records for 1 (R #122) of 1 (R #122) residents reviewed for facility discharges. This deficient practice could likely cause an unsafe discharge due to a lack of information or documentation. The findings are: A. Record review of R #122's face sheet revealed R #122 was admitted into the facility on [DATE] and discharged on 05/23/23. B. Record review of R #122's Nursing Progress Notes, dated 05/23/23, revealed R #122 became verbally and physically abusive to his wife (who was a resident at the facility). The Nurse Practitioner ordered R #122 be sent out for further evaluation and better placement. R #122 was transported to a local hospital. C. Record review of R #122's medical record revealed the record did not contain documentation of the following: 1. Orders from the Physician, 2. Basis for transfer, 3. The needs that the facility was not able to meet and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents or their representatives received a written notice of their bed hold policy indicating the duration the bed would be held for 1 (R #19) of 1 (R #19) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: A. Record review of R #19's medical record revealed the following: 1) R #19 was sent to the hospital on [DATE]. 2) No written bed hold policy was found. B. On 11/03/23 at 8:39 AM, during an interview, the Business Office Manager (BOM) confirmed R #19 was not given a bed hold policy. The BOM stated she called the resident or representative, and if they elected to pay for the bed hold then they will gave them a copy of the policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create a Baseline Care Plan that accurately reflected the resident's current condition for 1 (R #175) of 2 (R #5 and R #175) residents sampled for falls. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #175's admission Record, (no date), revealed R #175 was admitted on [DATE]. B. Record review of R # 175's baseline care plan, (no date), revealed R #175: 1. Received physical therapy (PT), occupational therapy (OT), and speech and language pathology (SLP). 2. Was independent (no assistance needed) for bed mobility, transfer, walking, toileting, locomotion, eating, grooming/hygiene, and bathing. C. Record review of R #175's nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure there was a system in place for the nursing staff to immediately determine code status [the residents choice as to whether or not they would like to be provided cardio- pulmonary resuscitation (CPR) in the event that they stopped breathing and/or their heart stopped] for 1 (R #128) of 3 (R #122, R #125, and R #127) residents reviewed for code status, when they failed immediately know R #128 would like CPR in an emergency. This deficient practice is likely to delay potentially lifesaving measures if staff are not immediately aware of residents' preferences for resuscitation. The findings are: A. On [DATE] at 08:49 AM, during an interview with R #128 he stated he had not been asked his preference for resuscitation. B. On [DATE] at 08:47 AM, during an interview, the Administrator confirmed R #128's code status was not documented in R #128's medical record. She stated the code status should have been obtained upon admission and documented in 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 observation, record review, and interview, the facility failed to ensure the enteral tube feeding [a device utilized to provide liquid nutrition and medications via a tube into the stomach or intestine] was administered per physician's orders for 1 (R #125) of 1 (R #125) resident reviewed for tube feeding when they failed to continuously administer R #125's feeding. This deficient practice could likely lead to malnutrition and weight loss. The findings are: A. On 10/31/23 at 11:34 AM, during an interview with R #125, he stated he did not know if the feeding tube was attached to the pump, tube, and bag or not. B. On 10/31/23 at 11:35 AM, an observation of R #125 revealed R #125's feeding pump, tube, and bag was not connected to him. C. On 10/31/23 at 12:05 PM, an observation of R #125 revealed R #125's feeding pump, tube, and bag was not connected to him. D. Record review of R #125's Physicians Orders, dated 10/26/23, revealed R #125 to receive tube feeding continuously throughout the day. E. On 11/02/23 at 3:51 PM, during an interview with the Administrator, she stated if…

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

Based on record review, observation and interview, the facility failed to ensure that staff received the appropriate training and skills to provide services for 1 (R #25) of 1 (R #25) resident reviewed. This deficient practice is likely to result in residents not getting the care and assistance they need. The findings are: A. Record review of the Incident Report, dated 06/01/23. revealed R #25 had altercation with CNA #20 after a fall at his bed side. R #25 strangled CNA #20 during the incident. B. Record review of the Initial Report to the State Agency, dated 06/06/23, revealed R #25 had an altercation with staff. CNA #20 had to seek medical attention after being attacked, and other staff were injured during the incident as well. C. Record Review of R #25's Nursing Progress Notes revealed the following: 1. 05/20/23 Pt (patient). is experiencing agitation/restlessness. Pt. is experiencing anxiety about surroundings. Pt. is experiencing impulsive behavior. Pt. is experiencing patient yells [sic] and screams, he can be physically agressive [sic] with grabbing and hitting. Pt has had…

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

Based on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #179) of 3 (R #123, R #124, and R #179) residents reviewed for medication administration when they failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication. The findings are: A. Record review of R #179's Physician's orders revealed: 1. Start date 10/07/23. End date 10/13/23. Metoprolol succinate [medication is a beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure, one missed dose of this medication can have significant adverse effects] ER (extended release), oral tablet, extended release 24 hour, 50 MG (milligram, dose of medication). 2. Start date 10/14/23. End Date 10/22/23. Metoprolol succinate ER, oral tablet, extended release 24 hour, Give 50 MG by mouth two times a day for HTN (high blood pressure). 3. Start Date…

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