Spring River Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, 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 1 (R #8) of 4 (R #2, R #8, R #9, and R #72) residents reviewed for pain when the facility failed to administer medications as per physician's orders. This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life. The findings are:A. Record review of R #8's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. End stage renal disease (ESRD; chronic irreversible kidney failure),2. Dependence on renal dialysis (treatment due to the inability of the kidneys to filter waste from the blood),3. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),4. Pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that resident preferences were honored for 1 (R #106) of 1 (R #106) residents reviewed when:- Alternative meals were not offered,- Meal did not contain adequate protein,-Facility meal ticket did not match the menu.This deficient practice is likely to result in residents being unable to make informed meal choices and not receiving meals consistent with their preferences.The findings are:R #106A. Record review of admission Record revealed R #106 was admitted to the facility on [DATE] with the following diagnoses:1. Chronic obstructive pulmonary disease (COPD; lung disease),2. Morbid obesity (severely overweight),3. Fluid overload (is a medical condition where the body retains an excessive amount of fluid, affecting tissues and organs),4. Shortness of breath,5. Type 2 diabetes (DM2, a condition results from insufficient production of insulin, causing high blood sugar).6. Heart Failure.B. On 03/25/26 at 9:02 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.

Based on observation, record review and interview, the facility failed to provide assistive devices for 1 (R #106) of 5 (R #4, R #5, R #7, R #72, and R #106) residents reviewed during dining observation. If residents are not provided with special eating equipment as needed, then residents might be unable to consume their meals and beverages and is likely to result in weight loss, malnutrition, and dehydration. The findings are:A. On 03/25/26 at 9:25 am, an observation and interview with R #106 revealed:1. R #106 was observed trying to eat oatmeal with a weighted fork.2. No other utensils were available to R #106.3. R #106 stated she rarely gets a weighted spoon unless she asks for one.B. Record review of physician orders dated 01/26/26 revealed an order for R #106 to use a weighted utensil during meals.

Based on interview and record review, the facility failed to provide a sufficient number of nursing personnel to meet the individualized care needs of its residents and failed to maintain accurate PPD (Person Per Day) to demonstrate compliance with federal staffing standards. This deficient practice has the potential to affect all 87 residents care residing in the facility. The findings are: A. Record review of the facility's PPD documentation dated 06/01/25 to 12/29/25 revealed the following:1. The facility failed to provide PPD documentation for 06/01/25 to 11/30/25 [change of ownership occurred on 12/01/25].2. Documentation for 12/03/25 revealed two Registered Nurses (RN) were scheduled to work two twelve-hour shifts for a total of 24 hours but 36 hours was reported.3. Documentation for 12/10/25 revealed two RN were scheduled to work two twelve-hour shifts for a total of 24 hours but 36 hours was reported.B. Record review of the facility's schedules and timecards revealed no documentation prior to 12/01/25 [change of ownership occurred on this day].C. On 12/30/25 at 11:15 am…

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 serve food under sanitary conditions when staff failed to use proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. This deficient practice is likely to affect all 87 residents listed on the census provided by the Director of Operations (DOO) on 12/30/25 and could likely cause an increase in illnesses if safe food handling practices are not followed. The findings are: A. On 12/31/25 at 12:00 pm, an observation of the lunch dining services revealed the following:1. Certified Nurse Aide (CNA) #1 moved a chair from one table to another, moved the table over approximately two feet, touched a different chair at another table and then served drinks to all residents in the dining room without washing or sanitizing her hands.2. CNA #2 touched R #4's right arm and chair while assisting R #4 to sit down. CNA #2 served R #5 his lunch without sanitizing or washing her hands. CNA #2 touched R #5's cup and bowl by the top of the rim (cupping) when placing them on the table.3. CNA #3…

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's Director of Operations (DOO) and Administrator (ADM) failed to manage the facility when they knew/should have known and prevented the following deficient practices which occurred in the facility: 1. Not ensuring incidents of abuse and significant injuries were reported to the State Survey Agency by the required time.2. Not ensuring or knowing if the follow-up reports were submitted to the State Survey Agency.3. Not ensuring or knowing notification to State Licensing Office is needed for the ADM's leave of absence.4. Not ensuring an interim ADM is available to manage the facility.5. Not ensuring or knowing and attempting to stop the State Survey Agency from completing survey-related tasks required to identify noncompliance when onsite at the facility. These deficient practices are likely to affect all 87 residents residing in the facility according to the daily census provided by the Director of operations on 12/30/25 and could lead to residents not maintaining their highest practicable physical, mental, and social well-being. 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 interviews, the facility failed to ensure the governing body appointed an administrator who is responsible for the management of the facility. This deficiency can result in the facility not having an administrator to ensure the residents' day-to-day needs are met. A. On 12/30/25 at 10:31 am, a random observation of the facility revealed a license for the listed Administrator (ADM) hanging on the wall behind the reception area. B. On 12/30/25 at 10:37 am during an interview with the Director of Operations (DOO), she stated the administrator was on vacation and not available. C. On 01/28/26 at 12:02 pm during an interview with the DOO, she confirmed the administrator is not available and that she was the person handling things. She did not state why he was not available. D. On 02/03/26 at 10:03 am, during an interview with Certified Nurse Aide (CNA) #4, she stated the Administrator is the DOO. CNA #4 confirmed she has not seen any other person acting in an administrative capacity in the building since before the Change in Ownership occurred on 12/01/25. E. On…

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

Based on record review and interview, the facility failed to report incidents involving allegations of abuse and allegations that resulted in serious bodily injury to the State Agency, no later than two hours for 2 (R #13 and R #14) of 5 (R #12, R #13, R #14, R #15 and R #16) residents reviewed for abuse and neglect. If the facility fails to report allegations of abuse and neglect to the State Agency, then the State Agency is unable to ensure residents are free from abuse and neglect. The findings are: R #13A. Record review of R #13's facility incident report dated 01/12/26 revealed the following:1. An incident resulting in serious bodily injury. R #13 had a fall resulting in a compression fracture (a break or crack in a vertebra that causes the bone to collapse) of L2 (location of the fracture; lower back). 2. The report was submitted to the State Survey Agency 01/21/26, approximately nine days after the incident. R #14B. Record review of R #14's facility incident report dated 12/28/25 revealed the following:1. An incident resulting in serious bodily injury. R #14 had a fall…

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 the results of all investigations to the State Survey Agency within five working days of an incident for 5 (R #12, R #13, R #14, R #15 and R #16) of 5 (R #12, R #13, R #14, R #15 and R #16) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation. R #12A. Record review of the facility's list of reportable incidents (list of events the facility reported to the State Survey Agency) revealed reportable incidents for R #12 on the following dates:1. 12/04/25,2. 12/22/25,3. 01/07/26,4. 01/11/26.B. Record review of the facility's five-day reports revealed the following:1. The investigations were completed.2. There was no evidence that the results of the investigation were submitted to the State Survey Agency.R #13C. Record review of the facility's list of reportable incidents revealed a reportable incident for R #13 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide quality of care for 2 (R #1 and R #2) of 3 (R #1, R #2, and R #3) residents reviewed when staff failed:1. To assist R #1 with fluid during mealtimes.2. To provide timely assistance for R #2's toileting needs. These deficient practices could likely cause residents to feel unimportant and frustrated. The findings are: R #1A. Record review of R #1's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Acute and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood),2. Emphysema (a respiratory disorder that results in the reduction of air intake),3. Heart failure (impaired heart function), unspecified,4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).B. On 12/31/25 at 12:06 pm, a random dining observation revealed R #1 sat at a table in the dining room near the…

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

Based on record review and interview, the facility failed to ensure medical records were readily accessible for 1 (R #7) of 1 (R #7) resident reviewed for documentation accuracy when staff failed to provide timely access to the State Agency (SA) to the entire Electronic Health Record (EHR) for R #7. This deficient practice prevented a thorough investigation of R #7's history and has the potential to negatively impact the care staff provide to meet residents' needs due to state surveyors not being able to complete an unannounced investigation.A. Record Review of R #7's EHR, revealed that the complete EHR was unavailable and inaccessible.B. On 12/30/25 at 3:17 pm, during an interview with the Director of Operations (DOO), she indicated she was unable to produce R #7's record in its entirety. She stated the previous owners are not providing complete access to residents' records who were in facility prior to 12/01/25 [change of ownership occurred on this day].C. On 02/03/26 at 10:45 am, during an interview with the DOO, she confirmed the facility is now able to and did provide access…

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 call lights were within reach of the residents while in the room for 4 (R #17, R #18, R #19, and R #20) of 6 (R #2, R #5, R #17, R #18, R #19, and R #20) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance. The findings are: A. On 02/03/26 at 10:00 am, a random observation of the facility revealed R #17 was lying in bed, and the call light was hanging on the light fixture that is attached to the wall near to the ceiling.B. On 02/03/26 at 10:03 am, a random observation of the facility revealed R #18 was lying in bed, and the call light was hanging on the light fixture that is attached to the wall near to the ceiling.C. On 02/03/26 at 10:05 am, a random observation of the facility revealed R #19 was lying in bed, and the call light was hanging on the light fixture that is attached to the wall near the ceiling. D. On 02/03/26 at 10:08 am, a random observation of the facility revealed R #20 was lying in bed, and the call light…

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

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 1 (R #15) of 1 (R #15) resident sampled for dignity, when staff failed to cover the resident's urine bag (medical device used to drain and collect urine when a person cannot urinate normally). This deficient practice could likely to result in residents feeling embarrassed and angry, and that their feelings and preferences are unimportant to the facility staff. The findings are: A. On 02/03/26 at 11:43 am, a random observation of the facility revealed R #15 in his wheelchair going down the North hallway of the facility, across the lobby area, up the South hallway of the facility, and into the activity area. R #15's urine bag was approximately a quarter full of urine and was not covered.B. On 02/03/26 at 11:56 am, during an interview with the Social Services Director (SSD), she confirmed R #15's urine bag was not covered, and it should be.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide podiatry (the medical care and treatment of the human foot) services for 1(R #3) of 5 (R #3, R #8, R #9, R #10, and R #11) residents reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections. The findings are: A. Record review of R #3's face sheet revealed she was admitted on [DATE] with the following diagnoses:1. Osteomyelitis, (inflammation of bone and bone marrow),2. Pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right heel, unstageable [a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined],3. Pressure ulcer of sacral (the portion of the spine between the lower back and the tailbone) region, stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone),4. Wedge compression…

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 provide respiratory care in accordance with professional standards for 1 (R #1) of 1 (R #1) resident reviewed for respiratory care when staff failed to follow the physician's order for oxygen use. This deficient practice is likely to result in residents experiencing worsening of their medical conditions. The findings are: A. Record review of R #1's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Acute and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood),2. Emphysema (a respiratory disorder that results in the reduction of air intake),3. Heart failure (impaired heart function), unspecified,4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).B. Record review of R #1's Minimum Data Set assessment (MDS; a federally mandated assessment instrument completed by…

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 post nurse staffing data daily, at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: -Registered nurses. -Licensed practical nurses. -Certified nurse aides. -Resident census. This deficient practice could likely result in residents and visitors not having the staffing information readily available. The findings are: A. On 12/31/25 at 9:02 am, an observation of the main entrance revealed the nurse staffing data sheet was dated 12/30/25.B. On 12/31/25 at 9:21 am during an interview with the facility's receptionist, she confirmed the nursing staffing data sheet should be posted daily and it was not.

Based on observation and interview, the facility failed to ensure staff administered and secured medications for 1 (R #17) of 1 (R #17) resident reviewed for medications when staff left a pre-poured (the practice of preparing and storing medications in advance of their scheduled administration) medication on the resident's dresser in his room. This deficient practice could likely result in residents not getting the medications they need. The findings are: A. On 02/03/26 at 10:00 am, a random observation of the facility revealed a medicine cup approximately halfway full of a white powder.B. On 02/03/26 at 10:23 am, during an interview with Licensed Practical Nurse (LPN) #1, she stated the white powder in the medicine cup is Nystatin powder (a medication used to treat skin infections). LPN #1 stated the medication should not have been left on the resident's dresser.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the failed to ensure home health services were in place prior to discharge for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for discharge. If the facility does not ensure the home health agency receives and accepts the resident, a delay in health care can potentially lead to negative outcomes including:1. Worsening wounds if they are not cared for,2. Worsening in mobility due to lack of physical therapy or occupational therapy.The findings are:A. Record review of R #1's face sheet indicated R #1 was admitted on [DATE] with the following diagnoses:1. Paraplegia (impairment in motor or sensory function of lower portions of the body),2. Cellulitis of left lower limb (cellulitis; deep inflammation of the tissues just under the skin; caused by infection),3. Type 2 diabetes (DM2, a condition results from insufficient production of insulin, causing high blood sugar),4. Need for assistance with personal care.B. Record review of R #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a functioning call light system for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents reviewed for call lights. If the facility fails to have call lights that are not functioning, residents cannot call staff in case of an emergency or get their needs met by the facility. The findings are:R#1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE], with the following diagnoses:1. Acute and chronic respiratory failure with hypoxia (when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning),2. Major depressive disorder, recurrent, moderate (causes a persistent feeling of sadness and loss of interest),3. Epilepsy, unspecified, not intractable, without status epilepticus (brain disease where nerve cells don't signal properly, which causes seizures),4. Generalized anxiety disorder (group of mental health conditions characterized by excessive…

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 #1 and R #5) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed. This deficient practice could likely result in staff not being aware of the residents' daily care events, changes, and needs. The findings are: R #1 A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: 1. Unspecified Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), unspecified severity, without behavioral disturbance, psychotic (a mental health condition characterized by a loss of contact with reality) disturbance, psychotic disturbance, mood disturbance, and anxiety, 2. Unspecified dementia, severe, without behavioral disturbance, 3. Cognitive (conscious intellectual activity) communication deficit, 4. Muscle weakness (generalized), 5. Old Myocardial (relating to…

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

Based on record review and interview, the facility failed to notify the physician of a change in condition in which a resident developed a fever for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice likely resulted in the resident receiving medication against physician orders. The findings are: A. Record review of R #1's admission record revealed the following: 1. admission date of 07/29/24. 2. Diagnoses included the following: a. Unspecified Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), unspecified severity, without behavioral disturbance, psychotic (a mental health condition characterized by a loss of contact with reality) disturbance, psychotic disturbance, mood disturbance, and anxiety, b. Unspecified dementia, severe, without behavioral disturbance, c. Cognitive (conscious intellectual activity) communication deficit, d. Muscle weakness (generalized), e. Old Myocardial (relating to the muscle tissue of the heart) Infarction (obstruction of the blood supply to an organ or geion of…

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

Based on record review and interview, the facility failed to ensure quality care that meets professional standards for 1 (R #1) of 1 (R #1) residents reviewed when the facility failed to follow a medical order and notify the provider about changes in a resident's onset of a fever. Failure to implement care orders and notify the provider about changes in resident's vital signs 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: A. Record review of R #1's admission record revealed the following: 1. admission date of 07/29/24. 2. Diagnoses included the following: a. Unspecified Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), unspecified severity, without behavioral disturbance, psychotic (a mental health condition characterized by a loss of contact with reality) disturbance, psychotic disturbance, mood disturbance, and anxiety, b. Unspecified dementia, severe, without behavioral…

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 ensure the consultant pharmacist's recommendations were reviewed and responded to by the physician. This deficient practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. The findings are: A. On 12/11/24 at 1:36 pm, during an interview with the Director of Nursing (DON) she stated that she does not have any documentation to submit to surveyors for review on the completion of medication regimen reviews because they were not completed prior to November 2024. The DON stated that she can provide the pharmacist's printed recommendations, but she has no evidence that the physician reviewed them. B. On 12/11/24 at 4:17 pm, during an interview with the Administrator, he confirmed the pharmacist's recommendations made through the medication regimen review process have not been completed prior to November 2024.

Based on observation, record review, and interview, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in the resident's dietary needs not being met and longer waiting times for meal service for all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. The findings are: A. On 12/08/24 at 11:30 am, during an initial observation of the facility, the doors to the dining room were closed and locked. B. On 12/08/24 at 11:35 am, during an interview with Medical Records (MR) #1 stated the dining room was closed because there is not enough staff to open it. C. Record review of the facility's posted mealtimes revealed meals are to be served at 7:00 am, 11:00 am, and 5:00 pm. D. On 12/10/24 at 11:51 am, during a dining observation in the main dining room, the first meal was served at 11:53 am (fifty-three minutes after lunch was scheduled to be served). E. On 12/10/24 at 12:02 pm, during an interview, R #64 stated 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.

Based on record review and interview, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) Plan. This can affect all 96 residents (per census list provided by the Administrator on 12/08/24). This deficient practice could likely result in the facility not making good faith attempts to identify and correct quality deficiencies that would lead to improvement in the lives of the residents. The findings are: A. On 12/12/24 at 12:26 PM, during an interview, the Administrator (ADMIN) he stated, he does not have a QAPI plan in place, he has no records of QAPI to review and he does not have a QAPI monitoring system in place since July of 2024. B. Record review of the facility's policy for QAPI, dated 10/24/22 revealed: Centers are committed to incorporating the principles of Quality Assurance and Performance Improvement (QAPI) into all aspects of the center work processes, service lines, and departments. QAPI activities will be integrated across all care and service areas and include clinical care, quality of life, and patient/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 observation, record review, and interview, the facility failed to develop and implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections). This deficient practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. This deficient practice could likely result in the spread of infectious diseases. A. On 12/08/24 at 1:33 pm, during a random observation of the facility, signs indicated special contact and droplet precautions were on the doorways of room [ROOM NUMBER] and 135. B. On 12/10/24 at 11:11 am, during a random observation of the facility, Unit Secretary (US) walked past the personal protective equipment (PPE) carts (where the facility stores clean equipment such as gowns, masks, gloves, etc. for staff's use prior to entering a resident's room) located outside the doorways of rooms [ROOM NUMBERS] and entering each room…

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 staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. This deficient practice could likely result in the inappropriate use of antibiotics. The findings are: A. On 12/11/24 at 1:36 pm, during an interview with the Director of Nursing (DON) she stated that she does not have any documentation to submit to surveyors for review on the facility's antibiotic stewardship program because the program was not implemented prior to November 2024. B. Record review of the facility's Antibiotic Stewardship policy, revision date of 08/07/23 revealed that Centers will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and systems for monitoring antibiotic use. The Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS; a federally mandated assessment completed by facility staff) was accurate for 3 (R #4, R #22, and R #49) of 5 (R #4, R #22, R #49, R #81 and R #148) residents reviewed for accurate MDS assessments. If the MDS assessment is inaccurate, then residents are likely to not receive the services and support they need. The findings are: R #4 A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] with multiple diagnoses including but not limited to: 1. Acute Respiratory Distress Syndrome 2. Traumatic Brain Injury 3. Contracture (is a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult). 4. Unspecified Convulsions (a medical event in which nerve cell activity in the brain is disrupted, causing muscles to involuntarily contract and spasm). B. Record review of R #4's Bed Safety assessment dated [DATE] revealed R #4 is safe to use…

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 staff completed the comprehensive care plans for 3 (R #34, R #42, and R #90) of 3 (R #34, R #42, and R #90) residents reviewed for comprehensive care plans. This failure has the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being. The findings are: R #34 A. Record review of R #34's electronic files, revealed R #34 physician orders for: 1. Clopidogrel Bisulfate (anticoagulant; a medication used to treat blood clots) 75 mg, once daily for blood clot prevention dated 08/13/24. 2. Trazadone (psychotropic (any drug that affects brain activities associated with mental processes and behavior); a medication used to treat depression) 100 mg, once daily for depression dated 08/13/24. B. Record review of R #34's MAR for December 2024, revealed R #34 was administered the following medications: 1. Clopidogrel Bisulfate 75 mg daily. 2. Trazadone 100 mg daily C. Record review of R #34's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised the care plan for 4 (R #'s 34, 42, 67 and 90) of 4 (R #'s 34, 42, 67 and 90) residents reviewed when staff failed to: 1. Update the care plan to continue to monitor for pain medication effectiveness for R #34. 2. Update the care plan to continue with anti-depressant medications for behavior monitoring and side effects of the anti-depressant medication use for R #42. 3. Update the care plan to continue with care for R #67's left ankle fracture. 4. Update the care plan to continue with Foley Catheter for R #90. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #34 A. Record review of R #34's electronic files revealed a physician order dated 10/23/24 for Hydrocodone-Acetaminophen (a combination medication used to treat moderate to severe pain), 5-325 mg, 1 tablet every 6 hours, PRN (as needed) for pain. B. Record review of R #34's MAR 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 observation, interview and record review, the facility failed to provide Foley catheter (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag) care for 1 (R #90) of 1 (R #90) residents reviewed for catheter care. This deficient practice is likely to result in a resident's catheters becoming unclean and unsanitary leading to urinary tract infections (UTI; an infection in any part of the urinary system) and other diseases. The findings are: A. Record review of R #90's face sheet, revealed an initial admission date of 08/07/24 and included the following diagnoses: 1. Metabolic Encephalopathy (is a change in how your brain works due to an underlying condition). 2. Adult Failure to Thrive (a state where an individual has a substantial decline in overall health and their functional ability). 3. Leiomyoma of Uterus, Unspecified benign tumors in the smooth muscle cells of the myometrium (thick middle layer of the uterus (inverted pear-shaped…

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 medication error rate was 5% or less when three medication errors occurred out of 31 opportunities, which resulted in an error rate of 6.45% for 1(R #4) of 8 (R #4, R #32, R #40, R #44, R #71, R #80, R #89, and R #92) residents observed during medication administration. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects. The findings are: Incorrect Administration via Feeding Tube A. On 12/11/24 at 11:49 am during an observation of medication administration via feeding tube for R #4 , Registered Nurse (RN) #2 poured 30 milliliters (ml's) of Guaifenesin (medication to help eliminate (remove) sputum (combination of saliva and mucus) from the respiratory tract) liquid into a cup, she then crushed Lamotrigine (medication used to treat epilepsy (a seizure disorder)) 100 milligrams (mg) capsule and poured into the same cup as the Guaifenesin liquid. RN #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: 1. Ensure all medications were not expired. 2. Ensure medical supplies in the medication storage room were not expired. These deficient practices are likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications and medical supplies due to inappropriate storage. The findings are: Medications A. On [DATE] at 2:05 pm, during an observation of the North Medication Storage room revealed three boxes of laxative enemas (injection of fluid to cleanse or stimulate the emptying of your bowel) with the expiration date of 10/24 and one bottle of opened Ibuprofen that expired on 11/24. Medical Supplies B. On [DATE] at 2:15 pm, during an observation of North Medication Storage room revealed four needless connectors that expired on 06/2024. C. On [DATE] at 2:20 PM, during an interview with Registered Nurse (RN) #1, she confirmed that the expired medication and supplies should be discarded.

Based on record review and interview, the facility failed to ensure residents had completed and signed consent/refusal forms to show they consented to or declined the pneumococcal (for pneumonia, an infection and inflammation of the lung) vaccine for 2 (R #38 and R #74) of 5 (R #27, R #36, R #38, R #74, and R #85) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia, then they have a higher likelihood of contracting the illness and spreading it to other residents in the facility. The findings are: R #38 A. Record review of R #38's Electronic Health Record (EHR) revealed the last pneumococcal vaccine was received on 04/25/19. B. On 12/12/24 at 12:30 pm, during an interview with the Director of Nursing (DON) she confirmed R #38's EHR does not contain any evidence that the facility offered the pneumococcal vaccination to R #38 since 04/25/19. The DON stated that the pneumococcal vaccination should have been offered to R #38 in April of 2024. R #74 C. Record review of R #74's EHR revealed that staff failed to offer the pneumococcal…

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

Based on record review and interview, the facility failed to offer 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) vaccinations to 3 (R #36, R #38, and R #74) of 5 (R #27, R #36, R #38, R #74, and R #85) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents getting COVID-19. The findings are: R #36 A. Record review of R #36's Electronic Health Record (EHR) revealed the last COVID-19 vaccination that R #36 received was in October 2022. B. On 12/12/24 at 12:30 pm, during an interview with the DON, she confirmed R #36's EHR does not contain any evidence that the facility offered the COVID-19 vaccination to R #36 after October 2022. R #38 C. Record review of R #38's EHR revealed the last COVID-19 vaccination that R #38 received was in November 2021. D. On 12/12/24 at 12:30 pm, during an interview with the DON she confirmed that R #38's EHR does not contain…

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 keep residents free from physical restraints for 1 (R #22) of 2 (R #22, and R #103) residents evaluated for bed rail use, when staff used the bed rails without orders, written consent or comprehensive assessment. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity. The findings are: A. On 12/09/24 at 9:08 am, during an observation of R #22's room, the bed had small side rails times two at the head of his bed used for positioning. B. Record review of R #22's physician orders revealed the use of bed rails were not ordered. C. Record review of R #22's consent for bedrails dated 10/04/24 indicated does not want bedrails. D. Record review of the 5-day MDS assessment, dated 11/29/24 indicated bedrails not in use. E. On 12/12/24 at 1:05 pm, during an interview with the Director of Nursing (DON), she confirmed that R #22 did not have any orders, or consent for bedrails. The MDS did not…

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

Based on observation, record review, and interview, the facility failed to keep residents free from accidents for 1 (R #64) of 1 (R #64) residents reviewed for smoking when staff failed to hold smoking supplies. This deficient practice led to R #64 smoking in his room at the facility. The findings are: A. Record review of R #64's face sheet revealed R #64 was admitted to the facility initially on 09/25/22 with multiple diagnoses including: 1. Multiple sclerosis (MS; a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue) 2. Anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). 3. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). B. Record review of R #64's Smoking Evaluation dated 10/03/23 revealed R #64…

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 adequate monitoring of medications for 1 (R #34) of 4 (R #34, R #49, R #67, and R #77) residents reviewed for unnecessary medications. This deficient practice is likely to result in failure to address adverse effects resulting in unnecessary medications. The findings are: A. Record review of R #34's current physician orders revealed R #34 had orders for: 1. Clopidogrel Bisulfate (anticoagulant; a medication used to treat blood clots) 75 milligrams (mg), once daily for blood clot prevention dated 08/13/24. 2. Trazadone (psychotropic; a medication used to treat depression) 100 mg, once daily for depression dated 08/13/24. B. Record review of R #34's medication administration record (MAR) for December 2024, revealed R #34 was administered the following medications: 1. Clopidogrel Bisulfate 75 mg daily. 2. Trazadone 100 mg daily C. Record Review of R #34's documentation survey report (a detailed report that included tasks, interventions, frequency, documentation details, and responses) for December 2024 revealed R #34…

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 a comprehensive person-centered care plan for 2 (R #1 and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for care plans. If the facility fails to develop and implement comprehensive person-centered care plans, then staff are likely to not understand the care and needs of the residents which may result in worsening of medical conditions. The findings are: R #1 A. Record review of R #1's Face Sheet revealed that she was admitted to the facility on [DATE] with multiple diagnoses including: 1. Sepsis (a serious condition in which the body responds improperly to an infection), unspecified organism. 2. Muscle weakness, (generalized). 3. Colostomy Status [a surgical procedure in which the colon is connected to the abdominal wall and an opening (stoma) is created in the abdominal wall created to allow waste to leave the body]. 4. Encounter for surgical aftercare following surgery on the Genitourinary (the sex organs of 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 that 2 (R #1 and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in boney areas of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing when staff failed to 1. Conduct consistent pressure ulcer wound assessments with measurements. 2. Obtain and implement wound care treatment orders timely. 3. Initiate and implement wound care treatment interventions in care plans. This deficient practice is likely to lead to residents developing new pressure ulcers or the worsening of current pressure ulcers. The findings are: R #1 A. Record review of R #1's Face Sheet revealed that she was admitted to the facility on [DATE] with multiple diagnoses including: 1. Sepsis (a serious condition in which the body responds improperly to an infection), unspecified organism. 2. Muscle weakness, (generalized). 3. Colostomy Status [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 accuracy of the Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) for 1 (R #3) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed. If the MDS assessment is inaccurate, then residents are likely to not receive the services they need. The findings are: A. Record review of R #3's Face Sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses including: 1. Anemia (low red blood cell count), unspecified. 2. Nontoxic Single Thyroid Nodule (a lump that forms in the thyroid gland). 3. Type 2 Diabetes Mellitus (a condition results from insufficient production of insulin, causing high blood sugar) with Hyperglycemia (high blood sugar). 4. Inflammatory Disease of Prostate (male reproductive gland). B. Record review of R #3's Weight Summary revealed that R #3 weighed 207.8 pounds on 06/03/24 and 156.2 pounds on 10/01/24 (weight loss of 24.8% in four months). 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.

Based on observation and interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 103 people residing in the facility by allowing unauthorized persons access to their medical supplies and personal health information. The findings are: A. On 09/04/24 at 8:19 am, during a random observation of the facility, the treatment cart located in front of the memory unit by nurses stations was unlocked and unattended. B. On 09/04/24 at 8:20 am, during an interview with Certified Nursing Assistant (CNA) #5, she confirmed the treatment cart was unlocked but should be locked. C. On 09/04/24 at 8:20 am, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed the treatment cart should be locked when unattended. D. On 09/04/24 at 1:16 pm, during a random observation of the facility, the treatment cart in front of the memory unit by the nurses station was unlocked and unattended. E. On 09/04/24 at 1:20 pm, during an interview with LPN #1, she confirmed the treatment cart should be locked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents were treated in a respectful manner that preserved the residents' dignity for 3 (R #1, R #3, and R #8) of 3 (R #1, R #3, and R #8) residents reviewed for residents' rights when they failed to: 1. Allow R #1 to refuse care. 2. Assist R #3 with incontinence care as needed. 3. Allow R #8 to exercise his right to visit other residents in the facility. 4. Speak to R #8 in a dignified manner. These deficient practices likely resulted in residents feeling unimportant, embarrassed, and undervalued. The findings are: R #1 A. Record review of R #1's Electronic Health Record (EHR) revealed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's Admission/Entry Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/26/24, indicated a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. The MDS indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure care plans were accurate and complete for 2 (R #3 and R #4) out of 2 (R #3 and R #4) residents reviewed for comprehensive care plans. This deficient practice could likely result in staff not understanding and implementing the needs and treatments of residents. The findings are: R #3 A. Record review of R #3's EHR revealed R #3 was admitted on [DATE]. B. Record review of R #3's hospital discharge documentation, dated 08/17/24, revealed the resident had an indwelling urinary catheter (a medical device that drains urine from the bladder) placed when he went to the hospital. C. On 09/05/24 at 12:25 pm, during an interview and observation of R #3, the resident stated he had an indwelling urinary catheter placed when he went to the hospital in August. Observation revealed the resident's catheter bag hung on the side of his bed. D. Record review of R #3's care plan, last updated on 08/10/24, revealed the following: 1. Staff did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to meet professional standards of quality for 3 (R #3, R #4, R #6) of 5 (R #3, R #4, R #5, R #6, and R #9) residents when staff: 1. Failed to properly transfer R #3 causing his indwelling urinary catheter (a medical device that drains urine from the bladder) to be pulled out. 2. Failed to obtain physician orders for the use and care of resident's catheters. 3. Failed to handle and assist a resident with medications in a safe manner. If the facility is not providing care that meets professional standards of quality, then residents are likely to experience pain, discomfort and not get the care they need. The findings are: Transfers A. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses: -Unspecified fracture of lower end of right tibia (the larger of the two bones in a person's lower leg). -Other fracture of upper and lower end of right fibula (the long bone that's…

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

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 3 (CNA #1, CNA #2, and CNA #3) out of 3 (CNA #1, CNA #2, and CNA #3) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #1 A. Record review of CNA #1's personnel file revealed CNA #1 was hired on 05/19/23. B. Record review of CNA #1's in-service training Transcript Report, dated 09/05/24, revealed CNA #1 did not complete any trainings from 05/19/23 to 09/05/24. C. On 09/05/24 at 4:23 pm, during an interview with the Administrator (ADM), he confirmed CNA #1 did not complete any trainings while she was employed at the facility. He confirmed that CNA #1 continued to work shifts providing care for residents in the facility even though she had completed no trainings. The ADM stated he expected all CNAs to complete at least 12 hours of training per year. CNA #2 D. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an allegation of staff to resident abuse was reported within two hours to the State Survey Agency for 1 (R #3) of 1 (R #3) residents reviewed for reporting of alleged violations. If the facility is not immediately reporting allegations of abuse, then residents are likely to be at risk of further abuse. The findings are: A. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE]. B. On 09/05/24 at 12:25 pm, during an interview with R #3, he stated Certified Nurse Assistant (CNA) #1 yelled at him but he could not remember the date of the incident. R #3 stated CNA #1 came into his room to assist him with a transfer from his bed to his wheelchair. He stated CNA #1 picked up the catheter bag, but he was afraid she picked it up too far and allowed urine to re-enter his body. R #3 stated he yelled at CNA #1 to put it down. R #3 stated he could not remember exactly what CNA #1 said to him, but she yelled very…

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 and document a thorough investigation for 1 (R #3) of 1 (R #3) residents when staff failed to: 1. Complete a thorough investigation regarding an allegation of abuse. 2. Provide a follow-up report to the State Agency within five working days from the date of the incident. If the facility fails to complete a thorough investigation and five day follow-up report then residents are likely to feel frustrated and unsafe. The findings are: A. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE]. B. Record review of R #3's hospital discharge documentation, dated 08/17/24, revealed the resident had an indwelling urinary catheter (a medical device that drains urine from the bladder) placed at the hospital. C. On 09/05/24 at 12:25 pm, during an interview with R #3, he stated Certified Nurse Assistant (CNA) #1 yelled at him but he could not remember the date of the incident. R #3 stated CNA #1 came into his room 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 observations, record reviews, and interviews, the facility failed to ensure baseline care plans were completed for 1 (R #2) out of 1 (R #2) residents reviewed for care plans. This deficient practice could likely result in staff not understanding and implementing the needs and treatments of residents. The findings are: A. On 09/04/24 at 12:56 pm during an interview with R #2, he stated he required some help with transferring, because he could not stand well on the foot he had surgery on. He stated staff also help him with showering to prevent his wound from getting wet. B. Record review of R #2's Electronic Health Record (EHR) revealed the following: 1. R #2 was admitted on [DATE] for surgical aftercare after removal of the small fifth toe to the left foot, diabetes, high cholesterol and an infection in the surgical site. 2. The record did not contain a baseline care plan. C. On 09/06/24 at 8:17 am, during an interview with the Director of Nursing (DON), she stated she was unable to find a care plan 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.

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 1 (R #3) of 1 (R #3) residents reviewed. This deficient practice could likely result in staff not being aware of the residents' daily care events, changes, and needs. The findings are: A. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses: -Unspecified fracture of lower end of right tibia (the larger of the two bones in a person's lower leg). -Other fracture of upper and lower end of right fibula (the long bone that's located on the outside of the tibia bone). -Pain, unspecified. -Other muscle spasm. -Muscle weakness, generalized. -Other lack of coordination. -Other reduced mobility. -Other abnormalities of gait and mobility. -Stiffness or other specified joint. B. Record review of R #3's hospital discharge documentation, dated 08/17/24, revealed the resident had an indwelling urinary catheter placed. C. On 09/05/24 at 12:25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure medications are properly stored in the medication carts; 2. Ensure the expired supplies were not kept in the medication cart; 3. Ensure wound care treatment supplies were kept in a separate cart than medication; 4. Ensure medication which needed to be kept in the refrigerators was refrigerated; 5. Ensure opened and accessed flex pen [a device pre-filled with insulin; should be dated with the last date staff should use the product (expiration date) and discarded in within 28 days of the date, unless the manufacturer specified a different date] were dated as to when nursing staff initially opened and assessed the pen; 6. Ensure expired medications or supplies were not stored in the supply room; 7. Ensure the refrigerator contains a permanently affixed compartment for controlled substances. The deficient practices have the likelihood to result in 94 residents that were identified on the census list provided by the Centers Executive…

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

Based on record review and interview, the facility failed to ensure the grievances identified by the Resident Council (RC) were resolved and the resolutions communicated back to the RC committee. This deficient practice could likely affect all 94 residents who reside at the facility, if the staff is not ensuring RC grievances are responded to and resolutions are communicated back to the RC group, then residents are likely to feel that their concerns don't matter and they have no influence over changing issues identified by residents. The findings are: A. Record review of Resident Council Meeting Minutes identified the following grievances: 1. On 11/28/23: Food options/food served cold, a resident went into other residents' rooms, not changed often enough, staff ignored residents, colored clothes bleached, housekeeping did not clean rooms, and ran out of toilet paper. The Department Response form included the following action items (items of concerns to be addressed): CNA (Certified Nurse Aide), Laundry, Housekeeping and Activities. The Response form was signed by the Interim…

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 provide an activities program desinged to meet the interest of each resdient for 11 (R #4, R #7, R #17, R #21, R #43, R #46, R #51, R #58, R #142, R #143 and R #293) of 11 (R #4, R #7, R #17, R #21, R #43, R #46, R #51, R #58, R #142, R #143 and R #293) residents reviewed for activities. This deficient practice could result in residents feeling less connected to their peers, having lower self-esteem, and experiencing a decline in psychosocial well-being. The findings are: A. Record review of the Actvity Calendar (not including Memory Care unit) for the months of December 2023, January 2023, and February 2023 consisted of 9:00 am exercise, 9:30 am daily chronicle, 10:00 am coffee, and 2:00 pm an activity that usualy included a craft, board/card game, or movie. The facility did not offer activites for the residents after 2:00 pm each day. Findings related to bed bound residents: B. On 02/08/24 at 11:30 am the facility Administrator provided…

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 (R #28) of 1 (R #28) resident reviewed for vision, had proper assistive devices to maintain her vision. If the facility is not assisting residents in accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see, read, and participate in activities. The findings are: A. Record review of R #28's face sheet identified R #28 was admitted on [DATE] and included a picture of R #28 wearing eye glasses. B. Record review of R #28's inventory of personal effects sheet, dated 07/25/22, identified the resident had one pair of eyewear/glasses. C. Record Review of R #28's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), revealed: - admission MDS, dated [DATE], the resident had impaired vision and wore corrective lenses, - Quarterly MDS, dated [DATE], the resident had impaired vision and wore corrective lenses, - Quarterly MDS, dated [DATE], the resident did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide adequate monitoring of behaviors for 3 (R #45, R #24, and R #70 ) of 4 ( R # 45, R #24, and R #70) residents reviewed for behaviors and psychotropic medication administration disclosure (referred to the types of medications that affects the mind, emotions and behaviors consent form). If the facility is not providing adequate monitoring of resident's behaviors that warrant the use of psychotropic medications (drugs that treat mental health disorders) then residents are likely to be receiving psychotropic medication unnecessarily. The findings are: R#45 A. Record review of R #45's Face Sheet revealed R #45 was admitted to the facility on [DATE] and had diagnoses of unspecified mood (affective disorder; when mood episodes impact daily functioning but cannot fit under any other diagnosis, they may be listed as other), bipolar disorder (mood disorder), depression (mental state of low mood), and anxiety (feeling nervous, restless, or tense). 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.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less when 4 medication errors occurred out of 35 medications given, which resulted in an error rate of 11.43% for 2 (R #24 and R #78) of 6 (R #9, R #24, R #42, R #47, R #56, and R #78) residents observed during medication administration. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects. The findings are: R#78 Orally Inhaled Medications/Small Volume Nebulizer (SVN; a small machine that turns liquid medicine into a mist that can be easily inhaled) treatments: A. Record review of the physician's order for R #78, start date 12/27/23, revealed Trelegy [brand name; an inhalant medication used long term to treat chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, and asthma in adults], Fluticasone-Umeclidin-Vilant Inhalation Aerosol Powder, breath activated, 100-62.5-25 MCG/ACT…

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 proper infection prevention measures when: 1. Staff reused foley catheter (indwelling flexible tube inserted into the bladder) tubing and bag for R #24. 2. The nurse did not wash hands prior to donning (put on) gloves. If the facility is not adhering to infection control practices then residents are likely to be at risk of infection or disease. The findings are: Findings related to catheter care: A. Record review of current ongoing physician orders for R #24, start date 10/06/22, revealed an order to replace the urinary drainage system (drainage system includes: drainage bag, flexible clear tubing, sterile end tip that connects directly into drainage catheter) if disconnections or leakage occur, and as needed. B. Record review of the facility policy titled, Catheter: Indwelling Urinary - Care of, dated 02/01/24, revealed the following: - 8.1 If disconnections or leakage occur, replace drainage system. - 15.1 Do not allow the drainage spigot to come in contact with the non-sterile collecting container.…

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 treat residents with respect and dignity for 1 (R #59) of 1 (R #59) residents observed during random observation when they failed to ensure staff knocked on the resident's bedroom door before entering their room. This deficient practice could likely result in residents feeling unimportant and lacking privacy. The findings are: Findings for R #59: A. On 02/05/24 at 4:34 pm during an interview, R #59 stated staff were rude and did not knock before they entered her room. R #59 stated this happened during both shifts, day and night. B. On 02/05/24 at 4:40 pm during an observation, R #59 pressed the call button and Licensed Practical Nurse (LPN) #1 entered R #59's room and did not knock on the door before entering. C. On 02/07/24 at 5:58 pm during interview with the Activities Director for the Memory Care Unit (ADMC), she confirmed staff were expected to knock on the door before entering residents' room.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #24) of 1 (R #24) resident reviewed for MDS accuracy. This deficient practice could likely result in the facility not having an accurate assessment of residents care needs. The findings are: A. Record review of the quarterly MDS for R #24, dated 01/12/24, identified R #24 took an anticoagulant (medication that slows down the process of making blood clots). B. Record review of the R #24's physician orders, dated 01/24/24, identified an order for aspirin, 81 milligrams (mg) for prophylaxis (to prevent disease), but the physician's orders did not identify R #24 took an anticoagulant. C. On 02/08/24 at 2:32 pm during interview with the MDS Coordinator, he confirmed that on the quarterly MDS assessment, staff documented R #24 took an anticoagulant because R #24 took aspirin. The MDS coordinator reviewed the MDS guidance and confirmed aspirin was not an anticoagulant. but an anti-platelet (a medication…

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

Based interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans which included information about a resident's preferences, discharge goals, and wound care for 2 (R #293 & R #42) of 4 (R #42, R #293, R #31, and R #78) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care and treatment needed to reach their highest practicable level of well-being. The findings are: Resident #293 A. On 02/06/2024 at 8:23 am during an interview, R #293 stated she was unaware of any participation in care planning and was unsure what her plans for discharge were. She also stated she had not been asked about her preferences for care or activities. B. Record review of resident's care plan, updated 02/07/2024, revealed the plan did not include information pertaining to the resident's preferences or discharge goals. C. Record review of baseline care plan, established on 01/13/2024, revealed the plan did not include information pertaining to the resident's preference or discharge goals. D. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan within seven days of completion of the comprehensive assessment and revise the care plan for 2 (R #28 and R #293) of 2 (R #28 and R #293) residents reviewed for care plan timing and revisions. This deficient practice could likely result in staff being unaware of changes in the care provided, and residents not receiving the care related to changes in their health status. The findings are: Resident #28 A. Record review of R #28's face sheet identified R #28 was admitted on [DATE] and included a picture of R #28 wearing glasses. B. Record review of R #28's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/03/23, revealed R #28 had impaired vision and wore corrective lenses. C. Record review of R #28's Care Plan, revised on 11/20/23, revealed the care plan did not identify R #28 had impaired vision or used corrective lenses. D. On 02/08/24 at 10:31 AM during…

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

Based on record review and interview, the facility failed to ensure the resident received treatment and care per physician's orders and in accordance with professional standards of practice for 1 (R #3) of 1 (R #3) residents reviewed for receiving antibiotics. This deficient practice is likely to result in residents not being appropriately treated for infections. The findings are: A. Record review of R #3's physician orders, revealed an order for R #3 to receive Cefepime HCI (antibiotic used to treat a wide variety of bacteria), intravenous solution, 1 gram (g)/50 milliliter (ml). Use one gram intravenously two times a day for pseudomonas aeruginosa (an infection that can affect your skin, blood, lungs, gastrointestinal tract (GI; stomach) tract and other parts of the body) urinary tract infection (UTI) for seven days. Start date 01/17/23 at 8:00 am. B. During a record review of R #3's Electronic Medication Administration Record (eMAR) revealed R #3 missed two doses of Cefepime HCL on 01/17/24. C. On 02/09/24 at 1:31 pm, during an interview with the Director of Nursing (DON), she…

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 Past Non-Compliance Based on record review and interview, the facility failed to ensure residents were free from accident and hazards for 1 (R #92) of 1 (R #92) residents reviewed for falls when R #92 fell and hit her head on the hoyer lift (portable whole body lift) that was left unattended in the hallway. If the facility is not ensuring that the environment is free from accidents hazards then residents are likely at risk of falling and getting injured. The findings are: A. Record review of the Care Plan for R #92, initiated on 09/28/23, revealed R #92 was at risk for falls due to cognitive loss, lack of safety awareness. Interventions included arrange the environment to enhance vision and maximize independence. B. Record review of progress notes for R #92, dated 12/04/23, revealed R #92 had a witnessed fall with head injury. The resident turned and did not move her cane. The cane crossed over causing her to fall. Lacerations and a hematoma (a collection of blood outside of a blood vessel) noted. C. On 02/08/24…

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

Based on observation, record review, and interview, the facility failed to properly date oxygen tubing or chart it in the Electronic Administration Treatment Record (ETAR) for 1 (R#7) of 1 ( R #7) resident reviewed for respiratory care. These deficient practices could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (process where water vapor becomes liquid) or becoming dirty leading to reduced flow of oxygen. The findings are: A. Record review of R #7's physicians orders, dated 06/24/16, revealed an order for every night shift, every Sunday, label each component of the oxygen equipment with date and initials. Change oxygen tubing out weekly. B. Record review of R # 7's ETAR revealed the staff should have changed the resident's oxygen tubing on 02/04/24. The record showed staff did not document they changed the tubing. C. On 02/05/24 at 4:27 pm, during an observation, R #7's oxygen tubing did not contain a date on the tubing. D. During an interview on 02/05/24 at 4:30 pm, Certified Nursing Assistant (CNA) #5 confirmed there was not a…

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

Based on record review and interview, the facility failed to ensure residents' money will be safeguarded from loss for 4 (R #1, 2, 3, and 4) residents reviewed for personal property when they failed to act as a fiduciary (involving trust, especially with regard to the relationship between a trustee and a beneficiary) of the residents' funds and report at least quarterly on the status of these funds in a clear and understandable manner. Managing the residents' financial affairs includes money an individual gives to the facility for the sake of providing a resident with a non-covered service. In these instances, the facility will provide a receipt to the gift giver and retain a copy. This deficient practice resulted in unaccounted property (loss of money) for the residents and made them feel as if their money was not safely handled. The findings are: A. Record Review of R#1's quarterly balance reveled an account balance of $309.38 on 10/27/23. B. Record Review of R#2's quarterly balance revealed an account balance of $597.14 on 10/27/23. C. Record Review of R#3's quarterly balance…

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.