Northstar Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a resident receiving psychotropic medications had non-pharmacological interventions in place to manage the resident's behaviors for 1 of 15 sampled residents (Resident #9) and residents receiving psychotropic medications had adequate monitoring for behaviors and side effects and appropriate indication for usage for 2 of 15 sampled residents (Resident #4 and #37). This deficient practice had the potential to result in a resident receiving unnecessary medications or lack of nonpharmacological interventions resulting in a resident receiving increased doses of psychotropic medications and adverse drug reactions. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, unspecified and schizophrenia, unspecified. An Order Summary Report and the November 2025 Medication Administration Record documented the resident had received the following medications:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure the facility did not employ a Registered Nurse (RN) with a disciplinary action against the RN's professional license as a result of a finding of abuse of a patient. This deficient practice placed all residents in the facility at risk for abuse. Findings include:On 01/27/2026, the facility provided a list of current employees of the facility. The list included names, titles, and original hire dates for all employees. The RN of concern was included on the list and had an original hire date of 12/11/2017.The facility schedules for January and February 2026 documented the RN of concern was scheduled to work in the facility.On 02/02/2026, in response to a request for the RN of concern's professional license number, the facility provided a printed copy of a Primary Source Board of Nursing Report Summary for the RN of concern from the Nevada State Board of Nursing's (NV SBON) website. The report documented the RN's license was active and restricted, with discipline. The basis for action was violation code 14, patient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, interview, and document review, the facility failed to identify and report neglect of a resident to the State Agency (SA) for 1 of 15 sampled residents (Resident #53). This deficient practice had the potential to result in allegations and incidents of possible abuse, neglect, and mistreatment of residents not being investigated by the facility and/or the SA.Resident #53Resident #53 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease with late onset and personal history of transient ischemic attack and cerebral infarction without residual deficits.An acute care hospital Discharge summary dated [DATE], documented Resident #53 was admitted to the hospital on [DATE] from a behavioral health crisis center for fever and sepsis. The resident was treated with Intravenous (IV) fluids and completed a course of Tamiflu. Discharge diagnoses, assessment and plan included severe dementia and history of cerebrovascular accident (CVA).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, interview, and document review, the facility failed to ensure a thorough investigation was conducted and documentation was completed and/or retained for 1 unsampled resident (Resident #71) who eloped from the facility. This deficient practice had the potential to result in psychosocial and physical harm to residents. Findings include:Resident #71Resident #71 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.An Interdisciplinary Team (IDT) post incident review note, dated 10/29/2024, documented on the morning of 10/27/2024 at 7:30 AM, Resident #71 was noted to be missing from the facility. The resident had a history of wandering. On 10/27/2024 at 5:30 PM the resident was found and taken to an emergency room (ER) for evaluation. The IDT met and it was determined due to the resident's daily habits of wandering and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a resident's behaviors were care planned with non-pharmacological interventions and a resident care plan was implemented to ensure residents were able to smoke independently and safely for 2 of 15 sampled residents (Resident #9 and #7). This deficient practice had the potential to result in a resident not receiving the necessary care to alleviate behavioral symptoms of psychiatric diagnoses and causing unnecessary pain and suffering and a resident suffering physical harm from smoking related injuries. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, unspecified and schizophrenia, unspecified. An Order Summary Report and the November 2025 Medication Administration Record documented the resident had received the following medications: Mirtazapine 7.5 milligram (mg) tablet, give one tablet by mouth at bedtime for anxiety disorder, unspecified.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and document review, the facility failed to revise and reinitiate the comprehensive care plan to address the continued or renewed use of a psychotropic medication after the care plan was marked resolved for 1 of 15 sampled residents (Resident #37) and the care plan for 1 of 15 sampled residents (Resident #5) included the current use of a Wander Guard. This deficient practice resulted in the resident receiving a psychotropic medication and facility use of a Wander Guard without an active care plan to guide staff interventions, monitoring, and evaluation, placing the resident at risk for unmet needs and adverse outcomes. Findings include: Resident #37 Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including depression, unspecified, other specified anxiety disorder, and insomnia, unspecified. Resident #37's clinical record documented a care plan for Clonazepam included behavior monitoring, side effect monitoring, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to 1) ensure the smoking evaluation was fully completed by the interdisciplinary team (IDT) as required by facility policy and failed to maintain safe smoking practices by providing adequate supervision to prevent accidents for 1 of 15 sampled residents (Resident #7), resulting in the resident having access to smoking materials and a lighter without documented confirmation of safe smoking ability, placing the resident at risk for injury or fire hazard; and 2) provide the supervision necessary to prevent the elopement of 1 unsampled resident (Resident #71).These deficient practices had the potential to result in physical and emotional harm to both residents. Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, mild, with psychotic disturbance, and chronic obstructive pulmonary disease, unspecified. On 01/27/2026 at 9:39…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and document review, the facility failed to ensure interventions implemented to care for a resident with dementia were revised based on assessment of the resident's condition when quarterly elopement and wandering risk assessments for 1 of 15 sampled residents (Resident #5) documented a wander alarm was not indicated and a Wander Guard device remained in use. This deficient practice had the potential to result in a resident being unnecessarily confined within the facility and experiencing feelings of isolation. Findings include:Resident #5Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including alcohol dependence with alcohol-induced persisting dementia and alcoholic cirrhosis of liver without ascites.A Physician's Order dated 09/12/2024, documented Wander Guard - check placement every shift, left side back of arm of wheelchair.An Elopement and Wandering Risk Observation/assessment dated [DATE], included instructions 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 observation, interview, and document review, the facility failed to ensure: 1) a medication cart containing resident medications was secured, 2) insulin pens for 3 of 15 sampled residents (Resident #4, #69, and #36) were stored separately to prevent cross-contamination; and 3) temperatures for the medication room and medication refrigerator were monitored and documented as required. These deficient practices had the potential to result in unauthorized access to medications, increased risk of medication errors or contamination, and compromised medication integrity, which could negatively impact resident health and safety.Findings include: On 01/26/2026 at 8:29 AM, a medication cart was left unlocked in the B wing hall entrance. On 01/26/2026 at 8:32 AM, a Registered Nurse (RN) returned to the unsecured medication cart and confirmed the cart was left unlocked. The RN confirmed the medication cart was out of direct line of site and it was important to ensure the medication cart was locked to avoid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee maintained an ongoing, facility-wide, and data-driven QAPI program and identified widespread concerns with vaccination programs and employee training and background checks. This deficient practice had the potential to result in residents suffering adverse outcomes and decreased quality of life due to widespread concerns not being identified by the QAPI committee.Findings include:On 02/02/2026 at 4:43 PM, the Administrator verbalized the Infection Preventionist (IP) was a member of the QAPI committee and would discuss concerns with the facility's infection prevention plan with the committee during QAPI meetings and as needed. The Administrator verbalized the QAPI committee was unaware of an issue with the vaccine program until the concern was brought to the facility's attention by a State surveyor on 01/29/2026.On 02/02/2026 at 4:45 PM, the Administrator confirmed Human Resources (HR) was a part of the QAPI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, document review, and interview, the facility failed to ensure appropriate infection control measures were maintained while administering medications to 1 of 15 sampled residents (Resident #69). This deficient practice had an increased risk of infection for residents related to cross contamination during medication administration. Findings included:Resident #69Resident #69 was admitted to the facility on [DATE], with diagnoses including cellulitis of left lower limb and drug induced constipation.A physician's order dated 01/21/2026, documented sennosides-docusate sodium (Senna Plus) 8.60-50 milligrams (mg). Give two tablets by mouth two times per day for bowel.On 01/29/2026 at 8:13 AM, a Registered Nurse (RN) was administering morning medications to Resident #69. Resident #69 verbalized the resident did not want to take the Senna Plus tablets. The nurse reached into the medication cup containing the resident's morning medications with a bare/ungloved hand, retrieved…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and document review, the facility failed to ensure residents and staff were screened to receive the Coronavirus (Covid) vaccine for 4 of 5 residents reviewed for Covid vaccination compliance (Residents #24, #3, #8, #10). This deficient practice had the potential to result in residents and staff not having the opportunity to accept the vaccine and potentially suffering severe and prolonged illness, with the risk of spreading to others in the facility, if they contract the virus.:Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia and acute respiratory failure with hypercapnia.Resident #3Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic systolic (congestive) heart failure and dependence on supplemental oxygen.Resident #8Resident #8 was admitted to the facility on [DATE], with diagnoses including…

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

Based on interview and record review, the facility failed to provide an effective training program for agency staff to ensure they were knowledgeable about facility policies and resident care procedures. This deficient practice had the potential to negatively impact the quality of care and safety of residents. Findings included:On 01/28/2026 and 02/02/2026, during personnel record review, the surveyor requested documentation of training provided to agency staff prior to assignment on the units. The facility was unable to provide evidence of comprehensive orientation or competency-based training for agency staff to include elder abuse training, dementia care training, Quality Assurance and Performance Improvement (QAPI) training, communication training, resident rights, infection control training, and compliance and ethics training. On 01/28/2026 at 12:54 PM, the Administrator verbalized the facility kept a contract with an outside agency to obtain staff for uncovered shifts. The Administrator explained the contract indicated all staff provided would have the training required for…

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

Based on interview, personnel record review, and document review, the facility failed to ensure initial effective communication with residents and family training was completed timely per facility policy for 1 of 19 sampled employees (Employee #11). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include:Employee #11 Employee #11 was hired as a Registered Nurse hired on an unknown date. Employee #11's personnel record lacked documented evidence of effective communication with residents and family training completed upon hire. On 02/02/2026 at 2:30 PM, the Administrator confirmed effective communication with residents and family training was required for all employees. The Administrator explained there was orientation training upon hire and go through the training before working on the floor. The agency staff did not go directly through the facility for orientation training. On 02/02/2026 at 3:26 PM, the Administrator confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, personnel record review, and document review, the facility failed to ensure initial resident rights and responsibilities training was completed timely per facility policy for 1 of 19 sampled employees (Employee #11). This deficient practice had the potential to prevent residents from being able and encouraged to practice their rights as residents. Findings included:Employee #11 Employee #11 was hired as a Registered Nurse hired on an unknown date. Employee #11's personnel record lacked documented evidence of resident rights training completed upon hire. On 02/02/2026 at 2:30 PM, the Administrator confirmed resident rights and responsibilities training was required for all employees. The Administrator explained there was orientation training upon hire and go through the training before working on the floor. The agency staff do not go directly through the facility for orientation training. On 02/02/2026 at 3:26 PM, the Administrator confirmed Employee #11's personnel record lacked documented evidence of resident rights and responsibilities training completed upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, personnel record review, and document review, the facility failed to ensure initial Quality Assurance and Performance Improvement (QAPI) training was completed timely per facility policy for 1 of 19 sampled employees (Employee #11). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include:Employee #11 Employee #11 was hired as a Registered Nurse hired on an unknown date. Employee #11's personnel record lacked documented evidence of QAPI completed upon hire. On 02/02/2026 at 2:30 PM, the Administrator confirmed QAPI was required for all employees. The Administrator explained there was orientation training upon hire and go through the training before working on the floor. The agency staff did not go directly through the facility for orientation training. On 02/02/2026 at 3:26 PM, the Administrator confirmed Employee #11 personnel record lacked documented evidence of QAPI training completed upon hire and before working on the floor with residents. The facility policy titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, personnel record review, and document review, the facility failed to ensure initial and annual infection control training was completed timely per facility policy for 3 of 19 sampled employees (Employee #4, #6 and #11). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases. Findings include:Employee #4 Employee #4 was hired as the Registered Dietician on 08/16/2021. Employee #4's personnel record documented infection control training completed on 11/20/2024; however, lacked annual training completed for 2025. Employee #6 Employee #6 was hired as the Food Services Supervisor on 08/16/2021. Employee #6's personnel record documented infection control training completed on 11/26/2024; however, lacked annual training completed for 2025. Employee #11 Employee #11 was hired as a Registered Nurse hired on an unknown date. Employee #11's personnel record lacked documented evidence of infection control training completed upon hire. On 02/02/2026 at 2:30 PM, the Administrator confirmed infection control training…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, personnel record review, and document review, the facility failed to ensure initial and annual compliance and ethics training was completed timely per facility policy for 3 of 19 sampled employees (Employee #2, #11 and #12). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include:Employee #2 Employee #2 was hired as the Director of Nursing on 03/24/2020. Employee #2's personnel record documented compliance and ethics training completed on 10/14/2024; however, lacked annual training completed for 2025. Employee #11 Employee #11 was hired as a Registered Nurse hired on an unknown date. Employee #11's personnel record lacked documented evidence of compliance and ethics training completed upon hire. Employee #12 Employee #12 was hired as a Licensed Practical Nurse hired on an unknown date. Employee #12's personnel record documented compliance and ethics training completed on 10/06/2024; however, lacked annual training completed for 2025. On 02/02/2026 at 2:30 PM, 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 personnel record review, interview, and document review, the facility failed to ensure initial behavioral health care training related to dementia, was completed timely for 4 of 20 sampled employees (Employees #11, # 12, #19, and #20). This deficient practice had the potential to prevent residents with dementia care needs from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include:Employee #11 Employee #11 was hired as a Registered Nurse (RN), hire date unknown. The facility lacked a personnel record for Employee #11 to include behavioral health care training for dementia. Employee #12 Employee #12 was hired as a Licensed Practical Nurse (LPN), hire date unknown. The facility lacked a personnel record for Employee #12 to include behavioral health care training for dementia. Employee #19 Employee #19 was hired as a Dietary Aide on 09/02/2025. Employee #19's personnel record documented initial behavioral health care training for dementia completed on 12/25/2025, 84 days late. Employee #20 Employee #20 was hired as 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 interview, clinical record review, and document review, the facility failed to offer a bowel and bladder retraining program for residents assessed to be candidates for retraining for 11 of 49 residents (Resident #13, #47, #22, #24, #34, #18, #23, #41, #20, #28, and #45). This deficient practice had the potential to affect all residents' ability to maintain and achieve their highest continent status and increase the risk of related health issues. Findings include: Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including strain of other muscles and tendons at lower leg level, left leg, and muscle weakness. Resident #13's Minimum Data Set 3.0 (MDS) Section H - Bowel and Bladder dated 12/06/2024, documented Resident #13 was occasionally incontinent of bladder and occasionally incontinent of bowel. A trial of a toileting program had not been attempted and a toileting program was not being used to manage the resident's bowel incontinence. Resident #13's Bowel and Bladder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to ensure expired medications were removed from 1 of 2 inspected medication carts and from 1 of 1 inspected medication storage rooms. This deficient practice had the potential to place residents at risk of receiving expired/outdated medications. Findings include: On 12/17/2024 at 11:54 AM, during a review of the B hall medication cart and in the presence of the Assistant Director of Nursing (ADON), a box of Aspercreme four percent (%) Lidocaine patches was found. Three patches remained in the box. The expiration date printed on the patches was 10/2024. The ADON confirmed the expiration date printed on the Lidocaine patches was 10/2024, and the patches should have been removed from the cart and discarded by 10/31/2024. On 12/17/2024 at 12:15 PM, during a review of the B hall medication storage room and in the presence of the ADON, the following items were found: -Two intravenous (IV) solution bags containing 50 milliliters (ml) of Normal Saline 0.9 percent. The expiration date printed on the bag was 10/2024.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than 5 percent (%). There were 25 opportunities and two medication errors. The error rate was 8%. This deficient practice resulted in a resident receiving a medication at a different concentration than ordered in the electronic Medication Administration Record (eMAR) and had the potential for medication errors and adverse effects. Findings include: Resident #24 Resident #24 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with a diagnosis of unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with routine healing. On 12/18/2024 at 2:56 PM, a Licensed Practical Nurse (LPN) began preparing medications for Resident #24. The LPN verbalized the physician ordered Diclofenac Sodium gel was not available in the facility. Resident #24's December 2024 Medication Administration Record (MAR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review and document review, the facility failed to ensure resident information was not visible on an unattended computer screen and hospice medication orders were entered timely into the electronic medical record (EMR) for 1 of 13 sampled residents (Resident #205). This deficient practice had the potential to expose a resident's private and protected health information and for records to be incomplete, placing a resident at risk of not receiving physician ordered medications. Findings include: On 12/18/2024 at 11:18 AM, a computer screen on an unattended medication cart in the B wing dining area displayed resident information. On 12/18/2024 at 11:19 AM, a Registered Nurse (RN) returned to the medication cart and verbalized the computer screen should not display resident information. The RN confirmed the computer screen was unlocked and unattended with resident information on display. On 12/18/2024 at 11:28 AM, the Director of Nursing verbalized the expectation was…

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

Based on observation, interview, and document review the facility failed to ensure a Registered Nurse (RN) performed hand hygiene between administering medications to different residents. This deficient practice had the potential to affect all residents receiving medication from the RN and placed residents at risk for spread of infection. Findings include: On 12/18/2024, during the medication pass from 8:44 AM through 9:12 AM, an RN administered medications to two residents, readjusted a resident's nasal cannula, touched a resident's shoulder, and donned and doffed a glove. The RN did not perform hand hygiene prior to preparing medication for each resident, prior to administering medication to each resident, after contact with the residents and the residents' environment, or after administering medication to each resident. On 12/18/2024 at 9:14 AM, the RN confirmed the RN did not perform hand hygiene prior to medication preparation and administration, after contact with the residents and the residents' environment, or after medication administration. The RN verbalized hand hygiene…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee record review, document review and interview, the facility failed to ensure timely completion for initial and annual training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation (abuse training) for 3 of 20 sampled employees (Employee #2, #9, and #13). The deficient practice had the potential to place residents at risk for abuse and neglect. Findings include: Employee #2 Employee #2 was hired as the Director of Nursing on 03/28/2024. Employee #2's personnel record documented abuse training completed on 04/12/2024, one month late. Employee #9 Employee #9 was hired as a Licensed Practical Nurse on 09/07/2021. Employee #9's personnel record documented abuse training completed on 04/17/2023 and annual training completed on 12/17/2024, eight months late. Employee #13 Employee #13 was hired as a Registered Nurse on 11/06/2024. Employee #13's personnel record documented abuse training completed on 11/20/2024, 14 days late. On 12/18/2024 at 9:58 AM, the Payroll Human Resources employee explained abuse training was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review the facility failed to ensure physician ordered medications were administered to a resident during the morning (AM) medication pass on 08/02/2024, and administered timely during the AM medication pass on 08/01/2024, for 1 of 5 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic respiratory failure with hypoxia, and hypertensive heart disease with heart failure. On 08/08/2024 at 2:15 PM, Resident #5 verbalized the resident often received the resident's morning medications late. On 08/08/2024 at 2:49 PM, a Licensed Practical Nurse (LPN) verbalized the LPN often felt the LPN did not have adequate time to complete the LPN's assigned tasks each shift due to being shorthanded. The LPN explained the LPN often struggled to get residents' medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review and document review, the facility failed to develop care plans for 1) the placement of beds against the wall for 31 of 49 residents (Resident #37, #25, #42, #18, #7, #34, #28, #21, #38, #22, #1, #31, #32, #26, #2, #29, #153, #36, #3, #12, #13, #20, #27, #40, #45, #355, #19, #39, #47, #307, and #308), 2) the use of bed rails for 1 of 14 sampled residents (Resident #34), 3) the administration and monitoring of anticoagulant medications and diuretic medications for 1 of 14 sampled residents (Resident #39), and 4) the monitoring and care of a urinary catheter (catheter) and monitoring and treatment of lymphedema for 1 of 14 sampled residents (Resident #308). Findings include: Resident #37 Resident #37 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, subsequent encounter, enterococcus as the cause of diseases classified elsewhere, and muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personnel record review, interview and document review, the facility failed to ensure communications training was completed by staff for 20 of 20 sampled employees (Employee #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20). Findings include: Employee #1 Employee #1 was hired as the Administrator on 07/31/23. Employee #1's personnel record lacked documented evidence of communication training. Employee #2 Employee #2 was hired as the Director of Nursing (DON) on 07/07/20. Employee #2's personnel record lacked documented evidence of communication training. Employee #3 Employee #3 was hired as the Activity Manager on 09/28/20. Employee #3's personnel record lacked documented evidence of communication training. Employee #4 Employee #4 was hired as the Registered Dietician on 02/20/23. Employee #4's personnel record lacked documented evidence of communication training. Employee #5 Employee #5 was hired as the Assistant Social Worker on 08/22/23. Employee #5's personnel record lacked documented evidence of communication training.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and document review, the facility failed to ensure the privacy of residents' protected health information (PHI) was maintained for 1 of 14 sampled residents (Resident #27), and for 5 of 49 residents residing in the facility whose names were visible on an unstaffed and open computer screen (Resident #19, #26, #40, #355, and #103). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, and mental disorder, not otherwise specified. On 02/15/24 at 11:39 AM, a medication cart located in the facility's lobby had an open computer terminal screen displaying Resident #27's PHI including the resident's photograph, room number, age, date of birth , vital signs, and a list of the resident's medication. There were three residents in the lobby, a nurse could not be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) training had been completed to include objectives of resident care needs for 11 of 20 sampled employees (Employee #1, #4, #7, #11, #12, #13, #15, #16, #17, #18, and #20) Findings include: Employee #1 Employee #1 was hired as the Administrator on 07/31/23. Employee #1's personnel record lacked documented evidence QAPI training had been completed. Employee #4 Employee #4 was hired as the Registered Dietician on 02/20/23. Employee #4's personnel record lacked documented evidence QAPI training had been completed. Employee #7 Employee #7 was hired as a Certified Nursing Assistant (CNA) on 12/05/22. Employee #7's personnel record lacked documented evidence QAPI training had been completed. Employee #11 Employee #11 was hired as the Wound Care Nurse, Licensed Practical Nurse (LPN) on 01/18/12. Employee #11's personnel record lacked documented evidence QAPI training had been completed. Employee #12 Employee #12 was hired as the Infection Preventionist on 09/07/23. Employee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and document review the facility failed to obtain informed consent for a psychoactive medication prior to the administration of the medication for 1 of 14 sampled residents (Resident #12). Psychoactive medications Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE] and 08/11/23, with diagnoses including unspecified dementia, moderate, with mood disturbance, adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder, single episode, unspecified. A physician's order dated 01/09/24, documented buspirone hydrochloride (HCl) 5 milligrams (mg), give two tablets by mouth two times a day for anxiety. A physician's order dated 02/13/24, documented mirtazapine tablet 7.5 mg, give one tablet by mouth at bedtime for depression. An informed consent dated 07/17/23 documented consent for buspirone, with a dose of 5 mg and a frequency of two times a day was obtained. Resident #12's clinical record lacked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to ensure a call light was within reach for 1 of 14 sampled residents (Resident #308). Findings include: Resident #308 Resident #308 was admitted to the facility on [DATE], with diagnoses including displaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with routine healing, fall on same level, unspecified, subsequent encounter, morbid (severe) obesity with alveolar hypoventilation, lymphedema, not elsewhere classified, and chronic kidney disease, stage 3B. On 02/12/24 at 10:35AM, Resident #308 verbalized the resident was cold and needed to have padding placed under the residents left lower extremity to help ease discomfort. Resident #308 was sitting in a wheelchair in the resident's room. The resident's nightstand was approximately four feet behind the resident and the resident's call light button was draped across the nightstand with the call button resting behind the nightstand. Resident #308 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 observation, interview, clinical record review, and document review the facility failed to honor a resident's request for a room change for 1 of 14 sampled residents (Resident #35). Findings include: Resident #35 Resident #35 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On 02/12/24 at 9:38 AM, Resident #35 verbalized the resident would like a different room with more privacy. Resident #35 verbalized the room was cramped with too many people. The room had three residents residing in it. On 12/14/24 at 7:28 AM, Resident #35 reported the resident had last asked facility staff for a room change approximately one month prior. The resident verbalized feeling crowded and as if the roommates' personal items were encroaching on the resident's space. The resident explained the resident did not like staring at a roommate's underwear all day long. Incontience briefs belonging to 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 clinical record review, interview, and document review the facility failed to ensure written acknowledgement of the Advance Directive notice was provided to the resident or the resident's representative for 3 of 14 sampled residents (Resident #306, #12, and #305). Findings include: Resident # 306 Resident #306 was admitted to the facility on [DATE], with diagnoses including traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, subsequent encounter, and fall on same level, unspecified, subsequent encounter. on 02/12/24 at 3:22 PM, the Executive Director confirmed Resident #306's clinical record did not include a signed Advanced Directive Acknowledgement. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, age related physical debility, and adult failure to thrive. On 02/12/24 at 3:23 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 interview and clinical record review, and document review the facility failed to ensure a resident received a Notice of Medicare Non-Coverage (NOMNC) prior to dicharge for 1 of 3 unsampled residents (Resident #55). Findings include: Resident #55 Resident #55 was admitted to the facility on [DATE], with a diagnosis of acute respiratory failure with hypoxia. The clinical record for Resident #55 lacked documented evidence the resident or the resident's representative were provided a NOMNC prior to discharge from the facility. On 02/20/24 at approximately 11:15 AM, the Director of Nursing explained the social services department was responsible for and handled all beneficiary notices. On 02/20/24 at 11:48 AM, the Assistant Social Worker (ASW) verbalized a NOMNC was used to notify a resident when the resident no longer met criteria for skilled services and explain the resident's right to appeal the decision for discharge. The ASW explained the NOMNC was required to be provided no later than two days prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review and interview, the facility failed to report an allegation of abuse to the State Agency within the required timeframe for 1 of 14 sampled residents (Resident #153). Findings include: Resident #153 Resident #153 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral, psychotic or mood disturbance, generalized anxiety disorder, and major depressive disorder. An initial and final Facility Reported Incident (FRI) with a submission date of 01/04/24 at 4:03 PM, documented the facility had investigated an allegation of abuse of a resident by the resident's family member. The FRI documented the time of the alleged abuse was 01/03/24 at 4:15 PM. A Social Services Progress Note dated 01/03/24 at 4:57 PM, documented Resident #153 was found to have an abrasion to the right forearm. Only the resident's family members were present at the time Resident #153 obtained the abrasion. On 02/20/24 at 10:38 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure 1 of 14 sampled residents (Resident #30) and the Resident's Representative, received written notification of transfer or discharge. Findings include: Resident #30 Resident #30 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cognitive social or emotional deficit following cerebral infarction, and type II diabetes mellitus with diabetic chronic kidney disease. On 02/12/24 at 1:13 PM, Resident #30 verbalized the resident was transferred to the hospital on [DATE] due to an infection. The resident was not sure what type of infection the resident was hospitalized for. Resident #30's Minimum Data Set 3.0 (MDS) assessment documented the resident was discharged from the facility on 01/14/24 and readmitted on [DATE]. A change of condition/transfer note date 01/14/24, documented Resident #30 was transferred 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 observation, interview, clinical record review, and document review, the facility failed to ensure a physician's order for wound care, wound vacuum, and dialysis was transcribed onto the admission orders for 3 of 14 sampled residents (Resident #2, #403 and #404). Findings include: Resident #403 Resident #403 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including encounter for orthopedic aftercare following surgical amputation, encounter for change or removal of surgical wound dressing, acquired absence of left leg below knee. On 02/12/24 at 11:46 AM, Resident #403 verbalized having the resident's leg amputated on 02/07/24 and having a wound vacuum for the surgical site. The resident explained the wound vacuum was blinking orange and thought the wound vacuum's batteries needed to be changed. On 02/12/24 at 3:38 PM, Resident #403 verbalized thinking the wound nurse (WCN) was unsure about what to do with the wound vacuum and believed the wound vacuum was no longer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and document review, the facility failed to ensure a baseline care plan was developed to address the use of a wound vacuum for 1 of 14 sampled residents (Resident #403), oxygen therapy and dialisys for 1 of 14 sampled residents (Resident #404). Findings include: Resident #403 Resident #403 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of encounter for orthopedic aftercare following surgical amputation. Wound care On 02/12/24 at 11:46 AM, Resident #403 verbalized having the resident's leg amputated on 02/07/24 and having a wound vacuum for the surgical site. The resident explained the wound vacuum was blinking orange and thought the wound vacuum's batteries needed to be changed. On 02/12/24 at 3:38 PM, Resident #403 verbalized thinking the wound nurse (WCN) was unsure about what to do with the wound vacuum and believed the wound vacuum was no longer working. On 02/13/24 at 1:16 PM, Resident #403 verbalized the wound vacuum 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 observation, interview, clinical record review, and document review, the facility failed to update a plan of care after a resident was discharged from hospice for 1 of 14 sampled residents (Resident #34). Findings include: Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses including hereditary motor and sensory neuropathy, hyperlipidemia, unspecified, and muscle weakness (generalized). A physician's order dated 05/04/23, documented admit to facility on hospice services for aortic valve disorder. The order was discontinued on 07/20/23. Resident #34's care plans documented the following: -Self-Care Deficit as evidenced by needing assistance with Activities of Daily Living (ADL) related to cardiac disease. On hospice care related to end of life diagnosis. The care plan was last revised on 04/23/23. -The resident had hypertension related to a diagnosis of hypertension. On hospice related to end of life diagnosis. The care plan was last revised on 04/23/23. -The resident desires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review and document review, the facility failed to ensure services provided met professional standards of quality of care by admitting a resident for orthopedic aftercare following surgical amputation without wound treatment or monitoring orders, physician orders were followed for the administration of pain medication, and the Director of Nursing provided assistance to a resident dependent on staff for activities of daily living (ADLs) when the resident attempted to disrobe the resident's pants for 1 of 14 sampled residents (Resident #403). Resident #403 Resident #403 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of encounter for orthopedic aftercare following surgical amputation. Wound Treatment and Monitoring Orders On 02/12/24 at 11:46 AM, Resident #403 verbalized having the resident's leg amputated on 02/07/24 and having a wound vacuum for the surgical site. The resident explained the wound vacuum was blinking orange and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and document review, the facility failed to ensure the Director of Nursing provided assistance to a resident dependent on staff for activities of daily living (ADLs) when the resident attempted to disrobe the resident's pants for 1 of 14 sampled residents (Resident #403). Findings include: Resident #403 Resident #403 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of encounter for orthopedic aftercare following surgical amputation A care plan focus initiated 02/12/24, documented a focus on self-care deficits as evidenced by needs assistance with ADLs related to left below knee amputation, weakness, diabetes mellitus and pain with an intervention of one-person physical assist required for dressing. A task documentation survey report dated 02/14/24, documented Resident #403's lower body dressing ability as follows: -02/11/24 at 3:24 PM, 04-meaning supervision or touching assistance -02/12/24 at 1:46 PM, 01-meaning dependent -02/12/24 at 9:59 PM, 02-meaning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and interview, the facility failed to ensure a resident admitted for orthopedic aftercare following surgical amputation was not provided wound treatment without physician's orders and physician's orders for wound treatment, monitoring and a wound vacuum were obtained upon admission for 1 of 14 sampled residents (Resident #403). Findings include: Resident #403 Resident #403 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of encounter for orthopedic aftercare following surgical amputation. On 02/12/24 at 11:46 AM, Resident #403 verbalized having the resident's leg amputated on 02/07/24 and having a wound vacuum for the surgical site. The resident explained the wound vacuum was blinking orange and thought the wound vacuum's batteries needed to be changed. On 02/12/24 at 3:38 PM, Resident #403 verbalized thinking the wound nurse (WCN) was unsure about what to do with the wound vacuum and believed the wound vacuum was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, document review, and interview, the facility failed to ensure a resident with a pressure injury received the necessary treatment to prevent the deterioration and infection of the pressure injury for 1 of 14 sampled residents (Resident #2) and wound care was provided per physician order for 1 of 14 residents (Resident #45). Finding include: Resident #2 Resident #2 was admitted to the facility on [DATE], with a diagnosis of pressure ulcer of right buttock, unstageable. Resident #2's Care Plan dated 09/15/23, documented the resident had a wound to the right buttock. A Skin and Wound Evaluation dated 10/04/23, documented the resident had an unstageable pressure injury to the right gluteus upon admission and the wound had no evidence of infection. The wound dressing was saturated, and the wound progression was deteriorating. An Advantage Wound Care Progress Note dated 10/05/23, documented an initial consult for Resident #2's right buttock. The progress note documented the wound as 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 The facility failed to ensure medications were not left unsecured in a resident's room by allowing a resident to self-administer a medication and creating a potential accident by leaving a medication unsecured for 1 of 14 sampled residents (Resident #17). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including gastro-esophageal reflux disease without esophagitis and sepsis due to Escherichia coli (E. coli). A physician order dated 01/15/24, documented antacid oral tablet, chewable 500 milligram (mg), give 2 tablet by mouth every six hours as needed for indigestion. On 02/12/24 at 10:59 AM, a medicine cup containing one antacid oral tablet was located in Resident #17's room on the bedside table. Resident #17's room door was open and accessible to other residents, including Resident #17's roommate. On 02/12/24 at 11:02 AM, an LPN confirmed the medicine cup on Resident #17's bedside table contained one antacid tablet. The LPN confirmed nurses were not allowed 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 observation, interview, clinical record review, and document review, the facility failed to ensure residents with oxygen therapy were administered oxygen per the physician's order for 3 of 14 sampled residents (Resident #12, #355 and #404). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE] and 08/11/23, with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, and dependence on supplemental oxygen. A physician's order dated 05/04/23, documented oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuous every shift. Resident #12's care plan documented Resident #12 had shortness of breath (SOB) related to COPD and anxiety. Interventions included administering oxygen per provider orders. On 02/12/24 at 1:42 PM, Resident #12 was receiving oxygen via NC. The oxygen concentrator was set at 2 LPM. Resident #12 verbalized the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review the facility failed to ensure alternatives were attempted and entrapment risk was assessed prior to installation of bedrails for 2 of 14 sampled residents (Resident #34 and #355) and alternatives were attempted and documented as unsuccessful prior to the installation of a grab bar for 1 of 14 sampled residents (Resident #21). Findings include: Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses including hereditary motor and sensory neuropathy, hyperlipidemia, unspecified, and muscle weakness (generalized). On 02/12/24 at 10:13 AM, the resident's bed had two quarter size bed rails, one on each side of the bed. A physician's order dated 01/30/24, documented grab bar to right side of bed to promote independence in transfers and bed mobility. No directions specified for order. The resident's clinical record lacked documented evidence a completed assessment, informed consent was obtained, and if alternatives were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure a sufficient number of Licensed Nurses and Certified Nursing Assistants (CNAs) were scheduled to perform resident care according to the Facility Assessment for 2 of 2 shifts during the weekends in July, August and September of 2023. Findings include: The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated 07/01/23 through 09/30/23, documented the facility had excessively low weekend staffing. The Staffing Plan documented the facility staffing projections. The CNA schedule was maintained over two separate shifts; 6:00 AM-6:00 PM (first shift) projected 1:12 ratio of CNAs per residents and 6:00 PM-6:00 AM (second shift) projected a ratio of 1:16 ratio of CNAs per residents. On 02/15/24 at 8:21 AM, the Administrator explained the Staffing Plan was something that was created in January 2024 for staffing projections and there was not a Staffing Plan in place prior to January 2024. The Administrator verbalized not knowing an average census to base the number…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and document review the facility failed to ensure physician ordered medications were available and administered for 2 of 5 residents observed for medication administration (Resident #1 and #47) and 1 of 14 sampled residents (Resident #403). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. On 02/15/24 at 8:31 AM, a Licensed Practical Nurse (LPN) administered medications to Resident #1. The LPN explained one of the physician ordered medications, senna, was not available in the facility and was on order from the pharmacy. A physician's order dated 02/09/24 documented senna tablet 8.6 milligrams (mg), give two tablets by mouth every day and at bedtime for constipation. Resident #1's Medication Administration Record (MAR) documented senna 8.6 mg was not administered to Resident #1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate of less than five percent (%). There were 30 opportunities and three medication errors. The medication error rate was 10%. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. On 02/15/24 at 8:31 AM, a Licensed Practical Nurse (LPN) administered medications to Resident #1. The LPN explained one of the physician ordered medications, senna, was not available in the facility and was on order from the pharmacy. A physician's order dated 02/09/24, documented senna tablet 8.6 milligrams (mg), give two tablets by mouth every day and at bed time for constipation. Resident #1's Medication Administration Record (MAR) documented senna 8.6 mg was not administered to Resident #1 during the 9:00 AM med pass 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 clinical record review, document review, and interview, the facility failed to complete Medication Administration Records (MAR) for the administration of an anti-diabetic medication, and two antibiotic medications for 1 of 14 sampled residents (Resident #21). Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, unspecified, bi-polar disorder, unspecified, major depressive disorder, recurrent, unspecified, chronic kidney disease, stage three unspecified, and type II diabetes mellitus with diabetic neuropathy, unspecified. A physician's order dated 09/07/23, documented glipizide tablet, five milligrams (mg). Give one half tablet by mouth one time a day for diabetes. Resident #21's MAR dated September and October 2023 lacked documented evidence the medication had been administered per the physician's order on 09/09/23, 10/05/23, 10/20/23, 10/23/23, 10/26/23, 10/28/23, and 10/31/23. A physician's order dated 11/14/23, documented…

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

Based on observation, clinical record review, document review, and interview, the facility's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Committee failed to identify, develop and implement plans of action for systemic issues related to beds placed against the walls for 37 of 49 residents (Resident #21, #38, #22, #1, #31, #32, #26, #2, #29, #153, #36, #37, #25, #42, #18, #7, #34, #28, #19, #39, #47, #303, #305, #306, #307, #308, #3, #12, #13, #20, #27, #40, #45, #354, #355, #403, and #404), the use of enhanced barrier precautions, and wound care. Findings include: Beds Against the Wall On 02/14/24 at 4:21 PM, during a tour of the facility, Resident #21, #38, #22, #1, #31, #32, #26, #2, #29, #153, #36, #37, #25, #42, #18, #7, #34, #28, #19, #39, #47, #303, #305, #306, #307, #308, #3, #12, #13, #20, #27, #40, #45, #354, #355, #403, and #404's beds were against the wall. On 02/20/24 at 4:18 PM, the Executive Director verbalized the facility had not identified or developed a plan for resident beds against the wall. The Executive Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review and interview the facility failed to maintain the required Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members to include the Medical Director. Findings include: The QAPI Committee meeting attendee's sheets dated 10/27/23 and 11/22/23 lacked documented evidence the Medical Director had participated. On 02/20/24 at 4:14 PM, the Director of Nursing (DON), verbalized the facility did not hold a QAPI Committee meeting in December 2023. The DON confirmed the Medical Director had not participated in the QAPI Committee meetings held on 10/27/23 and 11/22/23. The DON confirmed the meetings for the last quarter of 2023 should have included the Medical Director or the Medical Director's designee. On 02/20/24 at 4:30 PM, the Executive Director verbalized it was difficult to get a hold of the Medical Director during the last months of 2023 and confirmed the Medical Director had not participated in the QAPI Committee meetings held on 10/27/23 or 11/22/23. The facility's Quality Assurance Performance Improvement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1) the facility's Infection Prevention and Control Plan (IPCP) was reviewed and/or updated annually to included current infection control standards and 2) a Licensed Practical Nurse (LPN) did not perform a finger stick/ blood sugar (FSBS) for one unsampled resident (Resident #19) while the resident was seated at a table in the community dining room. Findings include: Infection Prevention and Control Plan The facility policy titled Infection Prevention and Control Plan documented the IPCP was last reviewed on 10/19/22. The policy lacked documented evidence the policy was updated and/or reviewed at any time after 10/19/22. The policy failed to address the following infection prevention and control concerns: -The different types of transmission-based precautions (TBP) and how they should be utilized including personal protective equipment (PPE) selection, hand hygiene, and cohorting. -Environmental cleaning and disinfection including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review and interview, the facility failed to ensure the Antibiotic Stewardship Program (ASP) policy was reviewed and/or update annually with the potential to affect the facility's entire resident census of 49. The facility policy titled Antibiotic Stewardship Program (ASP), last reviewed 11/2017, lacked documented evidence the policy was reviewed and/or updated annually. The policy did not include the following items. -A process for trending and reporting staff and resident infections. -A process for communicating information at the time of transfer when a resident had an infection or was colonized. -A process for surveillance including outcomes such as SHEA's criteria. On 02/15/24 at 12:12 PM, the Director of Nursing (DON) confirmed the policy provided was the most current version of the policy and was last reviewed 11/2017. The DON confirmed the policy should have been reviewed annually. The facility policy titled Antibiotic Stewardship Program (ASP), last reviewed 11/2017, documented the ASP policy would be reviewed annually and as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #12) was screened for eligibility to receive an influenza vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined. Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, age related physical debility, and adult failure to thrive. Resident #12's clinical record lacked documented evidence the resident was screened in 2023 for eligibility to receive influenza vaccine, education regarding the vaccine was provided to Resident #12 and/or the resident's representative, and the vaccine was either administered or declined. Resident #12's state immunization…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, interview, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) was screened for eligibility to receive a COVID-19 (COVID) booster vaccine, education regarding the vaccine was provided, and the vaccine was offered and either administered or declined. Findings include: Employee #1 was hired as a CNA on 10/09/22. Employee #1's COVID-19 Vaccination Record Card documented Employee #1 was administered a COVID vaccine on 02/01/21 and 02/22/21. Employee #1's personnel record documented the CNA received a COVID vaccine on 02/21/21 and 02/22/21. The facility was not able to provide documented evidence Employee #1 was screened for eligibility to receive the most recent COVID vaccine, provided education regarding the vaccine, and if the vaccine was offered and administered or declined. The facility policy titled COVID-19 Vaccination Program, dated 08/2023, documented the facility maintained an immunization program against COVID-19 disease in accordance with national standards of practice, and offered COVID vaccinations approved…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personnel record review, interview, and document review the facility failed to ensure resident rights training was completed timely for 2 of 20 sampled employees (Employee #4 and #12). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 02/20/23. Employee #4's personnel record documented resident rights training was completed on 06/05/23. Employee #12 Employee #12 was hired as the Infection Preventionist on 09/07/23. Employee #12's personnel record documented resident rights training was completed on 09/14/23. On 02/20/24 at 2:34 PM, the Business Office Manager verbalized resident rights training was required for all staff one time, upon hire. The Business Office Manager confirmed Employees #4 and #12 did not complete resident rights training in time. The facility policy titled Resident Rights, dated 10/2022, documented the facility would ensure all direct care staff and indirect care staff members were educated on the rights of residents and the responsibility of the facility to properly care for its residents. The facility document titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personnel record review, interview, and document review, the facility failed to ensure elder abuse training was completed timely for 3 of 20 sampled employees (Employee #4, #9, and #30). Findings include: Employee #4 Employee #4 was hired as the Registered Dietitian with a start date of 02/20/23. Employee #4's personnel record documented elder abuse prevention training was completed on 06/05/23. Employee #9 Employee #9 was hired as a Certified Nursing Assistant with a start date of 05/30/18. Employee #9's personnel record lacked documented evidence elder abuse prevention training was completed for 2023. Employee #30 Employee #30 was hired as a Laundry Aide with a start date of 07/11/23. Employee #30's personnel record lacked documented evidence elder abuse prevention training was completed. On 02/14/24 at 2:23 PM, the Human Resources Payroll Clerk verbalized elder abuse training was to be completed in employee orientation and annually thereafter. The Payroll Clerk confirmed Employees #4, #9, and #30 lacked timely elder abuse prevention training. The facility policy titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to provide timely infection control training to all staff to ensure proper procedures and standards of the program for 3 of 20 sampled employees (Employee #4, #6, and #12). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 02/20/23. Employee #4's personnel record lacked documented evidence of infection control training for 2023. Employee #6 Employee #6 was hired as the Dietary Manager on 11/09/23. Employee #6's personnel record documented infection control training completed on 11/10/23, a day late. Employee #12 Employee #12 was hired as the Infection Preventionist on 09/07/23. Employee #12's personnel record documented infection control training completed on 09/14/23, seven days late. On 02/20/24 at 2:34 PM, the Business Office Manager verbalized all staff were required to complete infection control training upon hire. The Business Office Manager confirmed Employees #4, #6 and #12 did not complete infection control training timely. The facility policy titled Covenant Care Employee Training…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personnel record review, interview, and document review the facility failed to ensure compliance and ethics training was completed timely for 5 of 20 sampled employees (Employee #2, #3, #4, #9, and #20). Findings include: Employee #2 Employee #2 was hired as the Director of Nursing on 07/07/20. Employee #2's personnel record lacked documented evidence of compliance and ethics training. Employee #3 Employee #3 was hired as the Activity Manager on 09/28/20. Employee #3's personnel record documented compliance and ethics training was completed on 02/20/23. Employee #4 Employee #4 was hired as the Registered Dietician on 02/20/23. Employee #4's personnel record lacked documented evidence of compliance and ethics training. Employee #9 Employee #9 was hired as a Certified Nursing Assistant on 05/30/18. Employee #9's personnel record documented compliance and ethics training was completed on 04/09/19. Employee #20 Employee #20 was hired as a Housekeeper on 04/10/22. Employee #20's personnel record lacked documented evidence of compliance and ethics training. On 02/20/24 at 2:34…

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.

Based on personnel record review, interview, and document review the facility failed to ensure behavioral health training was completed for 7 of 20 sampled employees (Employee #1, #3, #4, #6, #10, #12, and #16). Findings include: Employee #1 Employee #1 was hired as the Executive Director on 07/31/23. Employee #1's personnel record lacked documented evidence of behavioral health care training. Employee #3 Employee #3 was hired as the Activity Manager on 09/28/20. Employee #3's personnel record lacked documented evidence of behavioral health care training. Employee #4 Employee #4 was hired as the Registered Dietician on 02/20/23. Employee #4 's personnel record lacked documented evidence of behavioral health care training. Employee #6 Employee #6 was hired as the Dietary Manager on 11/09/23. Employee #6's personnel record lacked documented evidence of behavioral health care training. Employee #10 Employee #10 was hired as the Minimum Data Set (MDS) Coordinator, Registered Nurse on 07/25/22. Employee #10's personnel record lacked documented evidence of behavioral health care training.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, interview and document review, the facility failed to protect a resident from being scratched and causing a resident to bleed and have multiple skin tears by another resident for 1 of 4 sampled residents (Resident #2). Findings include: FRI #NV00069451 documented on 09/16/23 a resident hit another resident for attempting to redirect a resident back to their room. Resident #1 Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified psychosis not due to a substance or known physiological condition, and other symptoms and signs involving cognitive functions following cerebral infarction. Resident #1's Care Plan last revised on 10/16/23, documented the resident had the potential to be physically aggressive related to dementia, history of harm to others and poor impulse control when provoked by another resident. Resident #2 Resident #2 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 observation, interview, clinical record review and document review, the facility failed to ensure residents were free from physical and verbal abuse for 1 of 5 sampled residents (Resident #1). Findings include: On 05/08/23, the facility submitted a facility reported incident (FRI) #NV00068536 initial report regarding a resident-to-resident altercation to the State Survey Agency. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including fibromyalgia, spondylolysis, lumbar region, and generalized anxiety disorder. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction and diabetes mellitus type two. A Situation, Background, Assessment, and Recommendation report (SBAR) documented on 05/08/23, Resident #1 was crying due to pain in the left arm and reported Resident #2 grabbed Resident #1's arm in anger and squeezed. An SBAR documented on 05/08/23, Resident #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.