Ormsby Post Acute Rehabilitation

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 care related to a gastrointestinal (GI) infection was coordinated between the facility and the resident's established GI physician for 1 of 19 sampled residents (Resident #44) and interventions were implemented, including administration of physician ordered medications, to address a resident's constipation for 1 of 19 sampled residents (Resident #97). This deficient practice had the potential to result in a resident not receiving timely treatment and suffering from complications of a prolonged parasitic infection in the resident's GI tract or fecal impaction. Findings include: Resident #44 Resident #44 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including gastrointestinal hemorrhage, unspecified and enterocolitis due to clostridium difficile, not specified as recurrent. A GI specialist consultation note, dated 12/15/2025, documented the resident would continue 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, record review, and document review, the facility failed to ensure a resident's report of pain was addressed with an intervention to reduce the pain level to the resident's acceptable level of pain for 1 of 19 sampled residents (Resident #2). This deficient practice had the potential to result in a resident experiencing prolonged pain at a level unacceptable to the resident causing the resident to experience diminished quality of life and emotional well-being.Findings include: Resident #2 Resident #2 admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified fracture of upper end of right humerus, sequela and unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing. On 05/11/2026 at 10:05 AM, Resident #2 verbalized the resident had pain in the resident's right leg. The resident verbalized the resident had a new pill but was unsure if it was working as the resident had continued pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents with trauma diagnoses were assessed by the facility to recognize and respond to the effects of the trauma and implementation of interventions for 2 of 19 sampled residents (Resident #12 and #88). This deficient practice had the potential to result in a resident experiencing re-traumatization due to the lack of assessments to recognize trauma-specific interventions.Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], with a diagnosis of post-traumatic stress disorder (PTSD), unspecified. Resident #12's Health and Physical dated 04/10/2026, documented a diagnosis of PTSD. The facility Physician Diagnoses Verification Summary signed on 04/27/2026, documented Resident #12 had a diagnosis of PTSD. Resident #12's Minimum Data Set (MDS) 3.0 admission summary dated [DATE], Section I - Active Diagnoses, documented the resident had a diagnosis of PTSD. 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.

Based on personnel record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) employed for more than one year had an annual performance review completed annually for 1 of 4 CNAs reviewed for completed performance reviews (Employee #9). This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of in-service education or training. Findings include:Employee #9Employee #9 was hired by the facility on 11/04/2025, as a CNA.Employee #9's personnel record documented a performance review completed on 11/14/2024.On 05/13/2026 at 2:46 PM, the Human Resource Coordinator (HRC) verbalized all CNAs were required to have a performance review completed by the CNAs anniversary date and confirmed Employee #9's performance review was completed 10 days late.On 05/14/2026 at 10:24 AM, the Administrator verbalized the facility did not have a policy related to CNA performance reviews; however, the facility followed all federal regulations.

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 1) a medication was not left on a resident's bedside table and unattended by authorized staff for 1 of 3 residents observed during medication administration (Resident #4) and 2) expired medications were removed from 1 of 2 medication storage rooms and 1 of 2 medication carts inspected for medication storage. This deficient practice had the potential to result in residents and staff without authorization to have unsupervised access to medications and for expired medications to be administered to residents.Findings include:Medication left unattendedResident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis of spinal stenosis, lumbar region with neurogenic claudication.An Order Summary Report for Resident #4 documented GlycoLax Powder (Polyethylene Glycol 3350), give 17 grams by mouth one time a day for constipation. The start date was 05/12/2026.On 05/13/2026 at 8:17 AM, a Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary recommendation was followed. This deficient practice had the potential to affect the resident's wellbeing and overall health.Findings include: On 05/13/2026 at 11:40 AM, during observation of the lunch tray line, a resident's diet ticket indicated a regular diet with no added salt. However, dietary staff placed two extra salt packets on the resident's tray. On 05/13/2026 at 11:45 AM, the dietary staff member confirmed the meal tray contained two salt packets. On 05/13/2026 at 12:00 PM, the Dietary Manager confirmed the resident's meal did not match the diet ticket and stated the ticket should have been followed to support resident health and comply with provider orders. A facility policy titled, Therapeutic Diet Orders, implemented 04/11/2025, documented the facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review the facility failed 1) to prepare food as required for residents on a physician ordered therapeutic diet, 2) to ensure a resident received a minced and moist diet as ordered and failed to prepare or serve meals in a form that met the resident's need for 1 of 19 sampled residents (Resident # 3). This deficient practice had the potential for reduced meal intake due to not following the prescribed diet order, and increased the risk of difficulty swallowing, which could lead to choking and/or aspiration.Findings include:On 05/13/2026 at 11:40 AM, during an observation of lunch tray line, dietary staff served a whole chicken breast, green peas, and cornbread to three residents with a meal ticket indicating a minced and moist diet. The Dietician approved menu for 05/13/2026 documented minced and moist level five diet (MM5) was to include baked chicken, garlic mashed potatoes, sliced carrots, soaked cornbread, margarine, vanilla pudding, and…

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

Based on observation, interview, and document review, the facility failed to ensure the outside garbage receptacles were sealed (lid closed) and free of debris on the surrounding pavement. This deficient practice had the potential to affect all residents in the facility by increasing the risk of pest and foodborne illnesses.Findings include: On 05/11/2026 at 9:22 AM, two dumpsters were located at the back of the facility. One dumpster had an open lid with exposed trash, and the second dumpster had trash on the ground around it, including gloves, cans, and paper. On 05/11/2026 at 9:30 AM, the Dietary Supervisor explained it was important to keep the dumpster area clean and the lids closed to prevent animals and pests. A facility policy titled, Disposal of Garbage and Refuse, implemented 04/08/2026, documented refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be covered when not being loaded. Surrounding areas shall be kept clean to minimize the accumulation of…

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

Based on document review and interview, the facility failed to update the facility assessment following a change in the medical provider group. This deficient practice had the potential to result in the facility assessment not accurately reflecting the current medical provider or clinical responsibilities of the newly contracted medical provider group providing necessary services to residents. Findings include: The facility's assessment updated 03/19/2026, documented a third-party vendor as the primary medical practitioners providing care to residents. The assessment documented the facility would review and update the facility assessment whenever changes required modifications to any part of the assessment. On 05/13/2026 at 12:33 PM, the Administrator confirmed the facility had recently changed the contracted medical group and provider as of 03/11/2026, and the third-party vendor was no longer the contracted medical provider group for the facility. The Administrator verbalized having been responsible for updating the facility assessment but had missed updating the change of provider…

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

Based on interview and document review, the facility failed to designate a member of the facility's interdisciplinary team responsible for coordinating the care of residents receiving hospice services. This deficient practice had the potential to result in uncoordinated care and a lack of communication between the facility and the hospice providers, delays of resident care, inadequate monitoring, and an increased risk of unmet physical, emotional, and psychosocial needs for residents receiving hospice services.Findings include: On 05/12/2026 at 12:57 PM, the Assistant Director of Nursing (ADON) verbalized the ADON was not the facility's hospice coordinator and was unaware who was responsible as the facility's hospice coordinator. On 05/12/2026 at 2:00 PM, the Administrator confirmed having been aware of the requirement for the facility to have a hospice coordinator, but the facility did not currently have a hospice coordinator. The Administrator verbalized hospice services were coordinated as a team effort with several facility staff but the oversite of hospice care to residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and address system-level issues related to 1) the facility's lack of a designated hospice coordinator, and 2) concerns related to the personnel training requirements on abuse, cardiopulmonary resuscitation (CPR) and first-aid certifications. This deficient practice had the potential to prevent the QAPI committee from implementing an ongoing, data driven process to monitor performance concerns and develop corrective actions, limiting the facility's ability to recognize patterns, prevent recurrence of problems, and ensure sustained improvement in resident care and facility operations related to employee requirements.Findings include: Hospice Coordinator On [DATE] at 2:52 PM, the Administrator confirmed the facility did not have a designated hospice coordinator. The Administrator verbalized the lack of a hospice coordinator was a concern the facility would be addressing, but had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and interview, the facility failed to provide the Quality Assurance and Performance Improvement (QAPI) committee member signature attendance sheets for the second, third, and fourth quarters of 2025. This deficient practice had the potential to result in the facility's failure to demonstrate the required QAPI committee members had participated in the quarterly meetings as required.Findings include: On 05/14/2026 at 2:30 PM, the Administrator verbalized not having access to the monthly QAPI meetings attendees list from April 2025 to [DATE], due to the change of ownership of the facility having taken place in January 2026. The Administrator could not confirm which committee members had participated in or attended the meetings during those months. The facility's QAPI Facility Plan, dated April 2026, documented the committee shall maintain written documentation of the meetings attendance records.

Based on observation, interview and document review, the facility failed to maintain the ice machine in good repair. This deficient practice had the potential to result in contamination of the ice and affect resident safety. Findings include:On 05/11/2026 at 8:30 AM, the kitchen ice machine had white mineral deposits on its exterior surfaces and door, and similar deposits were present on the ground surrounding the machine. On 05/11/2026 at 8:36 AM, the Dietary Supervisor confirmed the ice machine should have been cleaned and maintenance and kitchen staff were responsible for the task. The Dietary Supervisor further stated keeping the ice machine clean was necessary to prevent residents from becoming ill. A facility policy titled, Sanitation Inspection, Implemented 12/22/2025, documented all food service areas shall be kept clean and sanitary.

Based on personnel record review and interview, the facility failed to ensure elder abuse prevention training was completed timely for 6 of 20 sampled employees (Employee #2, #3, #16, #17, #18, and #19). This deficient practice had the potential to place all residents at risk for abuse and neglect.Findings include:Employee #2Employee #2 was hired by the facility on 12/30/2025, as the Director of Nursing.Employee #2's personnel record documented initial elder abuse training completed on 02/16/2026.Employee #3Employee #3 was hired by the facility on 09/15/2025, as the Assistant Director of Nursing/Infection Preventionist.Employee #3's personnel record documented initial elder abuse training completed on 02/06/2026.Employee #16Employee #16 was hired by the facility on 01/30/2026, as a Registered Nurse (RN).Employee #16's personnel record documented initial elder abuse training completed on 02/13/2026.Employee #17Employee #17 was hired by the facility on 01/30/2026, as an RN.Employee #17's personnel record documented initial elder abuse training completed on 02/12/2026.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 clinical record review, interviews and document review, the facility failed to protect a resident's right to be free from neglect when licensed nurses failed to notify the physician of a diabetic resident's multiple episodes of hypoglycemia (low blood glucose) and when a Registered Nurse (RN) administered oral glucose gel, not in accordance with physician orders, to an unresponsive resident experiencing severe hypoglycemia for 1 of 14 sampled residents (Resident #8). This deficient practice had the potential to result in lack of necessary adjustments to the resident's medication orders and plan of care and for additional episodes of hypoglycemia to occur placing the resident at risk for organ damage, coma, and death.Findings include:Resident #8Resident #8 was admitted to the facility on [DATE], with diagnoses including type one diabetes mellitus with other circulatory complications and type one diabetes mellitus with diabetic autonomic (poly) neuropathy.A final Facility Reported Incident (FRI) report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document review, the facility failed to provide documented evidence the facility conducted a thorough investigation of an incident suspicious for neglect of 1 of __ sampled residents (Resident #8). This deficient practice had the potential for ongoing physical and/or psychosocial harm to residents due to allegations of neglect not being thoroughly investigated and documented to ensure appropriate protections were put in place to prevent future neglect. Findings include:Resident #8Resident #8 was admitted to the facility on [DATE], with diagnoses including type one diabetes mellitus with other circulatory complications and type one diabetes mellitus with diabetic autonomic (poly) neuropathy.A final Facility Reported Incident (FRI) report submitted by the facility on [DATE], documented the report was related to an incident on [DATE] involving Resident #8. The incident type was neglect and the allegation against the alleged perpetrator was verified. A Certified Nursing Assistant (CNA) found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain cooking temperatures and holding temperatures of chicken prior to plating the chicken to serve to residents for lunch service. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include: On 03/26/2025 at 11:30 AM, dietary staff had removed three large trays of chicken breasts from the oven. The chicken was transferred to a holding tray and placed in the steam table. The chicken was then placed on a plate and ready to be placed in a steam cart to deliver to residents. The Dietary Aide failed to obtain cooking temperatures and holding temperatures prior to plating the chicken to serve to residents. On 03/26/2025 at 11:46 AM, the Dietary Manager confirmed temperatures were not taken nor documented for the chicken prior to placing the chicken on plates to serve to residents. The Dietary Manager verbalized the chicken temperatures were taken while the chicken was cooking, however the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review, and interview, the facility failed to ensure the coordination of hospice care between the facility and hospice agencies and ensure the activities and services detailed in the hospice agency's care plan were provided to residents, documented by the hospice agency and received by the facility for 3 of 6 residents on hospice services (Resident #230, #50, and #4). The deficient practice had the potential to compromise the overall quality of hospice care due to the lack of coordination between the facility and hospice agencies and had the potential to jeopardize the health and safety of residents under hospice care in the facility. Findings include: Resident #230 Resident #230 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, chronic diastolic (congestive) heart failure, severe protein calorie malnutrition, paroxysmal atrial fibrillation, and adult failure to thrive. Resident #230 was admitted by the hospice agency to hospice care in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the proper Medicare Notice of Medicare Non-Coverage letter was completed and provided for 2 of 3 unsampled residents selected for beneficiary notification review. The deficient practice resulted in non-compliance with Medicare requirements, that could hinder the resident's ability to make informed decisions regarding their coverage and care. Findings include: Resident #231 Resident #231 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including primary generalized osteoarthritis, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease, unspecified. Resident #231 was discharged home on [DATE]. Resident #231's clinical record lacked documented evidence the Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-coverage Form (NOMNC) was provided to the resident or the resident's representative. On 03/26/2025 at 1:35 PM, the Business Office Manager (BOM) confirmed the BOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 4 of 10 months, starting June 2024. The deficient practice had the potential to impact resident care by delaying the resident care plan. Findings include: Jun 2024: 10.3% of admission assessments were completed late (11 of 107) [DATE]: 12.5% of assessments were completed late (8 of 64) 14.5% of admission assessments were completed late (9 of 64) [DATE]: 13.5% of assessments were completed late (12 of 89) [DATE]: 11.9% of assessments were completed late (7 of 59) On 03/27/2025 at 7:19 AM, the Executive Director (ED) verbalized the MDS Coordinator was responsible to submit the MDS assessments for the facility and confirmed the facility had filed the aforementioned MDS assessments late. The ED verbalized the facility had a change in MDS Coordinators which attributed to the late filings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and document review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 19 sampled residents (Resident #4) and 1 of 3 residents sampled for closed records (Resident #79). This deficient practice had the potential to deprive residents of necessary care and services relative to current health management needs in the facility and upon discharge home. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other specified spondylopathies, lumbar region and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Hospice Plan of Care for certification period 01/08/2025 through 03/18/2025, documented Resident #4 was receiving hospice services. A quarterly MDS assessment dated [DATE], Section O - Special Treatments, Procedures, and Programs included instructions to check all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a person-centered Comprehensive Care Plan for the use of insulin, for 1 of 19 sampled residents (Resident #32). This deficient practice had the potential to result in residents not receiving care and services to meet their needs related to the use of insulin. Findings include: Resident #32 Resident #32 was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes mellitus. A physician's order dated 10/20/2024, documented HumaLOG Injection Solution 100 unit/milliliter (ml), inject 10 units subcutaneously with meals for type 2 diabetes mellitus. A physician's order dated 08/26/2024, documented Insulin Glargine Solution 100 unit/ml, inject 56 unit subcutaneously two times a day for type 2 diabetes mellitus with diabetic polyneuropathy. Resident #32's Medication Administration Record (MAR) dated March 2025, documented the administration of HumaLOG Injection Solution, and Insulin Glargine Solution as per the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for 1 of 19 sampled residents (Resident #32). The deficient practices had the potential to cause residents to use an unnecessary medication with possible adverse effects. Findings include: Resident #32 Resident #32 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses including major depressive disorder, recurrent, unspecified, and generalized anxiety disorder. Resident #32's psychotropic physician's order documented the following; -Buspirone Hydrochloride (HCL) tablet 5 milligram (mg), give 5 mg by mouth three times a day for anxiety as evidence by hyper verbalization, ordered 12/17/2024. -Clonazepam tablet 1 mg, give 1 mg by mouth three times a day for anxiety, ordered 03/13/2025. -Duloxetine HCl capsule delayed release particles 60 mg, give 60 mg by mouth two times…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) temperatures were monitored and recorded on each shift for 1 of 4 medication storage refrigerators, 2) medications were not stored with food items in 1 of 4 medication storage refrigerators, 3) a multi-dose vial was discarded within 28 days of opening, and 4) a medication cart was not left unsecured and unattended. The deficient practices had the potential to contaminate medication with food products, compromise medication integrity by not maintaining and recording the daily refrigerator temperatures between 36-46 degrees Fahrenheit (F), place the residents and staff at risk of receiving expired/outdated vaccines, and to allow unauthorized access to medications on the medication cart in the 200 Hallway. Findings include: Medication Storage On 03/24/2025, during a review of the Staff Development Coordinator (SDC) office medication storage refrigerator, the following items were found: -two mozzarella…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facing a public area and a clinical record was complete for 1 of 19 sampled residents (Resident #8). This deficient practice had the potential for unauthorized access to residents' protected health information and for care provided to residents, resident response to care provided, and refusals of care to not be documented and available for review as necessary. Findings include: On 03/24/2025 at 7:22 AM, a computer screen on a medication cart in the 200 hallway displayed medication information for a resident. On 03/24/2025 at 7:23 AM, a Registered Nurse (RN) returned to the medication cart. The RN confirmed the computer displayed resident information and verbalized when walking away from a medication cart. The RN explained the process was to always ensure the cart was locked and the computer screen was locked to prevent access 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.

Based on observation, interview, and document review, the facility failed to document facility training and competencies required for a Registered Nurse (RN) to provide resident care (Employee #22). The deficient practice had the potential to negatively affect resident quality of life and/or jeopardize resident safety when training competencies and orientation were not met prior to providing resident care. Findings include: Employee #22 Employee #22 was employed as an agency Registered Nurse by the facility starting 03/08/2025. A facility document dated 03/08/2025, documented Employee #22 worked an overnight shift at the facility from 5:55 PM on 03/08/2025, until 6:15 AM on 03/09/2025. On 03/27/2025 at 7:39 AM, the Staff Development Coordinator (SDC) confirmed all new nurses were required to complete an orientation packet, which included training competencies, prior to working on the nursing unit. The SDC explained the SDC was the weekend manager when Employee #22 worked on 03/08/2025, and had taken report of Employee #22 being overwhelmed and had not administered medication to 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 Verbal abuse A FRI submitted 06/23/2024, documented LPN1 was responding to a call light by Resident #3, and while providing care, LPN1 began yelling at the resident. Yelling was heard by other staff in the facility. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute reversible ischemia of large intestine, extent unspecified. On 09/18/2024 at 12:19 PM, Resident #3 explained on the date of the incident, Resident #3 turned on the call light after having had a bowel movement. Resident #3 explained the LPN came to answer the call light, but the LPN had an ear plug in and was talking with someone on the phone. The LPN undid the resident's briefs and turned the resident on the left side. The LPN left the room and after 20 minutes, Resident #3 began calling out for help. Resident #3 explained when LPN1 returned, LPN1 told the resident LPN1 went to get a CNA because LPN1 was too busy to help the resident. Resident #3 told LPN1 if LPN1 wasn't 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 interview, clinical record review, and document review, the facility failed to ensure a resident's insulin was not self-administered by a staff member for 1 of 12 sampled residents (Resident #2). This deficient practice had the potential to result in a resident not having an adequate amount of insulin available to treat the diagnosed condition for which the medication was prescribed. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type I diabetes mellitus with diabetic polyneuropathy, type I diabetes mellitus with unspecified diabetic retinopathy without macular edema, and type I diabetes mellitus with hypoglycemia without coma. A Facility Reported Incident (FRI), documented on 08/05/2024 a Licensed Practical Nurse (LPN) had witnessed another nurse administering Resident #2's insulin for the nurse's personal use. An Order Review Report for Resident #2, documented the resident had an order for Humalog injection solution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards for prescribing medications were followed by a practitioner for 1 of 12 sampled residents (Resident #1). This deficient practice had the potential to result in a resident suffering an adverse health outcome from receiving medications for diagnoses the resident did not have. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including metabolic encephalopathy, acquired absence of right leg above knee, and sequelae of protein-calorie malnutrition. A Facility Reported Incident (FRI), dated 06/10/2024, documented Resident #1 was readmitted from the hospital on [DATE]. The admitting nurse input medication orders for Resident #1 from another resident's hospital discharge summary. The resident received the incorrect medications for three days before the error was discovered and reported. The resident was sent to the Emergency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident was not administered medications without a diagnosis related to the indication for the use of the medications for 1 of 12 sampled residents (Resident #1). This deficient practice resulted in a resident requiring hospitalization to monitor for adverse side effects of the unnecessary medications. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including metabolic encephalopathy, acquired absence of right leg above knee, and sequelae of protein-calorie malnutrition. A Facility Reported Incident (FRI), dated 06/10/2024, documented Resident #1 was readmitted from the hospital on [DATE]. The admitting nurse input medication orders for Resident #1 from another resident's hospital discharge summary. The resident received the incorrect medications for three days before the error was discovered and reported. The resident was sent to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the Infection Preventionist (IP) had the skills necessary to review lab results to determine the appropriateness of implementing transmission-based precautions (TBP) 2) a nurse administering medications had completed a competency for medication administration. This deficient practice could lead to residents not being placed on transmission-based precautions when necessary, causing other residents to be exposed to communicable diseases and residents not receiving medications as prescribed, creating increased potential for adverse medication reactions 3) the Infection Preventionist (IP) had the knowledge necessary to ensure the appropriate selection and administration of pneumococcal vaccines resulting in residents not being offered the pneumococcal vaccines recommended for the resident by the Centers for Disease Control and prevention (CDC), and 4) the IP had the knowledge needed to correctly complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food preparation counters were kept clear of personal items with the potential to cross contaminate food for the facility census; and failed to ensure staff performed hand hygiene while serving meal trays to residents. Findings include: Personal Items On 05/19/2024 at 10:09 AM, a personal beverage from a fast food restaurant and personal bag was located on a counter with plate holders stacked next to the items. The Dietary Aide verbalized it was not a food prep counter and it was okay to have personal items there. The Dietary Aide confirmed the stacked plate holders were clean. The Dietary Aide pointed at a second counter against the wall and verbalized it was the food prep counter. On 05/19/2024 at 10:10 AM, the second food prep counter had one charging cord on the counter and one charging cord hanging from the wall with the cord laying on the counter. The Dietary Aide confirmed the cords were present and were not supposed to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to demonstrate effective and knowledgeable administration by not ensuring an allegation of sexual abuse was thoroughly investigated and an alleged perpetrator of sexual abuse was not allowed to continue to work in the facility until an investigation was completed (see tag F610), 2) the Infection Preventionist (IP) had the skills and knowledge necessary to accurately monitor and track infections and antibiotic use. The IP's failure to consistently track infections and antibiotic use from the onset of the infection through to the resolution of the infection had the potential to result in residents developing infections with Multi Drug Resistant Organisms (MDRO). Further potential to spread infections with MDROs througout the facility's entire resident census of 89; and 3) and the IP had the skills and knowledge necessary to correctly identifiy the pneumococcal vaccines residents were eligble to receive. The IP's lack of understanding related to screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Quality Assurance and Performance Improvement (QAPI) committee failed to identify 1) concerns related to the identification for the need of Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP), 2) an Advanced Practice Registered Nurse (APRN) signed documentation with the credentials of Medical Doctor, 3) a lack of thorough investigation related to resident abuse, 4) the lack of an effective process for tracking and reconciling narcotic medications, including hospice medications, 5) the facility lacked a designated Hospice Coordinator, and 6) concerns related to screening and offering pneumococcal vaccines. Findings include: Transmission Based Precautions On 05/28/24 at 4:31 PM, the Director of Nursing Services (DNS) confirmed the QAPI committee had not identified concerns related to TBP, including EBP. The DNS explained the QAPI committee could have identified the concern by conducting an audit for EBP as a new requirement which would have led to the identification of the need for a 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 document review and interview, the facility failed to ensure 1) the facility's form titled Line Listing for Infections by Resident, (Line Listing Report) completed by the Infection Preventionist (IP) included the necessary elements the IP needed for tracking infections and antibiotic use, 2) the IP accurately documented on the Line Listing for Infections form each month and included 10 of 31 residents prescribed antibiotics for infections from 01/01/2024 - 05/23/2024, on the form (Resident #5, #24, #71, #62, #54, #60, #9, #69, #72, and #66) with the potential to affect the facility's entire resident census of 89, and 3) staff and residents received education related to antibiotic use and the Antibiotic Stewardship Program (ASP). Findings include: Line Listing for Infections Form: The facility form titled Line Listings for Infections by Resident, included the following areas for documentation: -Resident name and age, -Resident room number, unit, and date of admission, -Date of infection (onset) -Site of…

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

Based on interview and document review, the facility failed to ensure compliance and ethics training was completed timely for 15 of 20 sampled employees (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #14, #16, #18, #19 and #20). Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented compliance and ethics training completed on 04/26/2024, 27 days after hire. Employee #2 Employee #2 was hired as the Director of Nursing (DON) on 11/01/2021. Employee #2's personnel record documented the last compliance and ethics training was completed on 04/24/2024. The employee's record lacked documented evidence compliance and ethics training had been completed for 2023. Employee #3 Employee #3 was hired as the Activities Director on 03/06/2023. Employee #3's personnel record documented the last compliance and ethics training was completed on 04/09/2024. The employee's record lacked documented evidence compliance and ethics training had been completed for 2023. Employee #4 Employee #4 was hired as the Dietary Manager on 06/15/21. Employee #4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure resident's medications were not left, unsecured, at a resident's bedside for 2 of 19 sampled residents (Residents #5 and #339), medicated powders were not applied by unlicensed staff for 1 of 19 sampled residents (Residents #5) and medications were not left unsecured on a medication cart while a Certified Nursing Assistant (CNA) was watching the cart. This deficient practice had the potential for a resident to administer medication at a dose not prescribed creating increased potential for adverse medication reactions and for a resident to not receive necessary monitoring and assessment for the application of medicated powders. Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including repeated falls, difficulty in walking, not elsewhere classified, and other abnormalities of gait and mobility. On 05/20/2024 at 9:05 AM, the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) medications were not left unsecured on a medication cart while a Certified Nursing Assistant (CNA) was to watch the medication cart, 2) medications were stored according to manufacturer guidelines, 3) discontinued medications were removed from a medication cart, and 4) medications were labeled. Unsecured Medication On [DATE] at 10:07 AM, upon entry into the Brookside nursing station, the medication cart parked on the outside of the nursing station was seen with greater than 20 over the counter plastic bottles with pills in the bottles sitting on top of medication cart. A CNA was at the nursing station watching the medications. The CNA left as soon as the nurse came out of the restroom. On [DATE] at 10:21 AM, the CNA verbalized watching the medications on top of the medication cart while the nurse used the restroom. The CNA explained having been asked by the nurse to watch the medication cart 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 interview, clinical record review, and document review the facility failed to ensure 1) 2 of 5 residents sampled for influenza vaccinations (Residents #62 and #9) were 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, and 2) 7 of 16 residents eligible to receive a pneumococcal vaccine (Residents #9, #80, #85, #77, #23, and #242) were screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the indicated pneumococcal vaccine was offered and either administered or declined. Findings include: Influenza Vaccines Resident #62 Resident #62 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, moderate, with psychotic disturbance, chronic combined systolic (congestive) and diastolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by staff for 9 of 20 sampled employees (Employee #1, #6, #9, #11, #14, #16, #18, #19 and #20). Findings include: Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented resident rights training completed on 05/17/2024, 48 days after hire. Employee #6 Employee #6 was hired as the Food and Nutrition Services Manager on 06/15/2021. Employee #6's personnel record documented resident rights training completed 05/02/2024, however lacked documented evidence resident rights was completed in 2023. Employee #9 Employee #9 was hired as a Certified Nursing Assistant (CNA) on 04/04/2018. Employee #9's personnel record documented resident rights training completed 05/01/2024, however lacked documented evidence resident rights training was completed in 2023. Employee #11 Employee #11 was hired as a Certified Occupational Therapist on 10/01/2023. Employee #11's personnel record lacked documented evidence of…

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

Based on 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 15 of 20 sampled employees (Employee #1, #2, #4, #5, #6, #7, #9, #10, #11, #12, #14, #16, #18, #19 and #20). Findings include: Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented QAPI training completed on 05/24/2024, 55 days after hire. Employee #2 Employee #2 was hired as the Director of Nursing Services on 11/01/2021. Employee #2's personnel record documented the last QAPI training was completed on 05/24/2024. The employee's record lacked documented evidence QAPI training had been completed for 2023. Employee #4 Employee #4 was hired as the Dietary Manager on 06/15/21. Employee #4's personnel record documented QAPI training last completed on 05/24/2024. The employee's personnel record lacked documented evidence QAPI training was completed for 2023. Employee #5 Employee #5 was hired as the Social Services Director on 05/01/2024.…

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.

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 7 of 20 sampled employees (#1, #9, #11, #14, #16, #18 and #19). Findings include: Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented infection control training completed on 05/17/2024, 48 days after hire. Employee #9 Employee #9 was hired as a Certified Nursing Assistant (CNA) on 04/04/2018. Employee #9's personnel record documented infection control training completed 05/01/2024, however lacked documented evidence infection control training was completed in 2023. Employee #11 Employee #11 was hired as a Certified Occupational Therapist on 10/01/2023. Employee #11's personnel record documented infection control training completed 04/07/2024, however lacked documented evidence infection control training was completed in 2023. Employee #14 Employee #14 was hired as a Licensed Practical Nurse (LPN) on 09/01/2023. Employee #14's personnel record…

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

Based on interview and document review, the facility failed to ensure behavioral health training was completed timely for 10 of 20 sampled employees (Employee #1, #4, #5, #9, #10, #11, #14, #16, #19 and #20). Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented behavioral health training completed on 05/24/2024, 55 days after hire. Employee #4 Employee #4 was hired as the Dietary Manager on 06/15/21. Employee #4's personnel record documented the last behavioral health training was completed on 05/24/2024. The employee's record lacked documented evidence behavioral health training had been completed for 2023. Employee #5 Employee #5 was hired as the Social Services Director on 05/01/2024. Employee #5's personnel record documented behavioral health training completed on 05/27/2024, 26 days after hire. Employee #6 Employee #6 was hired as the Food and Nutrition Services Manager on 06/15/2021. Employee #6's personnel record documented the last behavioral health training was completed on 05/25/2024. The employee's 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 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 3 of 19 sampled residents (Resident #23, #28 and #66). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with acute exacerbation, major depressive disorder, single episode, unspecified and anxiety disorder, unspecified. Resident #23's Order Summary Report, with active orders as of 05/21/2024, documented the following: -Hydroxyzine Hydrochloride (HCl) oral tablet 25 milligrams (mg), give 25 mg by mouth two times a day for anxiety. -Duloxetine HCl oral capsule delayed release particles 60 mg, give 60 mg by mouth one time a day for depression. -Melatonin oral tablet 3 mg, give 9 mg by mouth one time a day for circadian rhythm regulation. Resident #23's Medication Administration Record (MAR) for April 2024, documented the following:…

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

Based on observation and interview, the facility failed to ensure the current menu was posted, allowing residents to review and request an alternative if preferred. Findings include: On 05/19/2024 at 10:27 AM, the menu for breakfast, lunch and dinner posted in the dining room near the Brookside Unit was dated for Friday 05/17/2024. On 05/19/2024 at 10:57 AM, the breakfast, lunch, and dinner menus posted on the menu board near the Classics Unit entry way was dated for Friday 05/17/2024. On 05/19/2024 at 10:02 AM, the menu for breakfast, lunch and dinner posted in the Advantage Unit was dated for 05/17/2024. On 05/20/2024 at 10:53 AM, the Nutritional Services Supervisor confirmed the menu posted on 05/19/2024 in the Advantage Unit was for 05/17/2024. The Nutritional Services Supervisor verbalized the current days menu should have been posted before breakfast was served. The Nutritional Services Supervisor verbalized having provided verbal instructions to have the menu changed but was not. The Nutritional Services Supervisor verbalized not having a policy on menu postings and had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review, the facility failed to ensure a resident was protected from employee-to-resident verbal abuse for 1 of 19 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including rheumatoid arthritis, unspecified, other specified functional intestinal disorders, and chronic kidney disease, stage 3. FRI #NV00070798 documented on 03/26/2024, Resident #3 reported to a Certified Nursing Assistant (CNA), being very upset following the care the nurse provided to the resident's urostomy. Resident #3 alleged the nurse was verbally aggressive and made the resident feel like an inconvenience when trying to inform the nurse of the resident's preferences. The nurse responded to Resident #3 stating I know what I'm doing, was there anything else you needed to tell me I already know?. Resident #3 further alleged the nurse verbalized I will not change your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, document review, and interview the facility failed to prevent the misappropriation of funds for 1 of 3 residents reviewed for closed records (Resident #52). Findings Include: Resident #52 Resident #52 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to embolism of left middle cerebral artery, major depressive disorder, recurrent, unspecified, and hypertensive urgency. A Facility Reported Incident (FRI) report dated 05/10/2024, documented on 05/09/2024, Resident #52 was discharged to another facility on hospice. After arriving at the new facility it was discovered the resident's wallet, containing a credit card, was missing and someone was using the credit card. The resident's family notified the facility of the missing wallet and credit card and expressed they had been taken by a staff member at the facility prior to discharge. An incident timeline, dated 05/09/2024, provided by the facility, documented Resident #52's family reported the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure a potential incidence of misappropriation of a resident's prescribed narcotic pain medication was reported for misappropriation of property for 1 of 2 residents reviewed for potential narcotic diversion (Resident #44). This deficient practice could lead to undetected narcotic diversion from residents causing increased pain and diminished quality of life. Findings include: Resident #44 Resident #44 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, and aphasia. On 05/22/2024 at 2:25 PM, a Registered Nurse (RN) from a contracted hospice agency verbalized the hospice had to replace a bottle of liquid Morphine for Resident #44 on 05/21/2024. The RN explained the bottle appeared to have been tampered with, the medication was discolored, and there was 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, record review, and document review the facility failed to provide the required documentation for discharge when a resident was transferred to an acute care hospital for 1 of 9 residents reviewed for Facility Reported Incidents and Complaint investigations (Resident #77). Findings include: Resident #77 Resident #77 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and acute and chronic respiratory failure with hypoxia. A diagnosis of personal history of methicillin resistant staphylococcus aureus (MRSA) infection was added on 05/01/2024. A Discharge summary dated [DATE], from the sending facility documented Resident #77 had extended-spectrum beta-lactamase (ESBL) in the resident's urine and MRSA in the resident's sputum resulted on 02/23/2024, a course of antibiotics was completed. A Daily Skilled Nursing Note dated 04/27/2024, documented Resident #77 had a percutaneous endoscopic gastrostomy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a person-centered Comprehensive Care Plan for 1) the use of insulin, and include the correct diagnosis for 1 of 19 sampled residents (Resident #50), and 2) for infection control related to indwelling devices and a history of Multi-drug Resistent Organisms (MDRO), including the use of Enhanced Barrier Precautions (EBP) for 1 of 9 residents reviewed for Facility Reported Incidents and Complaint investigations (Resident #77). Findings include: Resident #50 Resident #50 was admitted to the facility on [DATE], with a diagnosis of type I diabetes mellitus. A physician's order dated 04/30/2024, documented NovoLOG Injection Solution 100 UNIT/milliliters (ml), inject as per sliding scale. Resident #50's Medication Administration Record (MAR) dated May 2024, documented the administration of NovoLOG Injection Solution as per the physician order. Resident #50's Care Plan lacked documented evidence of the use of insulin and of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure the care plan for a resident with a history of falls was updated following an unwitnessed fall for 1 of 19 sampled residents (Resident #5). This deficient practice could prevent the implementation of new interventions to prevent the resident from further falls with the potential for the resident to become injured from a preventable fall. Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including repeated falls, difficulty in walking, not elsewhere classified, and other abnormalities of gait and mobility. On 05/20/2024 at 8:57 AM, Resident #5 verbalized the resident had been experiencing more difficulty with walking and fell on [DATE]. The resident explained the resident was attempting to transfer themselves to the wheelchair and fell on the floor. The resident verbalized the resident's roommate had found the resident on the floor and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide showers to a dependent resident for 1 of 19 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility originally admitted [DATE], readmitted on [DATE]. Resident #3 discharged on 05/05/2024 and readmitted on [DATE], with diagnoses including rheumatoid arthritis, unspecified, other specified functional intestinal disorders and chronic kidney disease, stage 3. On 05/20/2024 at 1:06 PM, Resident #3 explained the resident had not been receiving a shower twice a week as scheduled over the last several months. Resident #3 verbalized the Resident felt bad not being able to take a shower when showers were scheduled twice a week. Resident #3 explained to take a shower the resident required assistance and the use of a Hoyer lift. Resident #3's care plan dated 05/12/24, documented the resident's bathing schedule was to be scheduled for Wednesday and Saturday, during the evening and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel record review, document review, and interview, the facility failed to ensure nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest for 1 of 5 sampled licensed nurses (Employee #2). The deficient practice could result in a negative outcome for a resident in cardiac arrest while awaiting the arrival of emergency medical personnel. Findings include: Employee #2 Employee #2 was hired as the Director of Nursing (DNS) with a start date of [DATE]. The DNS's personnel record documented CPR training and certification expired on 03/2024. On [DATE] at 10:37 AM, the Human Resources staff verbalized CPR was required to be taken by all licensed nurses and confirmed Employee #2 did not have a current CPR certification. The facility policy titled Cardiopulmonary Resuscitation (CPR), updated 09/2017, documented licensed nurses employed by the facility were required to have current CPR certification.

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 1) wound care was provided as ordered and a resident's plan of care, including medications for pain and symptom management, was coordinated with a contracted hospice provider for 1 of 19 sampled residents (Resident #9), 2) a resident was evaluated after a fall per facility policy for 1 of 19 sampled residents (Resident #5), 3) an order was in place prior to administering medication to a resident for 1 of 6 residents observed during medication administration (Resident #5), 4) the pharmacy, the physician and an on-call manager were notified when ordered medications were not available in the facility for 1 of 19 sampled residents (Resident #23) and 5) the physician was notified when a resident's blood sugar was over a certain level for 1 of 19 sampled residents (Resident #50). This deficient practice could result in additional pain and discomfort and poor palliative wound care outcomes for a resident on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review, the facility failed to ensure 1 of 19 sampled residents (Resident #62) did not develop a new wound and failed to ensure the new wound was reported timely to the wound care team, physician orders for treatment were obtained prior to providing wound care, and nutritional support for wound healing was assessed resulting in the wound developing into a stage II pressure injury (PI). Findings include: Resident #62 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, moderate, with psychotic disturbance, and cognitive communication deficit, muscle weakness (generalized), cognitive communication deficit, age related physical debility, and chronic combined systolic (congestive) and diastolic (congestive) heart failure. Resident #62's Minimum Data Set 3.0 (MDS) assessment dated [DATE], Section M, documented the resident was at risk of pressure injury but did not have any unhealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's urostomy drainage bag was kept off the floor while the resident was laying in bed for 1 of 19 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including rheumatoid arthritis, unspecified, other specified functional intestinal disorders and chronic kidney disease, stage 3. A physician's order dated 05/10/2024, documented to maintain urostomy care every shift. Resident #3's care plan included an intervention to provide urostomy care at least once each shift, start date 05/10/2024. On 05/22/2024 at 9:58 AM, Resident #3 was laying in bed and the resident's urostomy drainage bag was on the floor. On 05/22/2024 at 10:01 AM, a Registered Nurse (RN) explained catheter drainage bags should never be on the floor due to the potential for drainage issues and the increased risk of infections. The RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen was administered as ordered for 1 of 19 sampled residents (Resident #339). Findings include: Resident #339 Resident #339 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and chronic respiratory failure with hypoxia. On 05/20/2024 at 1:30 PM, Resident #339 verbalized Resident #339's nose and mouth got dry because the resident's oxygen did not have a humidifier on it. A physician's order dated 05/18/2024, documented oxygen three liters per minute (LPM), continuous delivery via nasal cannula (NC), humidified. Resident #339's Care Plan documented a problem of Establish Baseline Plan of Care. Interventions included oxygen, three LPM, continuous deliver via NC humidified. Date initiated was 05/18/2024. On 05/22/2024 at 12:55 PM, a Licensed Practical Nurse (LPN) confirmed Resident #339 had a current order for oxygen administration. The LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review the facility failed to ensure Dialysis Transfer forms were completed and maintained for 2 of 19 sampled residents (Resident #80 and #57). Findings include: Resident #80 Resident #80 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with other diabetic kidney complications, end stage renal disease (ESRD), and dependence on renal dialysis. A physician's order dated 04/18/2024 documented dialysis on Monday, Wednesday, and Friday (M, W, F), pick up time at 10:00 AM. On 05/21/2024 at 12:15 PM, Resident #80's dialysis binder, located at the nurse's station, contained only blank copies of the Dialysis Transfer forms and did not include documentation related to dialysis or pre and post dialysis assessments. On 05/21/2024 at 2:16 PM, a Registered Nurse (RN) explained Resident #80 was transported by the facility to dialysis the morning of 05/21/2024. The dialysis binder, used to communicate with the…

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

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 visits were completed timely for 1 of 19 sampled residents (Resident #9). This deficient practice could result in a resident not receiving assessments a physician can perform. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including local infection of the skin and subcutaneous tissue, unspecified, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, and cellulitis of right lower limb. The clinical record for Resident #9 included documentation of the resident's last physician visit on 04/07/2024. On 05/28/2024 at 2:52 PM, the Director of Nursing Services confirmed the resident had not been seen by a physician or nurse practitioner since 04/07/2024 and verbalized the resident should have had a visit from a provider since the last documented visit. The facility policy titled Physician Visits, updated 02/2008,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were scheduled to perform resident care according to the Facility Assessment for 1 of 2 shifts during the weekends in December of 2023. Findings include: The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated 10/01/2023 through 12/31/2023, documented the facility had excessively low weekend staffing. The Facility Assessment Tool documented the facility capacity and staffing projections. The licensed nursing schedule was maintained over two separate shifts; 6:00 AM-6:00 PM (first shift) projected three to four licensed nurses and 6:00 PM-6:00 AM (second shift) projected three to four licensed nurses. On 05/28/2024 at 1:01 PM, the Director of Nursing Services (DNS) explained the Facility Assessment Tool staffing projections were based on an average daily census of 72. The Schedule Staffing sheet for 12/17/2023, documented the second shift had two licensed nurses working the shift. The facility census on 12/17/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ordered medications were available and administered for 2 of 6 residents observed for medication administration (Resident #88 and #5) and 1 of 19 sampled residents (Resident #23). Findings include: Resident #88 Resident #88 was admitted to the facility on [DATE], with diagnoses including aftercare following joint replacement surgery and essential (primary) hypertension. On 05/22/2024 at 8:08 AM, a Licensed Practical Nurse (LPN) was preparing medications for Resident #88. The LPN verbalized the ordered medication, Amlodipine-Olmesartan 10-20 milligrams (mg), was not available in the facility. A physician's order dated 05/19/2024, with a start date of 05/20/2024, documented Amlodipine-Olmesartan oral tablet 10-20 mg, give one tablet by mouth one time a day for hypertension. Resident #88's Medication Administration Record (MAR) documented Amlodipine-Olmesartan 10-20 mg was not administered to Resident #88…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 47 opportunities and four medication errors. The medication error rate was 8.51%. Findings include: Resident #88 Resident #88 was admitted to the facility on [DATE], with diagnoses including aftercare following joint replacement surgery and essential (primary) hypertension. On 05/22/2024 at 8:08 AM, a Licensed Practical Nurse (LPN) was preparing medications for Resident #88. The LPN verbalized the physician ordered Amlodipine-Olmesartan 10-20 milligrams (mg) was not available in the facility. The LPN explained the process when a physician ordered medication was not available in the facility was staff would contact the pharmacy and notify the physician. The LPN verbalized it was concerning due to the resident's elevated blood pressure and the resident had already missed two doses of the medication on previous days. 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 clinical record review, document review and interview, the facility failed to complete Medication Administration Records (MAR) for the administration of an anti-coagulant for 1 of 19 sampled residents (Resident #66), and to ensure documentation in resident records accurately represented the licensure of a Provider for 74 of 89 residents (Residents #2, #3, #4, #5, #8, #9, #10, 12, #14, #15, #16, #19, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #36, #37, #38, #39, #40, #41, #42, #44, #45, #46, #49, #50, #53, #54, #55, #56, #59, #60, #61, #62, #63, #64, #65, #66, #68, #69, #70, #71, #72, #73, #74, #75, #76, #78, #79, #80, #83, #85, #238, #239, #240, #241, #242, #243, #244, #245, #246, #338, and #339), and failed to ensure complete resident clinical records were maintained for 2 of 19 sampled residents (Resident #80 and #68). Findings include: Medication Administration Record Resident #66 Resident #66 was admitted to the facility on [DATE], with a diagnosis of pulmonary embolism. A…

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

Based on interview and document review, the facility failed to accurately report weekend staffing coverage documented on the payroll-based staffing (PBJ) requirements submitted to the Center for Medicare and Medicaid Services (CMS). Findings include: The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated 10/01/2023 through 12/31/2023, documented the facility had excessively low weekend staffing. Facility nursing schedules and timesheets indicated sufficient staffing coverage for weekends for 10/01/2023 through 12/31/2023, excluding the weekend of 12/17/2024. The PBJ reports submitted to CMS lacked sufficient staffing coverage for weekend for 10/01/2023 through 12/31/2023. On 05/28/2024 at 1:05 PM, the Director of Nursing Services (DNS) indicated the facility had been submitting PBJ data. The DNS confirmed the PBJ reports submitted to CMS were inaccurate and the facility did have sufficient staffing coverage for weekends for 10/01/2023 through 12/31/2023, excluding the weekend of 12/17/2024.

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 1) a resident with a multi-drug resistant organism (MDRO) infection ( an infection with a germ resistant to an antibiotic, for which certain treatments would not work or would be less effective) was not provided care with the use of transmission based precautions (TBP) to prevent the spread of the MDRO to other residents in the facility for 1 of 19 sampled residents (Resident #9). This deficient practice could cause the spread of an MDRO to other residents in the facility with the potential to result in serious adverse effects to resident's health, 2) a bin for the disposal of used Personal Protective Equipment (PPE) was placed inside a room for a resident requiring TBP for 1 of 19 sampled residents (Resident #9) and 3) a resident's urostomy drainage bag was kept off the floor while the resident was lying in bed for 1 of 19 sampled residents (Resident #3). Findings include: Resident #9 Resident #9 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 clinical record review, interview, and document review the facility failed to ensure a Registered Nurse (RN) 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 an RN on 07/10/2023. Employee #1's COVID-19 Vaccination Record Card documented Employee #1 was administered a COVID vaccine on 02/01/2021 and 02/22/2021. Employee #1's State Immunization Record documented the RN received one dose of [NAME] COVID vaccine on 09/17/2021. The facility was not able to provide documented evidence Employee #1 was screened for eligibility to receive a COVID booster vaccine, provided education regarding COVID booster vaccines, and if a booster vaccine was offered and administered or declined. On 05/23/2024 at 11:41 AM, the Infection Preventionist (IP) verbalized the facility held a COVID vaccination clinic twice per year with a third party…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 20 sampled employees (Employee #11, #14, #16, and #20). Findings include: Employee #11 Employee #11 was hired as a Certified Occupational Therapist on 10/01/2023. Employee #11's personnel record lacked documented evidence of communication training. Employee #14 Employee #14 was hired as a Licensed Practical Nurse (LPN) on 09/01/2023. Employee #14's personnel record lacked documented evidence of communication training. Employee #16 Employee #16 was hired as a CNA on 09/07/2023. Employee #16's personnel record lacked documented evidence of communication training. Employee #20 Employee #20 was hired as a Housekeeper on 03/28/2024. Employee #20's personnel record lacked documented evidence of communication training. The Facility Assessment, last reviewed on 05/08/23, lacked documented evidence of staff completing communication training nor a plan for communication training. On 05/28/2024 at 2:17 PM, the Human Resources staff verbalized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 of 20 sampled employees (Employee #1, #4, #14, #19 and #20). Findings include: Employee #1 Employee #1 was hired as the Administrator on 03/30/2024. Employee #1's personnel record documented elder abuse training completed on 04/26/2024, 27 days after hire. Employee #4 Employee #4 was hired as the Registered Dietician on 11/07/2018. Employee #4's personnel record documented elder abuse training completed 04/16/2024, however lacked documented evidence elder abuse training was completed in 2023. Employee #14 Employee #14 was hired as a Licensed Practical Nurse (LPN) on 09/01/2023. Employee #14's personnel record lacked initial elder abuse training completed prior to starting work on the floor. Employee #19 Employee #19 was hired as a Hospitality Aide on 04/30/2024. Employee #19's personnel record lacked initial elder abuse training completed prior to starting work on the floor. Employee #20 Employee #20 was hired as a Housekeeper on 03/28/2024.…

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 interview, medical records review, and policy review the facility failed to obtain a consent prior to the administration of a psychotropic medication for 1 of 21 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease without dyskinesia, without mention of fluctuations, weakness, other abnormalities of gait and mobility, and cognitive communication deficit. Resident #14's physician order dated 12/06/23 documented Hydroxyzine 25 milligrams (mg) tablet by mouth one time a day for insomnia. Resident #14's physician order dated 12/24/23, documented Hydroxyzine 25 mg tablet, give one and one half tablet by mouth one time a day for anxiety as evidenced by inability to sleep. Resident #14's Medication Administration Record (MAR) dated 12/01/23-12/31/23, documented the following for the administration of Hydroxyzine: -12/07/23 through 12/23/23: 8:00 PM -12/25/23 through 12/31/23: 8:00 PM Resident #14's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and document review, the facility failed to protect the residents' right to be free from verbal abuse for 7 of 21 sampled residents (Resident #1, #2, #3, #7, #9, #10, #11) , physical abuse for 2 of 21 sampled residents (Resident #5, #6), and sexual abuse for 1 of 21 sampled residents (Resident #12). Findings include: On 02/16/23 at 3:40 PM, the Administrator verbalized being the Abuse Prevention Coordinator and the Resident Care Manager conducted the investigations and submitted the FRIs to the State Agency. An FRI documented on 12/15/23, Resident #2 entered Resident #1's room. Resident #1 stated get out, you are nothing but a thief. Resident #2 told Resident #1 shut up, you are such a <expletive>, and left the room. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including generalized anxiety disorder and chronic obstructive pulmonary disease. Resident #2 Resident #2 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.

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 care plan was developed and implemented related to the use of a psychotropic medication for 1 of 21 residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease without dyskinesia, without mention of fluctuations, weakness, and other abnormalities of gait and mobility. Resident #14's physician order dated 12/06/23, documented Hydroxyzine 25 milligrams (mg) tablet by mouth one time a day for insomnia. Resident #14's physician order dated 12/24/23, documented Hydroxyzine 25 mg tablet, give one and one half tablet by mouth one time a day for anxiety as evidenced by inability to sleep. Resident #14's Comprehensive Care Plan lacked documented evidence of a care plan related to the use and monitoring of a psychotropic medication. On 02/16/24 at 1:50 PM, the Resident Care Manager (RCM) explained the purpose of a care plan was 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 update a fall care plan with the most recent fall and new interventions for 1 of 21 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease without dyskinesia, without mention of fluctuations, weakness, and other abnormalities of gait and mobility. A nursing progress note dated 12/21/23, documented Resident #14 had used the call light and the Certified Nursing Assistant (CNA) found the resident sitting on the floor and leaning against the bed for support. The resident tried to transfer to the wheelchair from the bed but the wheels were not locked and the wheelchair moved. The resident lowered to the floor because the resident did not think the resident could get back into the bed. A physician progress note dated 12/22/23, documented Resident #14 had a fall on 12/21/23. The resident got out of bed and attempted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fall risk assessment was accurately completed upon admission in an attempt to prevent future falls and completed an assessment after an actual fall for 1 of 21 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease without dyskinesia, without mention of fluctuations, weakness, and other abnormalities of gait and mobility. A hospital discharge summary 12/01/23, documented Resident #14 was brought to the emergency department with complaints of weakness and had a fall at home. The resident was weak and deconditioned upon transfer to the facility for rehabilitation. A Baseline Care Plan initiated 12/01/23, documented a problem of safety due to history of falls/fall risk. A Nursing Progress Note dated 12/02/23, documented Resident #14 was a high fall risk due to Parkinson's disease, a very unsteady gait, and lack of…

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

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 resident was protected from verbal abuse from another resident for 1 of 5 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other specified arthritis, multiple sites, chronic obstructive pulmonary disease, unspecified, and type two diabetes mellitus with diabetic polyneuropathy. Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], type two diabetes mellitus with ketoacidosis without coma, morbid (severe) obesity due to excess calories, and other secondary pulmonary hypertension. A Facility Reported Incident (FRI) documented Resident #1, and Resident #4 were roommates. On 09/21/23, Resident #4 yelled at Resident #1 and called the resident a derogatory name. A Nursing Progress Note for Resident #4, dated 09/21/23, documented a nurse heard screaming and yelling coming…

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