Highland Manor Of Fallon Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to 1) ensure neurological assessments were documented for a resident with a fall and loss of consciousness for 1 of 18 sampled residents (Resident #98), and 2) ensure a resident with a skin condition requiring medicated cream for treatment had an accurate skin integrity assessment completed upon admission to the facility for 1 of 18 sampled resident (Resident #99). These deficient practices had the potential to result in 1) unmonitored and avoidable physical harm to the resident, and 2) the resident's skin condition not being treated timely and potentially worsening without a baseline assessment for comparison or accurate assessment information to communicate to all staff responsible for the resident's care. Findings include: Resident #98 Resident #98 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 07/20/2025, with a diagnosis of muscle weakness. A progress note dated 05/15/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview and document review, the facility failed to ensure nursing staff reported a wound to a physician/provider for 1 of 18 sampled residents (Resident #101), obtained an order for the care and monitoring of the wound, and continued to reassess the wound during daily skin assessments. This deficient practice had the potential to result in worsening of the wound including infection and increased pain for the resident. Findings include:Resident #101Resident #101 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, malignant neoplasm of the brain, and chronic kidney disease, stage IV (severe). On 08/25/2025 at 2:49 PM, Resident #101 verbalized the resident had a wound on the resident's lateral right ankle. The resident explained the wound was noticed by staff the previous day and was told the wound was a pressure injury (PI). The resident was not sure if the wound was open or closed and did not recall what stage the nurse told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with limited range of motion received appropriate services to maintain or improve mobility for 1 of 18 sampled residents (Resident #34). This deficient practice resulted in increased resident pain and had the potential to result in avoidable mobility decline.Findings include:Resident #34 Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including peripheral vascular disease, unspecified, acquired absence of right leg below knee, left knee contracture, right knee contracture, chronic pain syndrome, and need for assistance with personal care. An active physician's order, dated 04/19/2024, documented monthly summary/monthly restorative summary.Resident #34's clinical record lacked documented evidence of the following items:-A restorative evaluation.-A monthly restorative summary.-A discontinue order for the monthly restorative summary.-A physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure the resident environment was free from accident hazards when a resident was observed smoking a cigarette inside the facility for 1 of 18 sampled residents (Resident #42). This deficient practice had the potential to result in harm to all residents of the facility.Findings include: Resident #42 Resident #42 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of shortness of breath. On 08/25/2025 at 2:15 PM, a no smoking oxygen in use sign was posted at the entrance to Resident #42's room. The door was closed. An idle oxygen concentrator was placed in the far-left corner of the resident's room. Resident #42 was seated in the resident's wheelchair with a lit cigarette in the resident's hand. Resident #42's last comprehensive Minimum Data Set 3.0 (MDS) Assessment, dated 04/17/2025, section J1300 (Health Conditions-Current Tobacco Use), documented 1 for Yes under current tobacco…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review and interview, the facility failed to ensure a resident with a trauma diagnosis was assessed for the facility to recognize and respond to the effects of the trauma for 1 of 18 sampled residents (Resident #5). 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 #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder (PTSD) and conversion disorder with motor symptom or deficit.Resident #5's Care Plan dated 12/09/2024, documented the focus care area: PTSD, the resident had experienced a traumatic event prior to admission with an intervention to assess for suicidal or homicidal ideations when applicable. A Psychosocial Assessment, completed on 06/26/2025, documented Resident #5 had a diagnosis of PTSD generalized anxiety disorder. Resident #5'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 observation, interview, and document review, the facility failed to ensure a refrigerator was maintained at a safe storage temperature in 1 of 4 satellite kitchens of the facility. This deficient practice had the potential to harm residents by increasing the risk of infection and foodborne illnesses.Findings include:On 08/25/2025 at 10:36 AM, during a tour of the 100-hall satellite kitchen, the refrigerator internal thermometer measured 50 degrees Fahrenheit (F). The following perishable food items were inside the refrigerator:-Four meat sandwiches.-Three four-ounce yogurt cups.-Two one-gallon jugs of milk.-Six pre-poured glasses of milk.-One tub cream cheese spread.On 08/25/2025 at 10:36 AM, the Dietary Supervisor verbalized refrigerator temperatures were to be maintained between 38 to 41 F. the Dietary Supervisor confirmed the refrigerator thermometer reflected 50 F and the food items containing animal products would need to be thrown out. The facility policy titled Monitoring of Cooler/Freezer Temperature, dated 04/11/2025, documented all refrigerated storage must be…

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

Based on clinical record review, personnel record review, document review, and interview, the Administrator failed to ensure employees identified to complete sections of the Minimum Data Set (MDS) 3.0 Resident Assessments (Employee #8 and #9) had the experience and knowledge to complete accurate resident evaluations, and failed to ensure the accuracy of the MDS assessments after having learned of a title discrepancy in the resident electronic health record (EHR) system. This deficient practice had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.Findings include: The Centers for Medicare & Medicaid Services (CMS), 42 CFR 483.20 (g) Resident assessment, defined the Accuracy of Assessments as meaning the appropriate, health professionals correctly documenting the resident's medical, functional, and psychosocial problems 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 clinical record review, personnel record review, document review, and interview, the facility failed to ensure employees trained to complete sections of the Minimum Data Set (MDS) 3.0 Resident Assessments for 16 of 18 sampled residents (Resident #3, #4, #7, #23, #24, #42, #78, #90, #99, #101, #5, #9, #10, #21, #34, and #84) were qualified for 2 of 2 employees trained to complete sections of the MDS Resident Assessments (Employee #8 and #9). This deficient practice had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.Findings include: Employee #8 Employee #8 was originally hired on 07/24/2024 in Medical Records and took the position of Resident Advocate on 07/07/2025. Employee #8's signed job description for Resident Advocate, dated 07/09/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified a widespread concern with completion of Minimum Data Set (MDS) 3.0 assessments by non-qualified individuals. This deficient practice had the potential to result in residents not receiving the required care or services due to the potential for inaccurate care plans generated from the MDS assessment. Findings include: On 09/04/2025 at 4:58 PM, the Administrator verbalized the QAPI committee had been unaware of the concern with non-qualified individuals completing portions of the MDS assessments. The Administrator confirmed the MDS Coordinator was a part of the QAPI committee. The Administrator explained the MDS Coordinator was responsible for conducting audits on the MDS data and shared the audit findings with the QAPI committee during meetings. The Administrator verbalized the QAPI committee could have caught the concern prior to the annual recertification. The facility document titled Facility QAPI Plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and document review, the facility failed to ensure infection control precautions were observed for 1 of 4 complaint residents when the resident's wound dressings were allowed to drip onto the floor in the hallways and common areas of the facility. This deficient practice had the potential to spread infection to other residents and staff throughout the facility. Findings include:Resident #97Resident #97 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including cellulitis, unspecified, idiopathic progressive neuropathy, localized edema, and peripheral vascular disease.A Nurse Note dated 09/17/2024, documented Resident #97 was taken out of the facility for an appointment and upon return transportation staff told the nurse Resident #97 had left a puddle of clear, non-odorous drainage on the floor of the van. The drainage was from the resident's lower extremities and occurred during the few hours the resident was transported to appointment…

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

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 regular inspection of a resident's bed frame and bed rails was completed for a resident with upper bed rails attached to the resident's bed frame for 1 of 19 sampled residents (Resident #21). This deficient practice had the potential to result in a resident injury from entrapment resulting from incompatible or malfunctioning bed rails.Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, severe, with other behavioral disturbance, muscle weakness (generalized), and anxiety disorder due to known physiological condition. On 08/25/2025 at 10:57 AM, Resident #21 was sleeping in the resident's bed. The bed had upper rails attached to both sides of the bed and the rails were in the up position. A Physician's order, dated 04/24/2024, documented upper, half side rails could be used as an enabler to aid in…

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

Based on interview and document review, the Administrator failed to ensure the facility did not employ a Certified Nursing Assistant (CNA) with a disciplinary action against the CNA's license as a result of a finding of abuse of a resident. This deficient practice placed residents in the facility at risk for abuse. Findings include: On 01/22/2025, the Administrator provided a list of current employees for the facility. The list included names, titles, and hire dates of all employees. The CNA of concern was included on the list and had a hire date of 09/18/2024. The facility schedule for January 2025 documented the CNA of concern was scheduled to work in the facility. On 01/22/2025 at 2:01 PM, the Office Manager (OM), who also functioned as the facility's Human Resources Manager (HRM) explained the facility's screening process when hiring staff included performance of background checks and verifying professional licenses. The OM/HRM verbalized findings during the screening process which would make an applicant ineligible for hire included not passing a background check, prior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with a known history of significant weight loss was monitored for further weight loss upon readmission to the facility for 1 of 7 sampled residents (Resident #4). This deficient practice had the potential to result in a resident experiencing impaired nutrition without interventions to address nutritional need. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] after transferring to the hospital on [DATE], with diagnoses including unspecified severe protein-calorie malnutrition, dysphagia, oropharyngeal phase, and nausea with vomiting, unspecified. A Weight Summary for Resident #4 documented the resident weighed 202.2 pounds (lbs) on 03/03/2024 and weighed 170.1 lbs on 08/04/2024 indicating a severe weight loss of 32.1 lbs or 15.88 percent (%) body weight loss. The Weight Summary documented the resident's weight obtained on 11/12/2024, was 156 lbs. This…

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

Based on interview, and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee held meetings quarterly at a minimum. This failure had the potential to result in the facility not identifying and addressing concerns related to the quality of care in all areas of the facility. Findings include: The QAPI sign in sheets documented all required committee members were in attendance during the 4th quarter 2023, with the last meeting held on 09/20/2023. The facility lacked documented evidence of a meeting being held from January 2024 through June 2024. On 08/22/2024 at 1:56 PM, the Administrator verbalized the committee would meet as often as needed and at a minimum quarterly. The Administrator confirmed the facility could not provide documented evidence a QAPI meeting was held from January 2024 through June 2024. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Plan, revised 04/2014, documented the QAPI Committee met monthly to review reports evaluate the significance of data, and monitor quality…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident #52 Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including encounter for orthopedic aftercare following surgical amputation, type II diabetes mellitus with diabetic nephropathy, and personal history of methicillin resistant staphylococcus aureus (MRSA) infection. A physician's order dated 04/24/2024, documented to place Resident #52 in EBP due to a history of MRSA in a wound. On 08/20/2024 at 1:43 PM, a Licensed Practical Nurse (LPN)/Wound Care explained Resident #52 had wounds including an area of Moisture Associated Skin Damage (MASD) and a stage II pressure injury (PI) on the sacrum. The wound had progressed and appeared to be a [NAME] Ulcer. On 08/20/2024 at 1:49 PM, a physician assessed Resident #52's wounds and per the LPN Wound Care Nurse, agreed the wound had progressed into a [NAME] Ulcer and approved a change in wound care orders. On 08/20/2024 at 1:51 PM, a Certified Nursing Assistant, (CNA) was at Resident #52's bedside to assist with wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there were eight hours of consecutive Registered Nurse (RN) coverage for 6 of 90 days reviewed for staffing. This deficient practice could have allowed all 87 residents residing in the facility on the affected dates to go without proper assessments or certain cares RNs can perform. Findings include: Review of the facility Daily Nursing Staff Posting and Census sheets revealed the following: - No RN coverage on 06/02/2024 - No RN coverage on 06/14/2024 - No RN coverage on 06/18/2024 - No RN coverage on 06/19/2024 - No RN coverage on 06/24/2024 - No RN coverage on 08/17/2024 On 08/22/2024 at 1:31 PM, the Director of Nursing (DON) verbalized there was no RN coverage on 06/02/2024, 6/14/2024, 6/18/2024, 6/19/2024, 6/24/2024, and 8/17/2024. The DON confirmed the facility did not meet the requirement for eight consecutive hours of RN coverage on the dates listed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #79 Resident #79 was admitted to the facility on [DATE], with diagnoses including effusion, right knee and pain, unspecified. On 08/19/2024 at 3:00 PM, Resident #79 verbalized the resident has 10 out of 10 knee pain and takes pain medications and Lidocaine patches to manage the pain. The resident explained the facility ran out of Lidocaine patches and the resident went without for a couple of weeks. A physician order dated 06/10/2024, documented Lidocaine external patch 4 percent (%), apply to right knee topically one time a day related to pain, unspecified. On 08/21/2024 at 2:42 PM, a Licensed Practical Nurse (LPN1) verbalized Resident #79 received pain medication, Voltaren gel, and Lidocaine patches for knee pain. The LPN explained the facility had been out of Lidocaine patches recently and the resident was not able to receive them during the time the facility did not have them in the building. On 08/22/2024 at 9:24 AM, LPN2 verbalized the facility had been out of lidocaine patches. LPN2 explained 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, clinical record review, interview, and document review the facility failed to ensure 1) a pharmacy label's instructions for administration on a medication dispensing card (medication card) matched the physician's order for1 of 19 sampled residents (Resident #4), 2) pre-poured medications were not stored unlabeled in a medication cart for 1 of 19 sampled residents (Resident #61), 3) expired medications were removed from one of three inspected medication carts, 4) insulin pens were correctly labeled and stored in medication carts, 5) medications requiring refrigeration were stored in a refrigerator, and 6) unlabeled and loose medications were not stored in medication carts. Findings include: Resident # 4 Resident #4 was admitted to the facility on [DATE], with diagnoses including chronic pain syndrome, rash and other nonspecific skin eruption, and opioid dependence, uncomplicated. A physician's order dated 08/14/2024, documented oxycodone hydrochloride (HCl) 10 milligram (mg) tablets. Give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 representative gave consent to the use of a psychotropic medication prior to the medication being administered for 2 of 19 sampled residents (Resident #51 and #32). This deficient practice had the potential for a resident to receive a medication without being fully informed of all potential side effects and adverse reactions or a medication the resident did not wish to receive. Findings include: Resident #51 Resident #51 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including atherosclerosis of aorta, other lack of coordination, and Alzheimer's disease, unspecified. The medication orders for Resident #51 documented the following: - Depakote oral tablet delayed release 125 milligrams (mg), give one tablet by mouth two times a day related to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. The order date was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure a resident was not verbally abused by a Certified Nursing Assistant (CNA) for 1 unsampled resident (Resident #17) and a resident was protected from resident-to-resident verbal abuse when a resident yelled racial slurs and profanity for 1 of 19 sampled residents (Resident #79). Findings include: An initial FRI dated 06/01/2024, documented a CNA became frustrated while trying to position a resident in a Hoyer lift and wrote on the resident's white board the resident was being over dramatic and was acting like a child. Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including monoplegia of lower limb following cerebral infarction affecting right dominant side, muscle wasting and atrophy, contractures of the left and right hands, and unspecified hearing loss, unspecified ear. On 08/21/2024 at 8:33 AM, a Licensed Practical Nurse (LPN) verbalized Resident #17 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 interview, clinical record review, and document review the facility failed to submit a final Facility Reported Incident (FRI) report to the State Agency (SA) for 1 unsampled resident (Resident #17). Findings include: An initial FRI dated 06/01/2024, documented a CNA became frustrated while trying to position a resident in a Hoyer lift and wrote on the resident's white board the resident was being over dramatic and was acting like a child. A final FRI dated 06/07/2024 was submitted late to the SA. Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including monoplegia of lower limb following cerebral infarction affecting right dominant side, muscle wasting and atrophy, contractures of the left and right hands, and unspecified hearing loss, unspecified ear. On 08/21/2024 at 8:33 AM, an LPN verbalized Resident #17 had hearing loss however the resident could read lips used a white board to communicate. An Incident Note for Resident #17 dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review the facility failed to investigate an allegation of resident-to-resident verbal abuse and submit a final Facility Reported Incident (FRI) report to the State Agency for 1 of 19 sampled residents (Resident #79). This deficient practice had the potential to allow allegations of abuse to occur and not be investigated by the facility and not reported to the State Agency with the potential for residents to be physically and/or psychosocially harmed. Findings include: Resident #61 An initial FRI dated 05/17/2024, documented on 05/17/2024 Resident #79 made the Administrator aware Resident #61 yelled at Resident #79 using racial slurs and profanity. Resident #61 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, violent behavior, and generalized anxiety disorder. Resident #79 Resident #79…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 19 sampled residents' (Resident #44) Minimum Data Set 3.0 (MDS) assessment was accurately completed. Findings include: Resident #44 Resident #44 was admitted to the facility on [DATE], with a diagnosis of essential (primary) hypertension. On 08/19/24 at 11:23 AM, resident verbalized she did not receive dialysis and had not received dialysis in the past. Resident #44's clinical record lacked documented evidence the resident was on dialysis, including progress notes, a care plan, and a physician's order to receive dialysis. An Admissions MDS assessment dated [DATE], Section O, item J documented 'no' for dialysis. A Quarterly MDS assessment dated [DATE], 11/05/2023, 02/02/2024, and 05/03/2024, Section O, item J documented no for dialysis. An annual MDS assessment dated [DATE], Section O, item J documented no for dialysis. A Quarterly MDS assessment dated [DATE], Section O, item J documented yes for dialysis. The next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate a submission for a determination of a Preadmission Screening and Resident Review (PASARR) level II for 1 of 19 sampled residents with a mental illness diagnosis of schizoaffective disorder (Resident #37). Findings include: Resident #37 Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including schizoaffective disorder, hallucinations, unspecified, anxiety disorder due to known physiological condition, and dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. Resident #37's PASARR Level I documented completion on 07/03/2018. The PASARR Level 1 documented IC - no Mental Illness, Mental Retardation, or Related Conditions. PASARR appropriate for Nursing Facility (NF) placement. A Level of Care maybe required for placement. Resident #37's Level of Care Determination (LOC) dated 05/21/2021, documented meets NF LOC. No further LOC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident #32 Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic cough, and paroxysmal atrial fibrillation. On 08/19/2024 at 11:01 AM, Resident #32 was seated in a wheelchair with a portable oxygen concentrator hanging on the back of the wheelchair. Next to the resident's bed was an oxygen concentrator. Resident #32 explained being on oxygen continuously at five liters per minute (LPM) because of the resident's heart conditions. A physician's order dated 08/19/2024, documented Oxygen at five LPM via nasal cannula continuous for shortness of breath. Resident #32's Comprehensive Care Plan lacked documented evidence of a care plan for the administration and monitoring of Oxygen. On 08/20/2024 at 10:57 AM, an LPN explained Resident #32 was on five LPM of Oxygen continuously for chronic obstructive pulmonary disease, exacerbation and a history of hypoxia. The resident had episodes of desaturations. The LPN 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to honor an intervention involving a recliner, aimed to aid sleep, for a resident exhibiting resistive care behaviors and who did not sleep in a bed, for 1 of 19 sampled residents (Resident #74). Findings include: Resident #74 Resident #74 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including paranoid schizophrenia, major depressive disorder, recurrent, moderate, and unspecified dementia, severe, with anxiety. On 08/19/2024 at 12:17 PM, Resident #74's mattress was on the floor in the room with a fall mat placed next to the mattress. No other personal items were located in the resident's room. Resident #74's Comprehensive Care Plan for behaviors-resisting cares and psychotropic medication use dated 05/13/2024, and revised on 08/19/2024, documented the resident had behaviors of resisting cares, not sleeping, throwing cups of liquid, striking out at others, screaming constantly,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dependent upon staff for Activities of Daily Living (ADLs) received showers for 1 of 19 sampled residents (Resident #46). Findings include: Resident #46 Resident #46 was admitted to the facility on [DATE], with diagnoses including hereditary motor and sensory neuropathy and muscle weakness (generalized). On 08/19/2024 at 1:28 PM, Resident #46's spouse verbalized the resident had not received two showers per week. The resident's spouse explained the resident was scheduled to receive showers on Wednesdays and Saturdays and had not received showers the last two Saturdays. On 08/19/2024 at 1:30 PM, Resident #46 verbalized the resident had not received showers the previous two Saturday shower days. Resident #46's clinical record lacked documented evidence the resident received or refused showers. On 08/20/2024 at 10:10 AM, a Certified Nursing Assistant (CNA) verbalized residents received two showers per week 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 interview, personnel record review, and document review, the facility failed to employ a trained Activities Director or a qualified professional to provide oversight to the activities department. Findings include: On 08/20/2024 at 8:32 AM, the State Agency was attempting to set up a Resident Council Meeting with the Activities Director. An employee in the activities room verbalized filling in for the Activities Director because the facility did not currently have an Activities Director. The employee explained filling in for the Activities Director, as an Activities Assistant, for the past three to four months. On 08/20/2024 at 9:12 AM, the Business Office Manager verbalized the Activities Assistant was the Activities Director for a total of six months, however resigned from the position a few weeks ago and the employee was creating activities calendars and setting up activities to do with the residents daily. The Business Office Manager searched for the employee's Activities Director qualifications and training requirements and could not produce the documents requested…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Physical Therapy (PT) evaluation was completed for a resident identified as a fall risk for 1 of 19 sampled residents (Resident #46). Resident #46 Resident #46 was admitted to the facility on [DATE], with diagnoses including hereditary motor and sensory neuropathy, muscle weakness (generalized), and history of falling. On 08/19/2024 at 10:28 AM, Resident #46 verbalized the resident had a rare hereditary condition that caused weakness of the legs and required the resident to wear braces on both lower legs. The resident had a fall prior to admitting to the facility and had been waiting to receive physical therapy. On 08/21/2024 at 8:45 AM, a Licensed Practical Nurse (LPN) verbalized Resident #46 had issues with their legs and did not have control of them. The LPN explained the resident wore braces on their legs for contractures and to prevent drop foot. Resident #46's Comprehensive Care Plan initiated 06/01/2024,…

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.

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 #32). Findings include: Resident #32 Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic cough, and paroxysmal atrial fibrillation. On 08/19/2024 at 11:01 AM, Resident #32 was seated in a wheelchair with a portable oxygen concentrator hanging on the back of the wheelchair. Next to the resident's bed was an oxygen concentrator and the concentrator was turned on, while the resident was not getting Oxygen administered from the concentrator. On 08/19/2024 at 11:11 AM, a Certified Nursing Assistant (CNA) confirmed the oxygen concentrator was actively administering Oxygen while the resident was not connected to the device. A physician's order dated 08/19/2024, documented Oxygen at five liters per minute (LPM) via nasal cannula continuous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) pain medications were administered timely when Lidoderm External Patches (Lidocaine patches) were administered late for a resident diagnosed with pain for 1 of 19 sampled residents (Resident #80), and 2) Lidocaine patches were available and administered for 2 of 19 sampled residents (Resident #80 and #79). Findings include: Resident #80 Resident #80 was admitted to the facility on [DATE], with diagnoses including other intervertebral disc degeneration, lumbar region, and pain, unspecified. Late Administration A physician's order dated 07/25/2024, documented Lidocaine patches. Apply to lower back topically one time a day for pain. Remove after twelve hours. On 08/21/2024 at 7:40 AM, a Licensed Practical Nurse (LPN1) explained the order for Resident #80 was scheduled to be administered at 7:00 AM to 9:00 AM. LPN1 explained nurses applied the Lidocaine patches at 8:00 AM and removed at 8:00 PM. The LPN 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.

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 reassessed for risk of entrapment after assessed to have a severe cognitive decline and prior to placing the resident in a bed with side rails for 1 of 19 sampled residents (Resident #52) and ensure residents were assessed for risk of entrapment prior to placing side rails on the residents bed for 2 of 19 sampled residents (Resident #134 and ). Findings include: Resident #52 Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], and 07/22/2024, with diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below knee, acquired absence of left leg below knee, cognitive communication deficit, disorientation, unspecified, and dementia in other diseases classified elsewhere, mild, with other behavioral disturbance. On 08/19/2024 at 10:44 AM, Resident #52 was resting in bed, there were side rails on both sides 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.

Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 1 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #8). Findings include: On 08/21/2024 at 2:29 PM, the Human Resources Manager and Regional Human Resources participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 18 employees. Employee #8 Employee #8 was hired as a CNA with a start date of 02/07/2023. Employee #8's personnel record documented the CNA had an annual performance evaluation completed on 08/19/2024. On 08/21/2024 at 2:54 PM, the Business Office Manager provided Employee #8's date of last performance evaluation dated 08/19/2024. The Business Office Manager was unable to provide evidence the CNA had an annual performance evaluation completed by 02/07/2024. The Business Office Manager confirmed the CNA annual performance evaluation was completed late. The facility policy titled Annual Performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was provided dental services timely related to damaged dentures for 1 of 19 sampled residents (Resident #27). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with a diagnosis of moderate protein-calorie malnutrition. Nursing Progress Notes dated 07/18/2024, documented the following: - At 1:28 PM, staff informed a nurse Resident #27's bottom dentures had been broken. The nurse entered the room to confirm, and the dentures were broken in half. - At 5:45 PM, staff noted Resident #27's bottom dentures were split in half. A Progress Note dated 08/06/2024 at 7:13 PM, documented Resident #27's lower dentures were broken in half. Until the dentures could be repaired, the nurse had downgraded the diet to mechanical soft. A physician's order dated 08/06/2024, documented regular diet, mechanical soft texture, thin liquids, level zero thin consistency (TN0), small…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, clinical record review, and document review, the facility failed to honor a resident's meal preferences for a vegetarian diet and provide a meat substitute for meat entrees for 1 of 19 sampled residents (Resident #40). This deficient practice had the potential to deprive the resident of equal nutritional value for a preference of a vegetarian diet. Findings include: Resident #40 Resident #40 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of metabolic encephalopathy. A Progress Note dated 07/04/2024, documented the resident wanted a vegetarian diet. On 08/19/2024 at 3:19 PM, Resident #40 verbalized the facility did not have a vegetarian menu. The lunch menu for 08/20/2024, documented barbeque beef ribs. On 08/20/2024 at 12:19 PM, Resident #40 was served lunch, which included beef. On 08/20/2024 at 12:19 PM, the Certified Nursing Assistant (CNA1) confirmed beef was served on Resident #40's plate. On 08/20/2024 at 3:19 PM, the CNA2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration of physician ordered nutritional shakes (Ensure) was documented for 1 of 19 sampled residents (Resident #27). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with a diagnosis of moderate protein-calorie malnutrition. A physician's order dated 08/06/2024 documented chocolate Ensure. May leave two at bedside per patient request one time a day. Resident #27's August 2024 Medication Administration Record (MAR) documented chocolate Ensure. May leave two at bedside per patient request one time a day, scheduled to be administered during the morning medication pass. The MAR had blank spaces for Ensure administration on 08/16/2024, 08/19/2024, and 08/20/2024. Resident #27's clinical record lacked documented evidence the Ensures were administered on 08/16/2024, 08/19/2024, and 08/20/2024. On 08/22/2024 at 11:32 AM, a License Practical Nurse (LPN) clarified Resident #27's…

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

Based on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure medications were correctly labeled and stored, and controlled substances were accurately documented and reconciled. Findings include: On 08/22/2024 at 2:14 PM, the Regional [NAME] President confirmed the facility had not identified a concern related to labeling and storage of medications, and reconciliation of controlled substances. The Regional [NAME] President verbalized the facility could have become aware of the concern by completing audits of medication storage areas and performing reconciliation of controlled substances. A facility policy titled Quality Assurance and Performance Improvement (QAPI) Plan, revised 04/2014, documented the QAPI plan designed to monitor and evaluate the quality and safety of resident care and pursue methods to improve care quality, and resolve identified problems. Cross reference with F755 and F761

Based on observation, interview, and document review, the facility failed to ensure a resident's dignity was maintained when an employee was standing over the residents while providing feeding assistance for 3 of 3 residents requiring assistance with eating in the 200 unit dining room. Findings include: On 04/30/2024 at 12:35 PM, a Certified Nursing Assistant (CNA) was observed assisting three residents with the lunch meal service at the same table while standing over all three residents. The CNA picked up silverware wrapped in a napkin off the first resident's lap and proceeded to use the knife and fork to cut up the resident's meal, assisting them with eating. While the resident was chewing, the CNA moved to a second resident and assisted the resident with eating their meal using their fork. The CNA did not use an alcohol-based hand sanitizer (ABHS) between assisting the first and second resident. The CNA then moved to help a third resident eat their meal using a spoon and a scoop plate, without using ABHS between the second and third residents. The CNA did not sit down with any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 neglected to ensure a resident was properly secured for transport in the facility's transport bus resulting in fall with injury for 1 of 24 sampled residents (Resident #11) and failed to ensure two residents were protected from resident-to-resident verbal and physical abuse for 2 of 24 sampled residents (Resident #12 and #13). Findings include: Fall Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, Parkinson's disease, type II diabetes mellitus with diabetic nephropathy, unspecified, osteoarthritis, unspecified site, other specified disorders of bone density and structure, unspecified site, pain in right knee, muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, and muscle weakness. A facility document titled Event Report, dated 12/05/2023, documented 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 interview, clinical record review , and document review, the facility failed to ensure reports of suspected abuse toward residents were submitted to the Ombudsman's office from January 2024 through April 2024 for 9 of 19 Facility Reported Incidents (FRI) investigated, and the final FRI investigation was submitted to the State Agency timely for 5 of 19 FRIs investigated. The deficient practice could result in inquiries of abuse not being investigated, allowing potential abuse to occur without being reported to the Ombudsman's office, the State Agency, and /or Law Enforcement. Findings include: FRI #NV00070519 dated 02/21/2024, documented Resident #8 became verbally abusive and agitated when a Certified Nursing Assistant (CNA) was assisting Resident #9 with cares during the night.The FRI lacked documented evidence of reporting to the State Ombudsman's Office. FRI #NV00070713 dated 03/17/2024, documented Resident #9 and Resident #10 were outside smoking a cigarette together. Resident #9 claimed Resident #10 was calling the resident names in Resident #10's mind and Resident #9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate allegations of abuse and lacked documented evidence of the abuse investigations for 1 of 25 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (primary) and chronic obstructive pulmonary disease, unspecified. An initial FRI dated 12/14/2023, documented an allegation of employee-to-resident abuse involving the Director of Rehab (DOR) and Resident #23. A progress note dated 12/14/2023, documented the Director of Nursing (DON) met with Resident #23. Resident #23 expressed concerns related to a staff member. The DON informed the abuse coordinator of Resident #23's concerns and the abuse coordinator was conducting an investigation. On 04/30/2024 at 2:51 PM, the DOR recalled the DOR was informed 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 Resident #3 Resident #3 , was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (Primary), major depressive disorder, recurrent, severe with psychotic symptoms, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, other symptoms and signs involving cognitive functions and awareness, and insomnia, unspecified. The Care Plan for Resident #3 lacked documented evidence the resident's comprehensive care plan was updated after a resident to resident altercation occurring on [DATE] and [DATE]. On [DATE] at 2:37 PM, the ADON verbalized when there was an altercation between residents, the resident's care plan would be updated to reflect a behavior problem, if not already identified, and documentation of the incident and new approaches developed to remediate future incidents. The ADON confirmed Resident #3's care plan was not updated for the incidents of [DATE] and [DATE]. FRI #NV00069946 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 interview and document review, the facility failed to ensure there were eight hours of consecutive Registered Nurse (RN) coverage for 1 of 30 days reviewed for staffing and the facility had a full time Director of Nursing (DON). This deficient practice could have allowed all 77 residents residing in the facility on the affected date to go without proper assessments or certain cares RNs can perform and compromise the supervision of nursing care due to lack of oversight. Findings include: RN Coverage Review of the facility nursing schedules, Staffing Report posting, and RN Timecard Reports for the date of 04/28/2024 revealed the following: - RN1 worked from 5:41 PM until Midnight for a consecutive total of six hours and 19 minutes. - RN2 worked from 6:00 PM until Midnight for a consecutive total of six hours. On 04/30/2024 at 1:56 PM, the Administrator verbalized RN1 and RN2 were the only RNs who had worked in the facility on 04/28/2024. The Administrator confirmed the facility did not meet the requirement for eight consecutive hours of RN coverage on 04/28/2024. Full Time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) ensure staff used appropriate hand hygiene when working in the kitchen and serving resident food items, and 2) ensure staff used appropriate hand hygiene when providing feeding assistance to residents. The deficient practice could impact the sanitary conditions of the working area for preparing resident food and meals and the potential to cause the spread of food borne illness to residents in the facility. Findings include: On 04/30/2024 at 12:15 PM, Certified Nursing Assistant (CNA1) entered the kitchen in Unit 200 to retrieve a tray of drinks and deserts from the refrigerator. CNA1 did not use the sink in the kitchen to perform hand hygiene prior to retrieving the food items from the refrigerator. On 04/30/2024 at 12:17 PM, CNA1 removed gloves from a box of gloves hanging on the wall. CNA1 dropped one of the gloves on the floor and retrieved the glove. CNA1 did not dispose of the glove and donned both gloves then picked up the tray of drinks from the refrigerator and distributed the drinks 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 clinical record review, interview and document review, the facility failed to ensure the Social Services department assessed and monitored residents for signs and symptoms of adverse outcomes following a resident-to-resident altercation for 3 of 15 Facility Reported Incident (FRI) sampled residents (Resident #50, #60, and #7). The failure to assess and monitor the residents had the potential for adverse outcomes and contributing behaviors to go unidentified resulting in the residents having increased or continued behaviors and/or adverse psychosocial outcomes. Findings include: An incident report dated 08/15/23, documented on 08/15/23, Resident #50 was verbally inappropriate towards Resident #60. The residents were redirected, and Resident #50 was re-educated regarding appropriate verbal communication with other residents. Both residents lacked safety awareness and the skills to interact appropriately. The action taken to prevent further occurrences was documented as care plans updated. Resident #50…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent resident to resident physical abuse for 1 of 15 Facility Reported Incident (FRI) residents (Resident #25). Findings include: Facility Reported Incident (FRI) #NV00068816 documented on 06/16/23, Resident #39 made contact with Resident #25's face. Resident #25 Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral palsy, unspecified, muscular dystrophy, unspecified, and functional quadriplegia. A Nursing Progress Note dated 06/16/23, documented full skin check completed with no obvious injuries noted. Resident non-verbal and was not showing any signs or symptoms of pain or discomfort. On 09/11/23 at 3:32 PM, a Certified Nursing Assistant (CNA) explained Resident #39 struck Resident #25 on the cheek while in the dining room on 06/16/23. The CNA verbalized Resident #39 did not like other males and staff had learned to redirect the resident to other areas to prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, document review, and interview the facility failed to prevent the misappropriation of funds for 1 of 15 Facility Reported Incident (FRI) residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including paraplegia, unspecified, bipolar disorder, unspecified, and cognitive communication deficit. FRI #NV00069348 initially submitted to the State Agency on 08/31/23, with a final report submitted on 09/5/23, documented on 08/31/23, the Business Office Manager (BOM) reviewed Resident #8's fund statement and found three charges withdrawn from the resident's account to the name of a Resident Aide (RA) on staff. The RA was interviewed and admitted to taking the resident's account information from Resident #8 and withdrawing cash to purchase the resident personal items. The RA was suspended during the investigation and terminated at the conclusion of the investigation. Resident #8's primary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan was developed 1) regarding the misappropriation of a resident's funds by a staff member for 1 of 15 Facility Reported Incident (FRI) investigated residents (Resident 8), and 2) following resident to resident abuse allegations for 2 of 15 FRI investigated residents (Resident #25 and #7). The failure had the potential to delay implementation of appropriate resident care interventions. Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including paraplegia, unspecified, bipolar disorder, unspecified, and cognitive communication deficit. An initial FRI dated 08/31/23, documented the Business Office Manager (BOM) had found a Residential Aide (RA) received or took money from Resident #8. The FRI documented Resident #8's bank statement had three withdrawals of cash in the RA's name. The RA was suspended during the investigation 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 clinical record review, interview, and document review the facility failed to ensure care plans were completed and up to date for 15 of 18 sampled residents (Resident #30, #37, #8, #35, #65, #7, #23, #49, #60, #25, #44, #74, #71, #284, and #25), and 1 of 5 residents for closed record review (Resident #22). The failure had the potential to delay implementation of appropriate resident care interventions. Findings include: Resident #30 Resident #30 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, anxiety, and cognitive communication deficit. Resident #30's physician's orders documented: -01/30/23 escitalopram oxalate tablet 10 milligram (mg), take one tablet by mouth once a day -06/01/23 mirtazapine tablet 7.5 mg, take two tablets by mouth at bedtime -01/30/23 Behavior monitoring: Anti-Depressant, Monitor every shift for signs and symptoms of depression, verbalizations of sadness, sad facial expression, and self-isolation. Resident #30's Comprehensive Care Plan 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, observation, and document review, the facility failed to ensure residents' rights to use silverware instead of plastic utensils was maintained for 21 of 21 residents located in the 100 hall and failed to provide the preferred shower scheduled to a resident requiring assistance for 1 of 18 sampled residents (Resident #20). On 06/06/23 at 2:30 PM, during the Resident Council Interview, 2 of 14 residents verbalized the residents had been eating with plastic utensils and wanted to know when the facility would serve the residents regular silverware. Another resident verbalized they hated eating with plastic spoons and forks because they break. The resident explained the resident had chewed on plastic when eating due to the tines of the forks breaking. The plasticware was not professional and screamed cheap. On 06/07/23 at 12:11 PM, during tray line in the 100 hall, Certified Nursing Assistants (CNAs) were observed providing 11 residents in the dining room with plastic utensils. A silverware caddy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had been informed of the possible side effects and risks of psychotropic medication and had been given the opportunity to consent or refuse the medication prior to administration for 1 of 5 residents selected for medication review (Resident #37). Findings include: Resident #37 Resident #37 was admitted to the facility on [DATE], with diagnoses including moderate unspecified dementia with behavioral disturbances, insomnia, depression, and anxiety. The Physician's Orders for Resident #37, dated 04/10/23, documented: -duloxetine capsule 30 milligram (mg), take one capsule by mouth once a day for depression. -trazadone tablet 50 mg, give one tablet by mouth at bedtime. The April, May, and June 2023 Medication Administration Record for Resident #37 documented the duloxetine and trazadone had been administered daily since 04/10/23. A Consent for Psychoactive Medication for the duloxetine and trazadone documented…

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

Based on interview, observation, and document review, the facility failed to ensure residents' rights to a homelike environment when the facility used silverware instead of plastic utensils for 21 of 21 residents located in the 100 hall. Findings include: On 06/06/23 at 2:30 PM, during the Resident Council Interview, 2 of 14 residents verbalized the residents had been eating with plastic utensils and wanted to know when the facility would serve the residents regular silverware. Another resident verbalized they hated eating with plastic spoons and forks because they break. The resident explained the resident had chewed on plastic when eating due to the tines of the forks breaking. The plasticware was not professional and screamed cheap. On 06/07/23 at 12:11 PM, during tray line in the 100 hall, Certified Nursing Assistants (CNAs) were observed providing 11 residents in the dining room with plastic utensils. A silverware caddy contained several sets of rolled plastic utensils. On 06/07/23 at 12:14 PM, CNA #1 verbalized residents were being served plastic utensils to eat with. CNA #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and clinical record review, the facility failed to ensure a resident's discharge status was accurately documented on a Minimum Data Set 3.0 (MDS) assessment for 2 of 5 closed resident records (Resident #58 and #59). Findings include: Resident #58 Resident #58 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including acute respiratory failure with hypoxia, edema, and circadian rhythm sleep disorder. The resident was discharged on 02/04/23. Resident #58's clinical record lacked documented evidence a MDS assessment for Discharge had been completed. Resident #59 Resident #59 was admitted to the facility on [DATE], with diagnoses including nonrheumatic aortic stenosis, idiopathic gout, and unspecified osteoarthritis. The resident was discharged on 01/06/23. Resident #59's clinical record lacked documented evidence a MDS assessment for Discharge had been completed. On 06/08/23 at 11:16 AM, the MDS Coordinator confirmed an MDS assessment for Discharge had not 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, interview, clinical record review, and document review, the facility failed to ensure a baseline care plan was created timely for the treatment and care needs for 1 of 5 residents selected for medication review (Resident #30) and 1 of 18 sampled residents (Resident #74). Findings include: Resident #30 Resident #30 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, anxiety, and cognitive communication deficit. Resident #30's physician's orders documented: -01/30/23 escitalopram oxalate tablet 10 milligram (mg), take one tablet by mouth once a day -06/01/23 mirtazapine tablet 7.5 mg, take two tablets by mouth at bedtime -01/30/23 Behavior monitoring: Anti-Depressant, Monitor every shift for signs and symptoms of depression, verbalizations of sadness, sad facial expression, and self-isolation. Resident #30's clinical record lacked documented evidence a baseline care plan was created for the treatment and use of psychotropic medications. On 06/08/23 at 12:41…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's gastric tubing was secured prior to transferring a resident, resulting in the gastrostomy feeding tube (G-tube) being pulled out with the inflated balloon intact for 1 of 18 sampled residents (Resident #25). Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], with diagnoses including cerebral palsy, unspecified, dysphagia, unspecified, and unspecified severe protein calorie malnutrition. A Nursing Progress Note dated 06/05/23, documented a Certified Nursing Assistant (CNA) reported Resident #25's G-tube was caught in the resident's wheelchair during transfer and was pulled out and the balloon remained inflated. The resident had minimal bleeding around the stoma and pressure was applied for a few minutes until the bleeding stopped. The G-tube was replaced with no issues. A physician's order for Resident #25, dated 11/15/22, documented clean around G-tube site with non-sterile…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a completed dialysis communication transfer form for 1 of 18 sampled residents (Resident #21). Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], with a diagnosis of end stage renal disease. A physician's order dated 01/16/23, documented dialysis, once a day, every Monday, Wednesday, Friday at the dialysis center. Resident #21's clinical record and Dialysis Transfer Form binder lacked documented evidence a Communication Transfer Form was completed for the following days. -January 2023, 23rd, 25th, 27th, and 30th -February 2023, 1st, 6th, 8th, 13th, 15th, 17th, 20th, 22nd 24th, and 27th -March 2023, 6th, 8th, 13th, 15th, 20th, 22nd, 24th, 27th, 28th, and 31st -April 2023, 3rd, 5th, 7th, 10th, 12th, 14th, 17th, 19th, 21st, 24th, 26th, and 28th -May 2023, 3rd, 5th, 10th, 12th, 15th, 17th, 19th, 22nd, 26th, 29th and 31st -June 2023, 5th, and 7th On 06/07/23 at 8:08 AM, a Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure residents with bedrails initiated had appropriate alternatives implemented and attempted prior to usage for 1 of 18 sampled residents (Resident #65). Findings include: Resident #65 Resident #65 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, other specified congenital deformities of the hip, and chronic pain syndrome. On 06/05/23 at 2:42 PM, Resident #65's bed had half bedrails up on both sides. Resident #65 verbalized the half bedrails came with the bed. Resident #65's physician's order dated 01/12/23, documented resident may have half side rails used as an enabler for bed mobility. Resident #65's Side Rail Device Assessment Consent, dated 12/30/22, documented the resident requested the bedrail for mobility. The form documented attempted to roll without using side rails without success for alternatives tried before use of bedrails. Resident #65's Comprehensive Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review the facility failed to ensure medication was available and administered timely and an error rate of less than 5 percent (%). The medication administration error rate was 5.26% Findings include: On 06/07/23, during the medication administration observation, there were 38 opportunities and 2 medication errors (Resident #10 and #8). The medication error rate was 5.26%. Resident #10 Resident #10 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including multiple sclerosis and essential (primary) hypertension. On 06/07/23 at 7:50 AM, a Licensed Practical Nurse (LPN #1) administered the following medications to Resident #10: -acidophilus 1 billion colony forming units (CFU), 1 tablet by mouth daily -baclofen 10 milligrams (mg), 3 tablets by mouth three times daily -vitamin D 1000 international units, 1 tablet by mouth daily -cipro 250 mg, 1 tablet by mouth daily -b12 500 micrograms, 2 tablets by mouth daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 expired medications were removed from 1 of 1 sampled medication storage room and 2 of 2 sampled medication carts, and medications were secured for 1 of 4 medication carts. Findings include: Medication Storage Room On 06/08/23 at 9:43 AM, the Medication Storage Room contained the following expired item: -Tubersol Tuberculin Purified Protein Derivative Diagnostic Agent, 5 Toxin Units (T.U.)/ 0.1 milliliter (mL) 5 mL vial, which did not have a date of opening or expiration written on the vial or on the box which contained the vial. On 06/08/23 at 9:46 AM, a Licensed Practical Nurse (LPN) confirmed the Tuberculin vial did not have a date of opening or date of expiration written on the vial or on the box the vial was stored. The LPN could not verbalize the number of days a multi-dose vial could be open before expiration. The LPN confirmed the Tuberculin vial should have been destroyed since the date of opening was not identified. 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, observation, clinical record review, and document review, the facility failed to provide meals based on resident's preferences for 1 of 18 sampled residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE] and re-admitted [DATE], with diagnoses including paraplegia, type 2 diabetes mellitus, and gastro-esophageal reflux disease. On 06/05/23 at 12:50 PM, a Certified Nursing Assistant (CNA) brought a lunch tray into Resident #8's room. The tray contained a cheese quesadilla and a cup of coffee. On 06/05/23 at 2:15 PM, Resident #8 verbalized the resident preferred to have fresh vegetables and a Caesar salad with lunch and had requested for a Caesar salad and fresh vegetables but had never received items on the resident's lunch tray. Resident #8's tray card, undated, notes Caesar salad and raw broccoli with ranch with lunch tray. On 06/07/23 at 9:30 AM, the Food Services Supervisor verbalized the Dietician interviewed the residents at admission to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and clinical record review, the facility failed to ensure an assistive device was provided to assist with eating for 1 of 18 sampled residents (Resident #49). Findings include: Resident #49 Resident #49 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, muscle weakness (generalized), difficulty in walking, not elsewhere classified, and other lack of coordination. Resident #49's nutritional care plan documented the resident was to be provided a teaspoon to eat with at meals. Resident #49's meal tray card documented the resident's assistive devices for eating included a small spoon. On 06/07/23 at 1:15 PM, Resident #49 was eating lunch in the memory care unit's dining room. The resident was provided a regular sized plastic spoon to eat with. On 06/07/23 at 1:19 PM, the Memory Care Unit Manager (Unit Manager) explained Resident #49's assistive devices for eating included a small spoon. The Unit Manager described the spoon as having a long handle…

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

Based on observation, interview, and record review, the facility failed to properly store food in a manner to prevent pests. Findings include: Stored Food On 06/05/23 at 8:52 AM, on the dry storage shelf, a box of powder grape juice mix was spilled in the storage box. The Food Services Supervisor confirmed the powder grape juice spilled in the box had the potential to draw pest into the kitchen. A facility policy titled Purchasing, Receiving and Food Storage, revised 09/2010 documented the Food Service Supervisor would check for torn/damage to sack or other packages.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure resident information was not visible on an unattended computer screen facing a public area for 1 of 26 residents residing in a unit (Resident #69) and a list of resident names and vital sign measurements were not visible and left unattended on the top of a medication cart. Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including cardiomyopathy and acute posthemorrhagic anemia. On 06/08/23 at 9:29 AM, a computer screen on a medication cart in the 200 hall displayed medication information for Resident #69. On 06/08/23 at 9:30 AM, a Licensed Practical Nurse (LPN) returned to the medication cart and confirmed the computer screen displayed Resident #69's medication information. The LPN verbalized the computer screen should have been locked to prevent access to protected health information. On 06/08/23 at 9:33 AM, the Director of Nursing (DON) verbalized the expectation was computer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility lacked a process to ensure 1) residents' homelike environment was maintained by not serving plasticware with meals, and 2) person centered care plans were developed to address the identified care needs of each resident. Findings include: Homelike Environment On 06/08/23 at 1:02 PM, the Administrator confirmed the QAPI committee had not identified the use of plasticware at meals as concern related to the residents' homelike environment and had not developed a Performance Improvement Project (PIP) to address the concern. (Cross referenced to F550) Person Centered Care Plan On 06/08/23 at 1:00 PM, the Administrator verbalized the QAPI committee discussed concerns related to care plans but had not developed a PIP related to the development of care plans to address each resident's individual care needs in a person-centered manner. (Cross referenced to F656) The facility policy titled QAPI Plan, dated 06/05/23, documented the scope 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 observation, clinical record review, interview, and document review the facility failed to ensure 3 of 4 residents on Transmission Based Precautions (TBP) (Resident #10, #25, and #44) had the appropriate infection control signage posted at the entrance of the residents' rooms and failed to ensure the facility Infection Prevention and Control Plan (IPCP) was reviewed and/or updated annually and included a plan to address staff with communicable diseases. Findings include: Transmission Based Precautions Resident #10 Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of multiple sclerosis. Resident #25 Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of cerebral palsy, unspecified. Resident #44 Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. On 06/05/23 at 10:58 AM, an isolation cart 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 1 of 5 residents sampled for vaccinations (Resident #60) was screened for eligibility to receive an influenza vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined. Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, with anxiety. Resident #60's state immunization record lacked documented evidence the resident was administered an influenza vaccine. Resident #60's clinical record lacked documented evidence the resident was screened for eligibility to receive an influenza vaccine, education regarding the vaccine was provided to Resident #60 and/or the Resident's Representative, and the vaccine was either administered or declined. On 06/07/23 at 10:58 AM, the Infection Preventionist confirmed the facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #54) was screened for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined. Findings include: Resident #54 Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of unspecified dementia, moderate, with other behavioral disturbance. Resident #54's state immunization record lacked documented evidence the resident was administered a COVID vaccine. Resident #54's clinical record lacked documented evidence the resident was screened for eligibility to receive a COVID vaccine, education regarding the vaccine was provided to Resident #54 and/or the Resident's Representative, and the vaccine was either administered or declined. On 06/07/23 at 3:31 PM, the Infection Preventionist…

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