Tlc Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure physician orders for monthly weights were followed for 1 of 6 sample residents (Resident 6). This deficient had the potential to impact monitoring of the resident's changes in weight (loss or gain), nutritional assessment, and delay dietary interventions. Findings Include: Resident 6 (R6) was admitted to the facility on [DATE] with diagnoses including Parkinson's disease without dyskinesia, dementia, and major depressive disorder.A physician order summary dated 07/03/2025, documented monthly weight one time a day starting on the 1st and ending on the 7th every month for monitoring.A physician/nurse practitioner progress note dated 12/11/2025 documented R6 had an eight-pound weight loss from August of 2025.R6's weight record documented the following:12/10/2025- 92.3 pounds (weight chair) 08/07/2025 -100.00 pounds (weight chair)The medical record lacked documented evidence of weights for September 2025, October 2025 and November 2025. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review the facility failed to ensure an orthopedic consult was obtained as per physician order for 1of 5 sampled residents (Resident 1). The deficient practice had the potential to delay treatment and healing of a fracture. Findings include: Resident 1 (R1) R1 was re-admitted on [DATE] with diagnoses including fracture of left wrist and hand, dementia without behavioral disturbance and major depressive disorder. A Change of Condition Note dated 02/22/2025 at 5:32 AM, documented R1 was noted calling for help. Immediately staff responded to R1's room and R1 was noted lying on the floor next to wheelchair holding left wrist. R1 moaned in pain. R1's left wrist had a small skin tear, swollen and painful to touch. R1 was assisted back to wheelchair. Supervisor and family were notified. R1 was sent to the emergency room for further evaluation. A Progress Note dated 02/22/2025, documented R1 returned from hospital via stretcher transport at 2:30 PM with a…

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

Based on interview and document review, the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 03/28/2025 in the afternoon, the administrator acknowledged the facility was not able to produce documentation providing evidence the facility had developed, implemented, and maintained an effective, comprehensive QAPI program. The Administrator provided evidence the facility had a QAPI meeting on 02/27/2025, 09/24/2024, and 07/30/2024. The administrator stated had been the administrator at this facility for a short time and was not able find where the electronic documents were filed or if they were filed. A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, undated, documented the facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. The State Operations Manual 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 and document review, the facility failed to maintain documented evidence of maintaining a Quality Assurance and Performance Improvement (QAPI) Committee consisting at a minimum of: the Director of Nursing services; the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the administrator, owner, or board member; and the infection preventionist. The facility also failed to maintain documentation of evidence of the committee meeting at least quarterly. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 03/28/2025 in the afternoon, the Administrator acknowledged the facility was unable to provide documented evidence the facility had a QAPI Committee meeting on 02/27/2025, 09/24/2024, and 07/30/2024. The Administrator acknowledged the 02/27/2025 QAPI Committee meeting was missing the Director of Nursing and the Administrator, Owner, or Board Member. The Administrator acknowledged the 09/24/2024 QAPI…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a physician's order was obtained, an assessment was completed, and care plan was developed for the self-administration of medication for one unsampled resident (Resident 38). The deficient practice had the potential for the resident's unsafe administration of medication or adverse reactions to medication. Findings include: Resident 38 (R38) R38 was admitted on [DATE], with diagnoses including peripheral vascular disease and age-related physical debility. The physician's order dated 10/18/2023, documented Ketotifen Fumarate Ophthalmic Solution 0.035% (eye drops), instill two drops in both eyes two times a day for itching. R38's Medication Administration Record (MAR) for March 2025, documented the medication was scheduled to be given at 8:00 AM and 8:00 PM. On 03/28/2025 at 8:44 AM, during the medication administration pass observation, a Licensed Practical Nurse (LPN) prepared R38's oral medications scheduled for…

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

Based on observation, interview, and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 35 sampled residents (Resident 102). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents. Findings include: Resident 102 (R102) was admitted to the facility with diagnoses of nontraumatic intracerebral hemorrhage and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R102 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. On 03/26/2025 in the morning, R102 stated do not get enough showers and two showers a week was not enough. R102 stated would like more showers because if the resident missed a shower for any reason, then the resident won't get another shower until the next week. R102 stated having to wait this long is too much. R102 complained about sweating in bed, hair becoming greasy, and body odor occurs when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to document a written response including rationale to address complaints brought forth in the resident council. The deficient practice had the potential to cause resident concerns to remain unresolved. Findings include: Resident council meeting minutes dated 02/19/2025 revealed residents complained of call lights were not answered in a timely manner, and staff were on their phones more than paying attention to residents. Resident council meeting minutes dated 03/19/2025 revealed a resident complained nurses were slow to answer their call light, resulting in waiting up to 45 minutes for assistance. A different resident complained had not had a shower in three months. Resident 57 (R57) R57 was admitted on [DATE]. The 02/04/2025 Quarterly Minimum Data Set (MDS) assessment indicated R57 had normal memory function. On 03/27/25 at 1:34 PM, R57 reported serving as the Resident Council President for greater than the prior four months. R57 reported 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, record review and document review, the facility failed to ensure a resident was kept safe from physical abuse for 1 of 35 sampled residents (Resident #43). The deficient practice had the potential for the resident to experience emotional and physical harm. Findings include: Resident #43 (R43) Resident #43 (R43) was admitted to the facility 01/02/2025 with diagnoses including encephalopathy, urinary tract infection, hypothyroidism, and hypertension. The facility reported incident (FRI) dated 02/27/2025 documented the following: -On 02/25/2025, R43 was in a wheelchair in the 700 hall and was arguing with Employee 20 (E20). R43 was trying to wheel the wheelchair back to the room R43 had just been transferred from. E20 got in front of R43 and blocked the ability of R43 to move forward in the wheelchair. R43 became agitated and started yelling at E20 to get their hands off R43. - Employee 14 (E14) stepped outside their office and witnessed E20 holding R43's arms down against the wheelchair. R43 began to kick at E20. E20 then told R43 if R43 kicks E20, E20 would kick…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure 1 of 35 sampled residents (Resident 168) remained free from restraints not needed to treat a medical symptom, identify the use of lower bed rails as a restraint, and follow policies and procedures in assessing the use of a physical restraint or alternatives considered prior to implementing a physical restraint. The deficient practice could have resulted in a decline in activities of daily living, loss of dignity, and physical and psychosocial harm to the resident. Findings include: Resident 168 (R168) R168 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, lack of coordination, major depressive disorder, anxiety disorder, chronic post-traumatic stress disorder, and a fracture of the base of the neck of the right femur. On 03/27/25 at 10:03 AM, R168 was observed sleeping in bed. The bed was in the lowest position with bilateral floor mats and full…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and document review, the facility failed to ensure an alleged incident of physical abuse was reported to the State Agency (SA) within the required timeframes for 1 of 35 sampled residents (Resident #43). The deficient practice had the potential to place residents at risk for incidents of physical abuse to not be adequately protected. Findings include: Resident #43 (R43) was admitted to the facility 01/02/2025 with diagnoses including encephalopathy, urinary tract infection, hypothyroidism, and hypertension. A Behavior Note dated 02/25/2025, documented R43 was kicking at staff and had become more verbally aggressive by yelling profanity and more physically aggressive when not allowed to enter other resident rooms. In an email thread from the Director of Social Services (DSS) to the Administrator-In-Training (AIT), the DSS notified the AIT of the potential abuse allegation on 02/27/2025 at 11:36 AM and the AIT verified receipt of the message on 02/27/2025 at 11:48 AM. An initial Facility Reported Incident (FRI) was submitted to the SA on 02/27/2025 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 observations, interview, record review, and document review the facility failed to ensure a resident-centered care plan was revised and physician order obtained for use of side rails for 1 of 35 sampled residents (Resident 6). The deficient practice had the potential to put the resident at risk for harm due to lack of communication between staff. Findings include: Resident 6 (R6) R6 was admitted on [DATE] with diagnoses including Parkinson's disease and need for assistance with personal care. A brief interview for mental status (BIMS) was conducted on 01/01/2025 with a result of 05/15 which indicated the resident had a severe cognitive deficit. A minimum data set (MDS) assessment was conducted on 01/01/2025 and documented resident required maximal assistance in bed mobility. On 03/26/25 8:49 AM, resident was lying down in bed, bed was flat, and side rails were installed in the middle of bed frame on both sides. R6 indicated not knowing what the rails were for. 03/28/25 09:48 AM, resident required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to provide incontinent care for 2 of 35 sampled residents (Resident 25 and Resident 417) and 1 unsampled resident (Resident 468). The deficient practice had the potential for the resident's skin integrity to be compromised. Findings include: Resident 25 (R25) R25 was admitted on [DATE], discharged on 09/18/2024, and re-admitted [DATE] with diagnoses including displaced bicondylar (upper and lower parts) fracture of right tibia. The Quarterly Minimum Data Set (MDS) dated [DATE] documented R25 required maximal assistance with toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. A Care Plan dated 01/10/2025 documented R25 was incontinent of bowel and urine due to generalized weakness with intervention to provide toileting hygiene as needed for incontinent episodes. On 03/25/2025 at 9:37 AM, R25 verbalized needing assistance with a brief change and having…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, interview, record review and document review, the facility failed to ensure physician orders were followed in medication administration and orders clarified for medication for 1 of 3 closed record sampled residents (Resident 469), a medication was administered per the physician's order for one unsampled resident (Resident 219), and staff administered medication in a timely manner for 2 of 35 sampled residents (Residents 210 and 147) and 2 unsampled residents (Residents 27 and 137). The deficient practice had the potential for the resident not achieving the therapeutic effect (specific and desired effect) of the medication. Findings include: Resident 469 (R469) R469 was admitted on [DATE] and discharged on 12/23/2024 with diagnoses including include metabolic encephalopathy, type 2 diabetes, and abnormalities of gait and mobility. A physician order dated 12/17/2024, documented Humalog Solution 100 units/Milliliter (ML) (Insulin Lispro (Human)) inject per sliding scale: if 1-70 notify MD;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to obtain a physician's order for the removal or use of an intravenous (IV) access, including assessing and monitoring the site, for 1 of 35 sampled residents (Resident 90). This deficient practice had the potential to cause complications such as infection, infiltration, phlebitis, or impaired venous access. Findings include: Resident 90 (R90) was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including anoxic brain damage, seizures, and carrier of carbapenem-resistant Enterobacter [NAME]. On 03/25/25 at 10:03 AM, R90 was observed in bed, sleeping and snoring. The resident had an undated IV port/site on the right arm. On 03/25/25 at 10:27 AM, the Director of Nursing (DON) inspected the IV site on R90's lower right arm. The DON confirmed there was no date on the dressing. On 03/25/25 at 10:33 AM, an Assistant Director of Nursing (ADON) inspected R90's arm and verbalized there was no date on the dressing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure 1 of 35 sampled residents (Resident 168) was assessed and reviewed for risk and benefits, appropriate alternatives were attempted prior to installing the bed rail, and physician orders were obtained for bed rails. The deficient practice had the potential to place the resident at risk of injury such as falls, entrapment, and broken bones. Findings include: Resident 168 (R168) R168 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, lack of coordination, major depressive disorder, anxiety disorder, chronic post-traumatic stress disorder, and a fracture of the base of the neck of the right femur. On 03/27/25 at 10:03 AM, R168 was observed sleeping in bed. The bed was in the lowest position with bilateral floor mats and full rails (two upper and two lower rails) raised. On 03/27/25 at 10:06 AM, a Certified Nursing Assistant (CNA) explained floor mats, bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, document review and interview, the facility failed to ensure pre-made foods were stored, labeled, dated, and used within seven days in the refrigerator. This deficient practice posed a potential risk to safety and health standards which could lead to food spoilage and place residents at risk of foodborne illness. Findings include: On 03/26/2025 in the morning, during a follow-up tour of the kitchen and dietary areas, there were three sandwiches in a plastic tub which were wrapped but not labeled or dated. The tub of sandwiches was in the walk-in cooler. The Dietary Account Manager acknowledged the sandwiches should have been labeled and dated so the kitchen staff would know how long the items had been stored in the cooler. A Healthcare Services Group Policy, revised 02/2023, with the subject entitled Food Storage: Cold Food revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medical records were complete and accurate for 1 of 35 sampled residents (Resident 98) and 2 unsampled residents (Resident 467 and Resident 469). The deficient practice had the potential for residents not to receive timely interventions needed and for the facility missing the opportunity to identify care issues. Findings include: Resident 98 (R98) R98 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, Type 2 diabetes mellitus, and dependence on supplemental oxygen. A physician order dated 08/13/2024 documented drug test, general toxicology one time only. Throughout the week of the survey the facility was unable to produce results for the ordered drug test. The Regional Director of Clinical Services verbalized the resident had refused the testing. The medical record lacked document evidence the resident refused the testing. On 03/28/25 at 1:50 PM, the Assistant Director of Nursing (ADON) confirmed being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure infection control practices were maintained for 1 of 35 sampled residents (Resident 25). The deficient practice had the potential to increase risk of cross-contamination, spread infectious diseases, and compromise health and safety for residents. Findings include: Resident 25 (R25) R25 was admitted on [DATE] discharged on 09/18/2024 and re-admitted [DATE] with diagnoses including displaced bicondylar (upper and lower parts) fracture of right tibia. On 03/25/2025 at 9:37 AM, R25 verbalized needing assistance with a brief change. R25 explained staff stated being out of the brief R25 needed. On 03/25/2025 at 9:52 AM, a Certified Nurse Assistant (CNA) explained checking with the nurse and central supply and the facility was out of the green brief R25 needed. On 03/25/2025 at 9:58 AM, the Central Supply Clerk confirmed the facility was currently out of green briefs. The Central Supply Clerk explained green briefs were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 1.) the Infection Preventionist had specialized training in infection control prior to appointment to the position; 2.) a COVID-19 outbreak was reported to the appropriate state agency; and 3.) N-95 respirator fit testing was completed, documented and staff training was provided per facility policy. The deficient practice had the potential for the facility's infection prevention program to be ineffective. Findings include: 1.) On 12/03/2024 at 3:08 PM, the RN Staff Development Coordinator/Infection Prevention RN (E3), explained had been appointed in their current position at the end of September 2024. E3 confirmed there was a COVID-19 outbreak accounting for 55 COVID-19 positive residents, many of them symptomatic, and 12 positive staff members. E3 did not know the COVID-19 cases should have been reported to the appropriate state agency. E3 indicated having health issues preventing them to be full time at the facility and not having a back-up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a grievance report was initiated and followed through for 1 of 37 sampled residents (Resident 1). The deficient practice had the potential to result in a resident having an unresolved grievance. Findings include: Resident 1 (R1) was admitted on [DATE] and discharged on 02/05/2024, with diagnoses including acute post traumatic pain, left femoral fracture and right distal femur fracture. R1's Face Sheet (demographics) listed the resident had a significant other. R1's significant other alleged on 01/19/2024, R1's feet and legs were massaged by a janitor. On 12/05/2024 at 2:00 PM, the Administrator indicated recalling R1's significant other reported an incident regarding a housekeeper massaging R1's feet and legs. The Administrator confirmed the alleged incident was not included nor documented in the facility's Grievance log for 2024. On 12/05/2024 at 2:26 PM, a Certified Nursing Assistant (CNA) recalled the alleged incident when a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to vancomycin medication was initiated upon admission for 1 of 37 sampled residents (Resident 20). The deficient practice had the potential prevent the continuation of a resident's medicine regimen for a serios infection. Findings include: Resident 20 (R20) was admitted on [DATE] with diagnoses including infection following procedure, enterocolitis due to clostridium difficile. The medical record revealed hospital discharge instructions for R20 included continuation of Vancomycin intravenous (IV) 750 milligrams (mg) once daily. A Physician Order dated 01/02/2024 documented Vancomycin HCl (hydrocholoride) Intravenous Solution. On 12/03/2024 at 11:40 AM, the Director of Admissions and Marketing verbalized the facility would use the discharge instructions from the hospital to order medications and treatments for the resident. Medications orders would be sent electronically to the pharmacy and staff would ensure room and equipment was ready for admission of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to provide documented evidence discharge planning was provided to 1 of 37 sampled residents (Resident 10). The deficient practice had a potential for inadequate post management and coordination of the continuation of care for a resident. Findings Include: Resident 10 (R10) was admitted on [DATE] for short term rehabilitation for open heart surgery. R10 was discharged on 03/01/2024. R10's medical record lacked documented evidence of a case manager's assessment for discharge needs during the resident's short-term stay. On 12/03/2024 at 1:19 PM, the Licensed Social Worker indicated case management oversaw discharge planning for short term skilled residents. On 12/03/2024 at 1:30 PM, the Case Manager (CM) verbalized a discharge assessment would be documented within twenty-hours of admission and the resident would continually be assessed throughout the stay for any discharge needs and coordination. The CM could not provide documentation of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to provide documented evidence assistance with activities of daily living (ADL) was provided for 1 of 37 sampled residents (Resident 3). The deficient practice had the potential for the resident's skin integrity to be compromised. Findings include: Resident 3 (R3) was admitted on [DATE] and discharged on 03/07/2024, with diagnoses including abnormalities of gait and mobility, and osteomyelitis of vertebra, sacral and sacrococcygeal region. R3's Care Plan documented the following: - Resident had an ADL self-care performance deficit as evidenced by Parkinson's disease and acute respiratory failure. The interventions/tasks identified in the resident's care plan included assistance of staff for toileting. -Resident had bladder incontinence related to impaired mobility. The interventions/tasks identified in the resident's care plan included to clean the peri-area with each incontinent episode. The admission Minimum Data Set (MDS) 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, record review and document review, the facility failed to ensure weekly wound evaluations were completed and weekly skin observations were documented accurately for 1 of 37 sampled residents (Resident 1) and failed to implement a physician order for a psychiatric consultatin for 1 of 37 sampled residents (Resident 32). The deficient practice had the potential to delay the assessment and treatment of residents' skin condition and management of a resident's mental health. Findings include: 1.) Resident 1 (R1) was admitted on [DATE] and discharged on 02/05/2024, with diagnoses including acute post traumatic pain, left femoral fracture and right distal femur fracture. The Weekly Skin Observation for R1 dated 01/14/2024 documented the following skin conditions: - right lateral thigh stapled incision - left elbow abrasion - left knee abrasion - right thigh stapled incision - left lateral thigh stapled incision The Weekly Skin Observations for R1 dated 01/21/2024, 01/28/2024, and 02/04/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure weekly wound evaluations were completed and weekly skin observations were documented accurately for 1 of 37 sampled residents (Resident 2). The deficient practice had the potential to delay the assessment and treatment of residents' skin condition. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and discharged on 01/11/2024, with diagnoses including endocarditis, other abnormalities of gait and mobility, and Type 2 diabetes mellitus. The Physician/Nurse Practitioner Progress note for Wound Care Consultation dated 12/11/2023 documented the following skin conditions of R2 which were present on admission: 1. Right heel wound stage 1 pressure related 2. Right buttock pressure stage 3 3. Left iliac crest deep tissue injury (DTI) intact The following Weekly Skin Observations were documented in R2's medical record: -12/10/2023: No bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and documentation review, the facility failed to provide a safe environment free from accident hazards by ensuring the sharps containers were replaced after it reached the manufacture fill line, used razors and syringes were disposed in an appropriate sharps container in a common shower room (Hall 600), residents were assessed for smoking, and the designated smoking area was under supervision. The deficient practice had the potential for increased risk of needle stick and compromised the resident's overall safety and well-being. Findings include: 1.) On 12/03/2024 at 9:41 AM, a sharps container on the medication cart for the 500 hall was full of sharp objects exceeding the three-quarters (¾) of its capacity over the manufacture fill line. On 12/03/2024 at 9:42 AM, a Licensed Practical Nurse (LPN) (Employee 33 (E33) assigned to the medication cart, confirmed the sharps container was past the fill line, and indicated it was the nurse's responsibility to change the sharps container once it reached the manufacture three-quarters (¾) fill line. On…

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

Based on observation, interview, record review, and document review, the facility failed to ensure staff did not use personal blood pressure monitors to take vital signs for residents in transmission-based precautions when disposable blood pressure cuffs were available. The deficient practice had the potential to increase the risk of cross-contamination. Findings include: On 12/04/2024 at 8:42AM, a Certified Nursing Assistant (CNA) explained using personal electronic blood pressure monitor for obtaining the resident's vital signs. The CNA confirmed using the same equipment for residents on transmission-based precautions (TBP). The CNA showed an electronic blood pressure cuff with a gray cloth wrist band which was kept in the CNA's personal bag. The CNA revealed using the bleach wipes in cleaning the equipment. The CNA was not familiar with the amount of time the bleach wipe would need to stay visibly wet on a surface to effectively kill germs. The CNA explained the blood pressure cuff was wiped with a tissue to dry it after cleaning with a bleach wipe. The CNA provided the canister…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure, 1) Oxygen tanks were stored appropriately, 2) medications were not left at bedside, 3) storage rooms were secured, 4) a respiratory cart and medication cart were secured, and 5) the facility's smoking policy was followed when residents were allowed to have possession of smoking supplies. The deficient practice had the potential to place residents at risk for harm or injury. Findings include: 1) Storage of Oxygen tanks: On [DATE] in the morning, in room [ROOM NUMBER], there were two free-standing unsecured portable oxygen tanks. One unsecured oxygen tank was next to the wall with the window and one unsecured oxygen tank was at the foot of the resident's bed. On [DATE] at 8:13 AM, a Certified Nursing Assistant (CNA) entered the room and observed the unsecured oxygen tanks. The CNA verbalized the oxygen tanks were not stored properly and should be stored in a rack. The CNA stated it was a safety issue. On [DATE] 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, interview and document review, the facility failed to ensure medications were not left unsecured in a medication cart at the 800-900-Hall nursing station, and medications were not left at bedside. The deficient practice posed a risk for resident's safety of obtaining medications not prescribed and not taking ordered medications. Findings include: On [DATE] at 2:06 PM, the medication cart at the 800-900 hallway was observed unlocked with a drawer ajar. On [DATE] at 2:07 PM, a Registered Nurse was at the nurse's station and confirmed the medication cart was unlocked and verbalized the cart should be locked. On [DATE] at 2:11 PM, the Licensed Practical Nurse (LPN) using the cart, was at the nurse's station and confirmed the medication cart was unlocked and verbalized the cart should be locked when not in use. The LPN verbalized residents could access the medications in an unlocked cart. On [DATE] at 2:35 PM, the Director of Nursing (DON) verbalized the DON expected the medication cart to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure: 1) residents with suspected scabies were placed on contact precautions for 1 of 35 sampled residents (Resident 112), 2) a staff member who was assigned to provide care to residents with unconfirmed rashes and who themself was undergoing treatment for scabies, was not assigned to another unit, 3) laundry items of residents with unconfirmed rashes were handled in accordance with the facility's policy, 4) the wound care team was notified of residents with unconfirmed rashes and 5) suspected resident and staff scabies cases were reported to the health department. The deficient practice placed other residents and staff at risk of contracting scabies. Findings include: On 02/06/2024 in the morning, two Certified Nursing Assistants (CNAs) showed surveyor rashes on their bilateral arms and reported being under treatment for scabies by their personal physicians. CNA #1 indicated submitting a physician's report regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was completed for a resident who was admitted with a surgical wound (Resident 635) and a resident with a contracture (Resident 108). The deficient practice had the potential the residents would not receive the wound care or contracture care the residents required. Findings include: Resident 635 (R 635) was admitted to the facility on [DATE] with diagnoses including left leg cellulitis and left leg wound. The clinical record contained an admission note dated 02/03/2024 which documented the resident was admitted from an acute care hospital via stretcher for left lower leg cellulitis. The History and Physical late entry note for 02/05/24 documented the resident had a non-occlusive left femoral deep vein thrombosis (DVT). The resident was also evaluated by the Surgical/Burn team for evaluation of left lower extremity complicated cellulitis with presence of open wound. Documentation in the clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to develop a care plan for a resident with bed rails (Resident 95). The deficient practice placed the resident at a risk for safety. Findings include: Resident 95 (R95) R95 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including encephalopathy, unspecified, personal history of traumatic brain injury and seizure disorder. On 02/06/24 at 10:21 AM, R95 was in bed with the upper side rails in the up position on both sides of the bed. On 02/08/24 at 9:15 AM, R95 was in bed with the upper side rails in the up position on both sides of the bed. R95's Comprehensive Care Plan lacked documented evidence of a care plan for bedrails, to include the risks, benefits, and evidence of alternatives tried and failed. R95's clinical record lacked documented evidence of an evaluation of the ability to raise and lower the bed rails. On 02/09/24 at 8:14 AM, the Director of Nursing (DON) confirmed a care plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to administer medications timely in accordance with the facility's policy for 1 of 35 sampled residents (Resident 42). The deficient practice had the potential to cause physical and psychosocial harm to the resident. Findings including: Resident 42 (R42) R42 was admitted on [DATE] with diagnoses including chronic pain syndrome, mononeuropathy, and anxiety disorder. On 02/07/24 at 7:52 AM, R42 indicated scheduled medication for pain and anxiety were frequently administered late. A review of the medical record documented: - A physician order for Lorazepam oral tablet 1 milligram (mg), give 1 mg by mouth three times a day for anxiety. - A physician order for Methadose oral concentrate 10 mg/milliliter (ml), give 0.5 ml by mouth three times a day for pain for 14 Days A review of the medication administration record (MAR) documented the following medications were administered more than 1 hour late: - Lorazepam scheduled for 2:00 PM on 02/01/24 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a physician's order for a pressure redistributing mattress was implemented for a resident with a stage four coccyx pressure ulcer. The deficient practice potentially resulted in the worsening of the resident's coccyx pressure ulcer. Findings include: Resident 182 (R182) R182 was admitted on [DATE] and readmitted on [DATE], with diagnoses including stage four pressure ulcer. An admission Nursing Evaluation dated 01/03/2024 revealed R182 was admitted with a stage four coccyx pressure ulcer. Interventions included use of specialty devices, positioning devices, and turning routine. An admission minimum data set (MDS) dated [DATE], revealed R182 had a stage four pressure ulcer. A physician's order dated 01/02/2024, documented to provide R182 with a pressure redistributing mattress. A care plan for actual skin impairment stage four pressure ulcer initiated 08/22/2023, documented to provide pressure redistributing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure restorative nursing services (RNA) was provided to residents in accordance with therapy recommendations for 3 of 35 sampled residents (Residents 34, 108 and 110). The failure to provide RNA services had the potential for the resident's further decline in mobility. Findings include: The facility's policy titled Restorative Nursing dated 06/01/2021, documented restorative programs were coordinated by nursing or in collaboration with rehabilitation and were resident specific based on individual resident needs. The practice standards included to review current clinical assessments to determine if restorative nursing programs were indicated such as after a resident's discharge from formalized rehabilitation therapy. Resident 34 (R34) R34 was readmitted on [DATE] with diagnoses including abnormalities of gait and mobility. On 2/6/2024 in the morning, R34 indicated having physical therapy (PT) until a month ago. R34…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure care orders were obtained and implemented for a resident who was admitted with an indwelling catheter for 1 of 35 sampled residents (Resident 182). Specifically, a physician's order was not obtained when the resident's catheter had to be replaced and perineal (area between the anus and posterior part of external genitalia) wash was not performed routinely in accordance with the facility's policy. The deficient practice placed the resident at risk for a recurrent urinary tract infection (UTI). Findings include: Resident 182 (R182) R182 was admitted on [DATE] and readmitted on [DATE], with diagnoses including severe sepsis with septic shock related to urinary tract infection. An admission Nursing Evaluation dated 01/03/2024, revealed R182 was admitted with an indwelling catheter and a history of chronic urinary tract infection (UTI). A physician encounter note dated 01/03/2024, documented R182 was treated for UTI in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure assessment for entrapment was completed, alternatives were attempted, and informed consent was obtained prior to installation of side rails for 1 of 35 sampled residents (Resident 95). Resident 95 (R95) R95 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including encephalopathy, unspecified, personal history of traumatic brain injury and seizure disorder. On 02/06/24 at 10:21 AM, R95 was in bed with the upper side rails in the up position on both sides of the bed. On 02/08/24 at 9:15 AM, R95 was in bed with the upper side rails in the up position on both sides of the bed. On 02/08/24 at 10:23 AM, a Certified Practical Nurse (CNA) confirmed R95 had upper side rails in the up position on both sides of the bed. The CNA explained an evaluation was to be completed by nursing upon admission. R95's record lacked documented evidence an informed consent was obtained, assessment for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure: 1) an admission and quarterly social services assessment was completed for 1 of 35 sampled residents (Resident 182), 2) the Social Worker followed-up with the acute care hospital and the onsite dental services regarding the missing dentures for 1 of 35 sampled residents (Resident 53), and 3) there were sufficient number of social services staff members in accordance with the facility assessment. The deficient practice had the potential for the facility not meeting the social services needs of the residents. Findings include: Resident 53 (R53) R53 was readmitted on [DATE] with diagnoses including respiratory syncytial virus pneumonia. R53 required the use of dentures. A review of the medical record revealed R53 was discharged to the acute care hospital on [DATE], and R53 was discharged from the hospital 12/08/23. On 02/06/2024 in the afternoon, R53 indicated they had been missing their dentures approximately 4 to 5 weeks after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) label and date food items, and 2) discard potentially hazardous foods. The deficient practice had the potential to expose resident to foodborne illness. Findings include: On 02/06/2024 at 7:55 AM, a tray of salads in the walk in refrigerator was unlabeled and undated. On 02/06/2024 at 7:57 AM, the following items were stored in the walk-in refrigerator in serving containers separate from the original packaging: - Two containers of cottage cheese dated 01/15/2024 - Five containers of mixed fruit dated 01/24/2024 - Five containers of orange slices dated 01/30/2024 On 02/06/2024 at 7:58 AM, the Dietary Manager confirmed the unlabeled and undated should have been discarded. Food items removed from their original container must be discarded within seven days. The Food Storage: Cold Foods policy, last revised 02/2023 documented, All time and temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA food code. All foods will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure the hospice physician's order to place a resident on transmission-based precautions for possible scabies infection was followed for 1 of 35 sampled residents (Resident 112). The deficient practice placed other residents and staff at risk for spreading scabies. Findings include: Resident 112 (R112) R112 was admitted on [DATE], with diagnoses including non-traumatic subdural hemorrhage and unspecified dementia and hospice status. A hospice face sheet dated 08/03/2024, revealed R112 was admitted to Hospice with primary diagnoses including encephalopathy and subdural hemorrhage. On 02/06/2024 in the morning, R112 laid in bed asleep and was unarousable. The resident's body including arms were covered in blanket. On 02/06/2024 in the morning, an individual was observed donning gown, foot cover, head cover, mask, and gloves outside R112's room. The individual introduced self as R112's hospice nurse and explained personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a dislodgement of a urinary indwelling catheter that resulted in urethral trauma and hematuria was promptly reported to the attending physician for 1 of the 33 sampled residents (Resident #1). The deficient practice had the potential to prevent the resident from receiving the treatments to prevent urinary complications. Findings include: Resident #1 (R1) R1 was admitted on [DATE], with diagnoses including hypertension, hyperlipidemia, diabetes, status post fall resulting in right proximal femoral fracture, and status post open reduction and internal fixation of femoral fracture. MD order dated 07/28/2023, documented change Indwelling Foley catheter French #16 (FR #16)(size of Foley catheter) (30)cc (amount of fluid to inflate the catheter's balloon), connect to bedside urine bag every 1st day of the month and PRN for dislodgement and leakage. A nursing progress note dated 07/30/2023 at 3:30 AM, documented R1 pulled out the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and document review, the facility failed to ensure a baseline care plan was developed for the care of surgical wounds for 1 of 33 sampled residents (Resident #1). The deficient practice had the potential to deprive the resident for receiving wound care services in a timely manner. Findings include: Resident #1 (R1) R1 was admitted on [DATE], with diagnoses including diabetes, status post fall resulting in right proximal femoral fracture, and status post open reduction and internal fixation of femoral fracture. The nursing admission assessment dated [DATE], documented wound related to surgical procedure. The assessment did not provide details related to the characteristics of the wound and a plan with interventions for the care of the surgical wound. The baseline care plan dated 07/29/2023, revealed a plan with interventions for the care of the surgical wounds was not developed. The treatment administration records for July and August 2023, did not document wound care treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and document review, the facility failed to develop and implement a comprehensive care plan to manage the pain for a resident with communication problems related to ventilator-dependent respiratory failure for 1 of 33 sampled residents (Resident #32). The deficient practice had the potential to deprive the resident for receiving effective pain management and treatment. Findings include: Resident #32 (R32) R32 was admitted on [DATE], with diagnoses including stroke with dysphagia, chronic encephalopathy, altered mental status, ventilator-dependent respiratory failure, and stage 4 pressure ulcer. A physician order dated 07/19/23, indicated to assess R32's pain every shift using a numeric rating scale from 0 to 10 as follow: 0: No Pain; 1: Mild (Pain scale: 1-3); 2: Moderate (Pain scale: 4-6); 3: Severe (Pain scale: 7-10). The order documented implementing non-pharmacologic interventions prior to medicating if appropriate and if pain was present. A physician order dated 07/18/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and document review, the facility failure to perform the initial assessment for wound care, obtain physician orders for wound care, and provide treatment for surgical wounds in timely manner for 1 of 33 sampled residents (Resident #1). The deficient practice placed residents at risk for unmet treatment care needs that could have resulted in surgical site complications such as infection, improper healing, and pain. Findings include: Resident #1 (R1) R1 was admitted on [DATE], with diagnoses including diabetes, status post fall resulting in right proximal femoral fracture, and status post open reduction and internal fixation of femoral fracture. The nursing admission assessment dated [DATE], documented a wound related to surgical procedure. The assessment did not provide details related to the characteristics of the wound. The treatment administration records for July and August 2023, did not document wound care treatment from the admission date on 07/28/2023 through 08/07/2023.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure 1) wound treatments were provided per physician's order and 2) wound assessments were conducted on a weekly basis in accordance with facility policy for a resident with an existing pressure ulcer for 1 of 33 sampled residents (Resident 6). The deficient practice placed the resident at risk for wound complications such as wound deterioration, infection, and pain. Findings include: Resident 6 (R6) R6 was admitted on [DATE], with diagnoses including unspecified dementia and anoxic brain damage. An admission skin assessment dated [DATE], documented R6 was admitted with an unstageable left coccyx pressure ulcer measuring 11.0 centimeters (cm) by 4.5 cm. R6's skin risk assessment dated [DATE], revealed R6 was at high risk for developing or worsening pressure ulcer due to limited sensory perception, bedfast status, occasional moisture, and poor nutritional intake. Treatment Orders The Documentation of Wound Treatments policy revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure post fall protocol was implemented for 1 of 33 sampled residents (Resident 22). The deficient practice had the potential for inaccurate assessment and monitoring following an unwitnessed fall, impacting the quality of life of the resident. Findings include: Resident 22 (R22) R22 was admitted on [DATE] with diagnoses including unspecified dementia, type II diabetes mellitus, epilepsy, and unspecified falls, sequela. A Brief Interview for Mental Status (BIMS) was not completed due to R22 having a memory problem. The medical record revealed a change of condition on 11/10/2022, documenting R22 had an unwitnessed fall, noted to be on the floor next to the bed, lying on the floor mat. The wound care team was notified, and an x-ray was ordered. A progress note dated Monday 11/14/2022, documented it was reported, R22 fell forward out of the wheelchair hitting the forehead and right arm causing pain in the right arm on 11/10/2022.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and document review, the facility failed to accurately assess the pain for a resident with communication problems related to ventilator-dependent respiratory failure for 1 of 33 sampled residents (Resident #33). The deficient practice had the potential to deprive the resident of receiving effective pain management and treatment. Findings include: Resident #33 (R33) R32 was admitted on [DATE], with diagnoses including stroke with dysphagia, chronic encephalopathy, altered mental status, ventilator-dependent respiratory failure, and stage 4 pressure ulcer. A physician order dated 07/19/23, indicated to assess R32's pain every shift using a numeric rating scale from 0 to 10 as follow: 0: No Pain; 1: Mild (Pain scale: 1-3); 2: Moderate (Pain scale: 4-6); 3: Severe (Pain scale: 7-10). The order documented implementing non-pharmacologic interventions prior to medicating if appropriate if pain was present. A physician order dated 07/18/2023, documented acetaminophen 325 milligrams…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to account for narcotics signed out on the controlled drug record for 1 of 33 sampled residents (R29). The deficient practice had the potential to delay a resident's pain management and increase risk for physical and psychosocial harm. Findings include: Resident 29 (R29) R29 was admitted on [DATE] and discharged on 06/08/2023 with diagnoses including cirrhosis of the liver, gastro-esophageal reflux, and ascites. A physician order dated 06/07/2023, documented Norco oral tablet 5-325 milligrams (mg) give 1 tablet by mouth every 4 hours as needed for pain. A review of R29's controlled drug record documented Norco was signed out to be administered on 06/07/2023, 06/08/2023, and 06/09/2023. The medical record lacked documented evidence Norco was administered on 06/07/2023 or 06/09/2023. On 11/01/2023 at 9:44 AM, the Director of Nursing (DON) confirmed R29's medical record lacked documented evidence the withdrawn Norco was administered on 06/07/2023 or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure physician orders were followed for Oxygen therapy for 1 of 32 sampled residents (Resident 14), and administration of a stool softener for one unsampled resident (Resident 271). The failure to follow physician orders had the potential for the resident's treatment plan to be ineffective. Findings include: Resident 14 (R14) was admitted on [DATE], with diagnosis including chronic obstructive pulmonary disease (COPD). A 5-day MDS assessment dated [DATE], documented a BIMS score of 10 which indicated R14's cognition was moderately impaired and R4 had Oxygen. A Physician Order dated 09/01/2022, documented administer Oxygen at 3 liters per minute (LPM) via nasal cannula continuous for shortness of breath. On 11/15/2022 at 10:17 AM, R14 was observed sitting on their front wheel walker (FWW). R14 had a nasal cannula attached to a portable oxygen tank strapped to their FWW. The portable oxygen tank's gauge revealed the tank was empty. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to report signs of possible urinary tract infection (UTI) to the physician in a timely manner for 2 of 32 sampled residents (Residents 7 and 96) and ensure there was a medical justification for the continued use of a urinary catheter for 1 of 32 sample residents (Resident 134). The failure could potentially increase the risk of complications related to urinary catheters. Findings include: 1) Resident 7 (R7) was initially admitted on [DATE] and readmitted on [DATE], with diagnoses including vascular dementia, urinary tract infection, benign prostatic hyperplasia, and neurogenic bladder. On 11/15/2022 at 10:00 AM, R7 had an indwelling urinary catheter. The drainage tubing connected to the catheter and drainage bag contained cloudy urine with solid particles. A Certified Nursing Assistance (CNA) confirmed the observation and explained nurses changed the urinary drainage bags. On 11/17/2022, R7's urinary drainage tubing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an attending physician personally visited a resident for 1 of 32 sampled residents (Resident 4). The failure denied the resident the right to be seen by a physician. Findings include: Resident 4 (R4) was admitted on [DATE], with diagnoses including depression. On 11/15/2022 at 12:14 PM, R4 conveyed they have not met their attending physician. An admission Minimum Data Set assessment dated [DATE], documented R4 had a Brief Interview of Mental Status score of 11 which indicated their cognition was moderately impaired. R4's medical record revealed a Nurse Practitioner (NP) had been seeing R4, but not by the attending physician. On 11/17/2022 at 10:02 AM, the Unit Manager (UM) indicated there was an assigned attending physician to oversee R4's care which the UM had not met. The UM confirmed the History and Physical (H&P) and physician notes from 08/22/2022, 09/26/2022 and 10/31/2022 were generated by an NP and not by the attending physician. The UM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure there was documented evidence a physician was notified of the laboratory results timely for 1 of 32 sampled residents (Resident 109). The failure could potentially delay treatments and interventions. Findings include: The facility's Lab and Diagnostic Test Results - Clinical Protocol revised 09/2012, documented a physician could have been notified by phone, fax, voicemail, e-mail, pager, or a telephone message to another person acting as the physician's agent. The facility staff should document information about when, how and to whom the information was provided and the response. Resident 109 (R109) was re-admitted on [DATE], with diagnoses including hypertension. A 5-day Minimum Data Set assessment dated [DATE], documented R109 had a Brief Interview of Mental Status score of 15, which indicated R109 was cognitively intact. A Laboratory Result dated 11/02/2022, documented Extended Spectrum Beta-Lactamase (ESBL) in the supra…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and document review, the facility failed to ensure the resident's food preferences were honored for one unsampled resident (Resident 31). The failure resulted in the resident being offered disliked foods. Findings include: On 11/16/2022 at 2:05 PM, six residents attended the Resident Council meeting. The residents indicated the food served by the facility often did not match the meal ticket which reflected the resident's food preferences and dislikes. On 11/17/2022 at 8:15 AM, a Licensed Practical Nurse (LPN) was observed entering R31's room with a breakfast tray. The LPN indicated the resident required assistance with eating. On 11/17/2022 at 8:26 AM, the LPN came out of the resident's room with the resident's breakfast tray which was barely touched. The LPN reported R31 had one bite, spit out the food and refused to continue eating. R31's tray had two scoops of an unidentified golden-brown food item and a bowl of hot cereal. The meal ticket documented, Only eggs. The LPN confirmed R31's meal tickets read eggs only and the tray did not…

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

Based on observation, interview, and document review, the facility failed to ensure burned Brussels sprouts were not served to residents. The failure to provide a palatable meal had the potential to cause a decrease in the residents' appetite and, as a result, the alteration in nutritional parameters such as weight. Findings include: On 11/17/2022 at 11:00 AM, a tray line meal observation was conducted. The main meal served for lunch consisted of smothered chicken thighs, roasted brussels sprouts, buttered noodles, tomatoes, and chicken soup. It was noted some brussels sprouts had dark black discoloration. A sample of the brussels sprouts was tasted by the inspector, and it was found to have a burnt taste. The cook discarded the rest of the brussels sprouts and started cooking new ones. On 11/17/2022 at 12:30 PM, meal taste was conducted from the last meal tray cart deployed to the residents' rooms. Two meals were tasted, a regular diet and a puree diet. Puree brussels sprouts were found to have a burnt taste. The Director of Food Service confirmed the taste and verbalized the cook…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure the pneumococcal vaccine was offered and re-offered to 1 of 32 sampled resident (Resident 134) and two unsampled residents (Residents 49 and 78). The failure prevented the residents/representatives to decline or avail the vaccine. Findings include: The facility's Pneumococcal Vaccine Policy revised 10/2014, documented residents would have been offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1) Resident 134 (R134) was admitted on [DATE], with diagnoses including acute kidney failure. The Annual Minimum Data Set (MDS) assessment dated [DATE], documented R134 was unable to complete the Brief Interview of Mental Status (BIMS). The medical record revealed R134 had a next of kin. R134's medical record lacked documented evidence the pneumococcal vaccine was offered. 2) Resident 49 (R49) was re-admitted on [DATE], with diagnoses including multiple sclerosis. A Quarterly MDS assessment dated [DATE],…

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