Caremeridian Llc, DBA Neurorestorative

Based on interview and document review, the facility failed to ensure Administration: (1) verified the Infection Preventionist (IP) possessed the required training and competency to effectively educate, track, and monitor staff COVID 19 (COVID) vaccinations, and (2) ensured staff were screened for eligibility, provided education on the COVID vaccine, and offered the vaccine with documentation of acceptance or declination. This deficient practice placed the resident population at increased risk of exposure to and infection from COVID. Findings include: Infection PreventionistOn 05/05/2026 at 10:41 AM, the Regional Director of Nursing (Regional DON), who was also the previous IP, provided the Infection Control Manual to survey team. The manual did not include COVID staff infection monitoring, staff immunizations, or resident care related to COVID. On 05/06/2026 at 1:32 PM, the Director of Nursing/IP (DON/IP) confirmed the facility followed the Centers for Disease Control and Prevention (CDC) guidelines, however the DON/IP did not know which guidelines were appropriate for COVID staff…

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

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met.Findings include:During the entrance conference with the facility on 05/04/2026, a list of residents who smoke residing in the facility was provided by the facility.The list identified three residents as smokers, including one resident who was a vaper, which was technically distinct from smoking. The designated smoking location was off the main entrance parking lot which resident smokers accessed by exiting the facilities main entrance.The current Facility Assessment, dated 01/08/2026, did not include nicotine abuse or addiction nor a list of the number of active or current substance abuse disorders.On 05/07/2026 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.

Based on observation, interview, and document review, the Quality Assurance and Process Improvement (QAPI) committee failed to identify the QAPI committee did not include the required members.Findings include: On 05/06/2026, the facility provided the sign in sheet of QAPI Committee members present at the Performance Improvement Committee Meeting dated 01/29/2026, documenting the QAPI committee was comprised of the Administrator, the Director of Nursing (DON), Director of Rehabilitation, Maintenance Director, Medical Director, and direct care staff. There was not an Infection Preventionist (IP) in attendance of the meeting. On 05/07/2026 at 3:54 PM, the Administrator verbalized the facility did not have the Infection Preventionist at the QAPI meeting on 01/29/2026. The Administrator confirmed the facility did not have all of the required members involved in the QAPI meeting when the IP did not attend the first quarter of 2026 QAPI meeting.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) Isolation Precautions were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 12 sampled residents (Resident #15), and 2) the Infection Prevention and Control Plan (IPCP) included all of the required elements. These deficient practices had the potential to increase the risk of spreading infectious organisms throughout the facility.Findings include: Isolation Precautions Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of chronic respiratory failure with hypoxia. A physician's order dated 05/03/2026, documented Isolation Precautions for seven days for human rhinovirus or enterovirus or until symptoms resolve every shift for upper respiratory infection (URI) isolation for seven days. A Care Plan focus revised 05/04/2026, documented Resident #15 was on Droplet Precautions…

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

Based on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely for 2 of 19 sampled employees (Employee #5 and #11). This deficient practice had the potential to place all residents at risk for abuse and neglect.Findings include: Employee #5Employee #5 was hired as a Registered Dietician on 01/07/2025.Employee #5's personnel record included initial abuse prevention training completed on 01/07/2025, and annual abuse prevention training completed on 01/14/2026, 7 days late.Employee #11Employee #11 was hired as a Registered Nurse (RN), hire date unknown.Employee #11's personnel record lacked documented evidence of abuse prevention training.On 05/06/2026 at 9:06 AM, the Office Manager (OM) verbalized all staff were required to complete abuse prevention training initially upon hire and annually by the anniversary date. The OM verbalized the OM was unable to identify when Employee #11 started at the facility, however confirmed Employee #11 worked in the facility with resident contact. The OM confirmed…

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

Based on interview, personnel record review, and document review, the facility failed to ensure behavioral health care training was completed timely for 3 of 19 sampled employees (Employee #5, #11, and #16). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.Findings include:Employee #5Employee #5 was hired as a Registered Dietician on 01/07/2025.Employee #5's personnel record included initial behavioral health care training completed on 01/07/2025, and annual behavioral health care training completed on 01/14/2026, 7 days late.Employee #11Employee #11 was hired as a Registered Nurse (RN), hire date unknown.Employee #11's personnel record lacked documented evidence of behavioral health care training.Employee #16Employee #16 was hired as a Certified Nursing Assistant (CNA) on 07/01/2025.Employee #16's personnel record included initial behavioral health care training completed 12/30/2025, 152 days lateOn 05/06/2026 at 9:06 AM, the Office…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review, the facility failed to ensure 1 of 10 sampled residents (Resident #4) was treated with respect and dignity when the resident's belongings were not inventoried and were removed from the resident's room without notification. This deficient practice had the potential to result in psychosocial harm to the resident and misappropriation of resident property. Findings include:Resident # 4Resident #4 was admitted to the facility on [DATE], with diagnoses including cerebral palsy, developmental disorder of motor function, and dysphagia.Resident #4's inventory list dated 10/13/2023, documented three coats, one shoes, three shirts, two sweaters, three slacks, one pajama, three socks, one bra, one E-Reader/iPad, one backpack, one stuffed plush animal, one bag hair ties, one bag hair accessories, one wheelchair tool kit, one two-piece bathing suit, one iPad stand, wheelchair and two cushions.An email from Resident #4's Guardian to the Social Worker…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an allegation of abuse was reported to the State Agency (SA) for 1 of 10 sampled residents (Resident #6). This deficient practice had the potential to prevent timely investigation of abuse allegations and leave residents vulnerable to abuse.Findings include:Resident #6Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, recurrent, unspecified, and generalized anxiety disorder.Resident #6's alert progress notes dated 02/10/2026 at 5:37 PM and 5:38 PM, documented Resident #6 was picked up from school due to behaviors. When the resident returned to the facility, the resident was calm and collected. Toileting was performed after school and the resident reported to the floor Certified Nursing Assistant (CNA) the resident was 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 interview, clinical record review, and document review, the facility failed to ensure an allegation of abuse was investigated for 1 of 10 sampled residents (Resident #6). This deficient practice had the potential to leave residents vulnerable to abuse.Findings include:Resident #6Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, recurrent, unspecified, and generalized anxiety disorder.Resident #6's alert progress notes dated 02/10/2026 at 5:37 PM and 5:38 PM, documented Resident #6 was picked up from school due to behaviors. When the resident returned to the facility, the resident was calm and collected. Toileting was performed after school and the resident reported to the floor Certified Nursing Assistant (CNA) the resident was being abused by the teacher and mentioned the teacher by name. The resident started to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview and document review, the facility failed to document the specific resident needs the facility could not meet and attempts to meet the resident's needs when the facility declined to readmit a resident following an acute care hospitalization for 1 of 10 sampled residents (Resident #2). This deficient practice had the potential for residents to be discharged from the facility without a safe discharge plan.Findings include:Resident #2Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia, quadriplegia, C1-C4 complete, and dependence on respirator (ventilator) status.An Admission/Discharge To/From Report documented Resident #2 was discharged from the facility to an acute care hospital on [DATE].A Nursing Shift Summary note dated 06/20/2025 at 2:40 PM, documented Resident #2 was alert and oriented to person, communicated verbally and was able to make basic needs known. The 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 clinical record review, interview and document review, the facility failed to provide written notice of the facility's bed-hold policy to a resident and the resident's representative upon transfer to an acute care hospital for 1 of 10 sampled residents (Resident #2). This deficient practice had the potential to result in psychosocial harm to residents due to not being able to return to the resident's previous room. Findings include:Resident #2Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia, quadriplegia, C1-C4 complete, and dependence on respirator (ventilator) status.An Admission/Discharge To/From Report documented Resident #2 was discharged to an acute care hospital on [DATE].A Social Services Progress Note dated 06/20/2025 at 3:02 PM, documented the Social Worker (SW) notified Resident #2's guardian of the physician's recommendation to transfer Resident #2 to an acute care hospital for surgical evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records were complete and accurate for 1 of 10 sampled residents (Resident #7). This deficient practice had the potential to result in duplicate administration of treatments/medications to residents and for residents' response to care provided and refusals of care to not be documented and available for review as necessary.Findings include:Resident #7Resident #7 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia and cystic fibrosis with pulmonary manifestations.Resident #7's February 2026 Respiratory Administration Record (RAR), documented the following:-Check emergency equipment at bedside including manual resuscitator every shift. The start date was 02/02/2026. Scheduled administrations on the RAR lacked documentation of the completion of the task and were left blank on 02/08/2026, 02/17/2026, 02/19/2026, and 02/23/2026.-Continuous pulse oximetry every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Assessment (FA) included all portions of the facility's resident population and any ethnic, cultural or religious factors with the potential to affect the care provided by the facility. This deficient practice had the potential to deprive residents of necessary care and services to meet each resident's individual needs and preferences. Findings include: The FA, approved by the Administrator on 01/16/2025, documented the facility provided a continuum of post-acute care and rehabilitation to children. The facility accepted infants to young adults. The section of the FA titled resident population, type of unit, and census documented the facility was designed to provide children with a safe, home-like environment, while receiving specialized, skilled care. The facility had created an atmosphere favorable to young patients' recovery including distinctly decorated rooms and rehabilitation equipment specifically designed for children. The FA lacked documentation related to the facility's adult 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 and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure corrective action was implemented to address identified problems related to the lack of Enhanced Barrier Precautions (EBP) for residents with a chronic wound or indwelling medical device. This deficient practice had the potential to result in the exposure of all residents, staff and visitors to harmful infectious agents. Findings include: On 02/21/2025 at 10:28 AM, during the QAPI review with the Administrator, the Administrator verbalized the facility had not identified a concern related to the lack of EBP for residents with a chronic wound or indwelling medical device until the middle of January 2025. The Administrator confirmed when the facility was made aware, no EBP was implemented and no current residents of the facility had EBP. The job description for facility Administrator dated 11/29/2011, documented the Administrator was responsible for the Performance Improvement Program. Cross reference with F880.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure 1) Enhanced Barrier Precautions (EBP) were implemented for 20 of 20 residents with an indwelling medical device (Resident #2, #14, #8, #23, #17, #10, #15, #6, #9, #228, #5, #7, #1, #20, #4, #176, #19, #3, #227, and #12) according to the facility's policy, training provided at a staff meeting, and Centers for Disease Control (CDC) guidance, 2) an increase in respiratory infections in the pediatric unit was investigated and control measures were implemented for 4 of 9 residents with infections in December 2024 (Resident #7, #17, #15, and #3) and 3) quarterly legionella testing was completed according to the facility's water management program. These deficient practices had to the potential for transmission of infectious diseases among all residents and staff in the facility without adequate identification, surveillance, and implementation of control measures. Findings include: Enhanced Barrier Precautions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident grievances were documented, investigated and a determination and/or resolution was provided to the resident(s). This deficient practice had the potential to result in a resident having an unresolved grievance. Findings include: The Resident Council Meeting Minutes dated 01/06/2025, documented the residents' concern of the facility not having responded to written submitted grievances. During the Resident Council Meeting with the surveyors on the morning of 02/19/2025, one resident verbalized the facility had yet to respond to a written grievance the resident submitted in December 2024. On 02/20/2025 at 4:47 PM, the Administrator verbalized the facility did not have documented complaints or grievances from residents as the binder where the grievance forms were kept could not be located. The Administrator verbalized the binder had been missing since the Licensed Social Worker left employment with the facility several weeks previous, and the facility had not made attempts to re-create or gather the missing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remove expired medications from the active supply in 2 of 2 medication storage rooms and 2 of 3 medication carts reviewed for medication storage. This deficient practice had the potential for expired medications to be administered to residents. Findings include: On 02/19/2025 at 3:10 PM, in the presence of a Licensed Practical Nurse (LPN), the medication cart in the 400 unit was inspected. A bottle of Diphenhydramine Hydrochloride (HCl), oral solution 12.5 milligrams (mg)/ 5 milliliters (ml) was found in the cart, stored with active medications. The expiration date printed on the bottle was January 2025. The LPN confirmed the bottle of Diphenhydramine HCl had expired at the end of January 2025. On 02/19/2025 at 3:22 PM, in the presence of the LPN, the medication storage room on the 400 unit was inspected. The following items were found in the cabinets in the medication storage room: -Three bottles of Iron supplement liquid 220 mg/ 5 ml. The expiration date printed on the bottles was December 2024. -One…

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

Based on personnel record review, interview and document review, the facility failed to ensure initial and annual elder abuse prevention training was completed timely for 6 of 18 sampled employees (Employees #2, #3, #6, #7, #10, and #11). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include: Employee #2 Employee #2 was hired as the Director of Nursing (DON) on 12/20/2024. Employee #2's personnel record lacked documented evidence elder abuse prevention training was completed upon hire. Employee #3 Employee #3 was hired as the Registered Dietician on 10/18/2018. Employee #3's personnel record documented elder abuse prevention training completed 10/06/2022, however lacked documented evidence elder abuse training was completed in 2024. Employee #6 Employee #6 was hired as a Certified Nursing Assistant (CNA) on 09/20/2023. Employee #6's personnel record documented elder abuse prevention training completed 09/26/2023, however lacked documented evidence elder abuse training was completed in 2024. Employee #7 Employee #7 was hired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to provide the Center for Medicare and Medicaid Services (CMS) Form 10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN), and Form 10123, Notice of Medicare Non-Coverage (NOMNC) for 1 of 2 residents discharged from a Medicare covered Part A stay with benefit days remaining within the previous six months (Resident #26). This deficent practice had the potential to negatively impact the resident(s) ability to make informed decisions about their care. Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including essential primary hypertension and generalized muscle weakness. Resident #26's documented Medicare Part A Skilled Services Episode start date was 12/20/2024. The documented last covered day of Part A services was 02/02/2025. Resident #26's record lacked documented evidence of having received either form CMS-10055 or form CMS-10123. On 02/19/2025 at 12:36 PM, the…

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

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 comfortable, homelike environment when a resident had reported the exit door for employees in the 200 Hall had been closing loudly resulting in disruption in the resident's sleep for 1 of 11 residents in the 200 Hall (Resident #2). This deficient practice had the potential to affect the resident's sleep patterns by exposing the resident to unnecessary noise disturbances, potentially leading to a less comfortable living environment. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including circadian rhythm sleep disorder, free running type, and sleep disorder, unspecified. On 02/19/2025 at 10:49 AM, Resident #2 verbalized having submitted a grievance in December 2024, about the exit door in the 200 Hall closing loudly when staff would exit the facility waking up the resident several times a night. The resident verbalized the facility had yet to address the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review the facility failed to ensure 1 of 12 sampled residents (Resident #17) was kept safe from neglect by a Respiratory Therapist (RT). This deficient practice had the potential for the resident to experience emotional and physical harm. Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, disorders of diaphragm, dependence on respiratory (ventilator) status, and tracheostomy status. A Facility Reported Incident (FRI) initial and final report dated 11/05/2024, documented an allegation an RT did not provide physician ordered care to Resident #17. The concern was reported by the resident's family member on 10/30/2024. The allegation of neglect was substantiated by the facility. On 02/18/2025 at 4:10 PM, Resident #17's family member recalled a concern related to Resident #17 requiring transfer to 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, record review, and document review, the facility failed to ensure a resident was protected from misappropriation of personal property for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to result in resident's limited access to financial resources as well as mental and emotional harm. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and discharged on 01/22/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. A Facility Reported Incident (FRI) was submitted to the State Agency on 01/07/2025, documenting an allegation of misappropriation of resident property involving the facility Administrator and the previous Recreational Therapist when resident property was commingled with facility petty cash. The FRI documented the alleged incident occurred around 12/20/2025, and the Interim Administrator was notified of the allegations on 01/07/2025. 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 Resident #25 Resident #25 was admitted to the facility on [DATE], and discharged on 01/22/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. An FRI was submitted to the SA on 01/07/2025, documenting an allegation of misappropriation of resident property involving the facility Administrator and the Recreational Therapist when resident property was commingled with facility petty cash. The FRI documented the alleged incident occurred around 12/20/2024, and the interim Administrator was notified of the allegations on 01/07/2025. A grievance form filled by the previous Assistant Director of Nursing (ADON) dated 12/26/2024, documented Resident #25 signed out the resident's wallet from the lock box in the Administrator's office, and noticed 100 dollars in cash was missing from the resident's property. The previous ADON calculated the resident's cash and confirmed the missing money. A witness statement from a Registered Nurse (RN), dated 02/03/2025,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview and document review, the facility failed to ensure an investigation of a Facility Reported Incident (FRI) related to a resident fall was available for State Agency to review for 1 of 4 residents investigated for FRI (Resident #1). This deficient practice had the potential to affect all residents, resulting in incomplete investigations of potential incidents of abuse and neglect. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including spastic diplegic cerebral palsy, diabetes insipidus, and contractures of the right and left knees. Resident #1's Care Plan revised 07/03/2024, documented the resident had a fall with injury on 07/01/2024, and to follow the facility's fall protocol. A Final FRI report submitted by the facility; documented Resident #1 had a fall in the resident's room while receiving care on 07/01/2024. The resident was assessed, and an X-ray was ordered. The FRI report lacked documentation where the fracture…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 not meeting the circumstances of discharge requirements was permitted to remain in the facility for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to result in an unnecessary and unsafe discharge. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and discharged on 01/22/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #25's progress notes documented the following: -On 01/22/2025 at 9:57 AM, Resident #25 was emotionally upset and angry about information received regarding a recent medical diagnosis and requested to get a second opinion. -On 01/22/2025 at 11:17 AM, Resident #25 requested to go to the store, and the request was denied by the physician related to blood sugar instability. -On 01/22/2025 at 11:35 AM, Resident #25 was noted to be gone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Based on interview, clinical record review, and document review, the facility failed to ensure a resident received written notification of discharge prior to discharge for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to prevent the resident from being informed of the date of, reason for, and right to appeal the discharge. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and discharged on 01/22/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #25's progress notes documented the following: -On 01/22/2025 at 9:57 AM, Resident #25 was emotionally upset and angry about information received regarding a recent medical diagnosis and requested to get a second opinion. -On 01/22/2025 at 11:17 AM, Resident #25 requested to go to the store, and the request was denied by the physician related to blood sugar instability. -On 01/22/2025 at 11:35 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and clinical record review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 12 sampled residents (Resident #19). This deficient practice had the potential to deprive the resident of a person-centered care plan and the associated interventions and services relative to their current health management needs. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with a primary diagnosis of hemiplegia, unspecified affecting left nondominant side. An admission MDS assessment dated [DATE], Section K - Swallowing/Nutritional Status, documented Resident #19 had a weight loss of 5 percent (%) or more in the last month or a loss of 10% or more in the last six months without being on a physician prescribed weight-loss regimen. A weights and vitals summary dated 02/20/2025, documented the following weights taken prior to or on the 01/02/2025 date of the MDS assessment: -152.7 pounds on 12/26/2024. On 02/19/2025 at 5:33 PM, the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge assessment and plan was completed prior to discharge, and medications were provided to a discharged resident for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to prevent the resident from having a safe discharge and could result in inadequate post-discharge care coordination. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and discharged on 01/22/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #25's progress notes documented the following: -On 01/22/2025 at 9:57 AM, Resident #25 was emotionally upset and angry about information received regarding a recent medical diagnosis and requested to get a second opinion. -On 01/22/2025 at 11:17 AM, Resident #25 requested to go to the store, and the request was denied by the physician related to blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel record review, document review, and interview, the facility failed to ensure direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for 2 of 12 sampled direct care employees (Employee #14 and #16). This deficient practice could result in a negative outcome for a resident requiring CPR while awaiting the arrival of emergency medical personnel. Findings include: Employee #14 Employee #14 was hired as a Licensed Practical Nurse (LPN) with a start date of [DATE]. The LPN's personnel record documented CPR training and certification expired on 09/2024. Employee #16 Employee #16 was hired as a Certified Nursing Assistant (CNA) with a start date of [DATE]. The CNA's personnel record documented CPR training and certification expired on 08/2024. On [DATE] at 12:58 PM, the Office Manager verbalized CPR certification was required to be taken by all direct care staff and confirmed Employees #14 and #16 did not have a current CPR certification. The Facility Assessment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #6). This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of insevice education/training. Findings include: Employee #6 Employee #6 was hired on 09/20/2023, as a CNA. Employee #6's personnel record lacked documented evidence an annual performance review had been conducted by the employee's anniversary date of 09/20/2024. On 02/20/2025 at 1:30 PM, the Office Manager confirmed Employee #6 did not have an annual performance evaluation for 2024 and Employee #6's annual performance evaluation for 2024 was completed late and the annual performance evaluation had not been completed for 2025. The Office Manager verbalized all CNAs were required to have an evaluation every year by the hire date and they were to be completed by the Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure an as needed (PRN) psychotherapeutic medication was prescribed to a resident with a diagnosed indication for use, was limited to 14 days, was monitored for side effects, and had behavior monitoring for 1 of 12 sampled residents (Resident #19). This deficient practice had the potential to result in an unmanaged medication regimen, missed signs of worsening condition, and compromised resident safety. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with a primary diagnosis of hemiplegia, unspecified affecting left nondominant side. An active physician's order dated 01/08/2025, documented Hydroxyzine Hydrochloride (HCl) oral tablet, give 25 milligrams (mg) via gastrostomy (g) tube every 24 hours PRN for episodes of feeling anxious or stressed over recent life changes. Resident #19's electronic health record (EHR) lacked documentation of an anxiety diagnosis. Resident #19's physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physical therapy (PT) frequency of treatment was provided per the physician's order for 1 of 12 sampled residents (Resident #3). This deficient practice had the potential to prevent residents from attaining or maintaining the residents' highest practicable level of strength, balance, and endurance. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including spastic quadriplegic cerebral palsy, muscle weakness (generalized), and abnormal posture. A Physician's Order dated 01/08/2025, documented PT quarterly reassessment completed. Recommend skilled PT one hour per week for 12 weeks to improve strength, endurance, balance, and overall functional activity tolerance. Resident #3's Care Plan documented Resident #3 had limited physical mobility and was a high fall risk related to diagnoses of spastic quadriplegic cerebral palsy and muscle weakness. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure 1) residents with psychotherapeutic medications had a documented pre-restraining assessment per facility policy for 5 of 5 residents sampled for unnecessary medications (Residents #9, #17, #2, #13, and #19) and 2) a consent had been obtained for a psychotherapeutic medication per the facility's policy for 1 of 5 residents sampled for unnecessary medications (Resident #9). This deficient practice had the potential to result in the accidental use of psychotherapeutic medications as chemical restraints and residents receiving psychotherapeutic medications prior to being informed of the risks and benefits of the medication. Findings include: Pre-restraining assessment Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including spastic hemiplegic cerebral palsy, unspecified, emotional and behavioral disorder, unspecified, and generalized anxiety, unspecified. A physician's order 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.

Based on interview, and document review the facility failed to ensure education regarding the facility's Antimicrobial Stewardship Program (ASP)/antibiotic use was provided to staff and facility staff documented an evaluation to determine if residents met or did not meet McGeer criteria, according to the facility's program/policy, prior to initiation of antibiotic therapy. This deficient practice had the potential to affect all residents in the facility and placed residents at risk of developing antibiotic-resistant infections. Staff training On 02/19/2025 at 2:45 PM, a Registered Nurse (RN) verbalized the RN had worked for the facility for approximately one year. The RN denied the RN had received any training related to the facility's antimicrobial/antibiotic stewardship program. The RN verbalized the facility did not have an antibiotic stewardship program, did not perform antibiotic timeouts, and all decisions related to prescribing of antibiotics were made by the physician. On 02/20/2025 at 12:01 PM, the Regional Support Director of Nursing (RSDON)/Infection Preventionist (IP)…

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

Based on interview and document review, the facility failed to provide twelve hours of in-service training as a result of performance evaluations for 2 of 2 sampled Certified Nursing Assistants (CNA) who have been with the facility for more than one year. This deficient practice had the potential to place all residents at risk of receiving care from staff without the required knowledge and competency to perform their duties. Findings include: Employee #6 Employee #6 was hired on 09/20/2023, as a CNA. The employee's personnel record lacked documented evidence an annual performance review had been conducted by the employee's anniversary date of 09/20/2024. Employee #7 Employee #7 was hired on 02/17/2023, as a CNA. The employee's personnel record documented an annual performance review had been conducted on 07/11/2024, 145 days after the employee's anniversary date of 02/17/2024. Employee #7's personnel record lacked documented evidence an annual performance review had been conducted by the employees anniversary date of 02/17/2025. On 02/20/2025 at 1:30 PM, the Office Manager confirmed…

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

Based on observation, interview, and document review, the facility failed to ensure food was discarded per facility policy, properly labeled, food was properly stored, hand hygiene was performed during a trayline observation, and a high temperature dishwasher reached 180 degrees Fahrenheit (F) on the rinse cycle. Findings include: Labeling, Discarding and Storage of Food On 01/29/24 at 8:48 AM, in the reach-in refrigerator, the following items were located: -salad kit Caesar salad 11.55 ounces (oz) and dressing 3 fluid (fl) oz with a receive date of 01/11 and best use by date 01/19. -shredded mild cheddar cheese 5 pound (lb) bag opened and dated 01/11. -California pasta salad 5 lb bag opened and dated 01/11. -sliced deli meat wrapped in saran wrap and dated 01/18. On 01/29/24 at 8:57 AM, the [NAME] verbalized opened food must be labeled with what it is, the date it was made or the date it was opened. Most opened food had a use by date of three days then discard. On 01/29/24 at 8:59 AM, the [NAME] verbalized and confirmed the following: -Caesar salad kit and dressing was in good…

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

Based on observation, interview and document review, the facility failed to ensure the dietary staff followed the menu or requested approval from the Registered Dietician to change the menu, prior to preparing and plating the meal, and posted the substitution for residents. Findings include: On 02/01/24, the Weekly Menu posted on the wall, outside of the kitchen for residents to view, indicated lunch was hamburger steak and onions, steamed red potatoes and maple roasted carrots. On 02/01/24 at 12:00 PM, the Dietary and Food Kitchen Supervisor (Supervisor) and [NAME] were plating the resident lunch trays. They were serving beef tacos, chips and guacamole. The Supervisor explained having made the decision to change the menu to tacos, chips and guacamole because the [NAME] and Supervisor like to have tacos on Thursdays when the two work together. The Supervisor confirmed the facility did not notify the residents of the menu change or request approval for the menu change from the Registered Dietician (RD). The Supervisor explained the RD had instructed the Supervisor to write down menu…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident or resident representative gave informed consent prior to the administration of a psychotropic medication for 2 of 12 sampled residents (Resident #17 and #77). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder. Resident #17's physician's orders for Lexapro were as follows: -Start date of 08/09/23, Lexapro oral tablet 20 milligrams (mg), give one tablet via nasojejunal (NJ)-Tube at bedtime for antidepressant. Discontinued 09/20/23. -Start date of 09/20/23, Lexapro oral tablet 20 mg, give one tablet via NJ-Tube at bedtime for depression. Discontinued 09/26/23. -Start date of 09/26/23, Lexapro oral tablet 20 mg, give one tablet orally at bedtime for depression. Discontinued 11/15/23. -Start date of 11/15/23, Lexapro oral tablet 10 mg, give 10 mg by mouth one time a day for depression. Dose is 15 mg daily, give one 10 mg tab with one 5 mg tab. Discontinued…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident Council was able to meet as a group. Findings include: On 01/29/24 at 3:36 PM, the Activities Director verbalized residents in the facility did not meet as a group for resident council meetings. The Activities Director explained residents had verbally declined to participate as a group in resident council, however the declination was not documented. The Activities Director conducted one-on-one meetings with each resident to review rights with residents in lieu of group resident council meetings. The Activities Director explained if residents wanted to participate in group resident council meetings, the resident council meeting would be held in the adult dining room. The Activities Director confirmed the adult dining room did not have doors to enable residents to meet in private. Resident Council Notes dated 11/29/23, indicated all residents visited one-to-one for rights review. The document indicated the meeting started at 9:00 AM and adjourned at 9:50 AM. Eight residents were visited. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure a care plan for resident discharge and a careplan for medication with side effect monitoring was developed for 4 of 12 sampled residents (Resident #24, #76, #77, and #78). Findings include: Resident #24 Resident #24 was admitted to the facility on [DATE], with diagnoses including perforation of intestine (nontraumatic), acute respiratory failure with hypoxia, dysphagia, and Parkinson's disease with dyskinesia, with fluctuations. On 01/31/24 at 9:17 AM, Resident #24 verbalized the resident was informed they were close to discharge; however, the resident did not know when discharge would take place. Resident #24's Comprehensive Care Plan lacked a care plan for discharge. An Interdisciplinary Team (IDT) Conference dated 01/02/24, documented Resident #24 was at nursing home short term for rehabilitation services, would discharge when safe. On 01/31/24 at 9:28 AM, the Licensed Social Worker (LSW) verbalized discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Comprehensive Care Plan was updated to include the care and interventions for wounds, infections, and falls for 3 of 12 sampled residents (Resident #4, #18, and #77). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including presence of prosthetic heart valve, pulmonary hypertension, unspecified, and long-term use of anticoagulants. Resident #4's Order Summary Report dated 12/01/23, documented the following: -Right Lower Extremity (RLE) wound care: Cleanse with normal saline. Apply hydrocolloid dressing. Monitor for signs and symptoms of infection every 72 hours, replace dressing every three days until healed. Active 10/31/23. Resident #4's Weekly Skin Check dated 01/18/24, documented there was a skin condition, injury, or skin change noted to the right front lower leg and had an open area being treated with hydrocolloid. A Licensed Nurse Shift Document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessment for entraptment were completed, alternatives were attempted, and informed consent was obtained prior to installation of side rails for 1 of 12 sampled residents (Resident #76). Findings include: Resident #76 Resident #76 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, osteomyelitis of vertebra, thoracic region, and muscle weakness. On 01/29/24 at 10:15 AM, Resident #76's was in bed with the upper and lower side rails in the up position on both sides of the bed. On 01/30/24 at 8:15 AM, Resident #76's was in bed with the upper and lower side rails in the up position on both sides of the bed. On 01/31/24 at 4:35 PM, Resident #76's was in bed with the upper and lower side rails in the up position on both sides of the bed. On 01/31/24 at 4:37 PM, a Licensed Practical Nurse (LPN) confirmed Resident #76 had upper and lower side rails in the up position on both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical supplies were removed from 1 of 3 medication carts. Findings include: On [DATE] at 9:02 AM, the facility's medication cart on the Pediatric unit was inspected with the Director of Nursing (DON). The cart contained the following expired medical supplies: -Five Medex Hi-flo three-way stopcocks, expired on [DATE]. On [DATE] at 9:06 AM, the DON confirmed the medical supplies were expired per the manufacturer's expiration date. The DON explained the concern of using the expired medical supplies was the device could fail and not work as intended due to poor integrity of the expired device. The devices were used for fluid transfusions and tube feedings. The DON confirmed expired medical supplies in the medication cart was not allowed and should have been removed from the cart. A facility policy titled Storage and Expiration of Medications, Biologicals, Syringes, and Needles, last revised [DATE], documented the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary staff were trained to understand the type of sanitization performed by the dishwashing machine (dishwasher) and to accurately and effectively monitor the temperature of the rinse cycle on the high temperature dishwasher. Findings include: The Dietary and Food Kitchen Supervisor had a start date of 06/29/23. A [NAME] had a start date of 01/04/24. On 01/29/24 at 8:29 AM, the [NAME] verbalized working Monday - Thursday and together with the Dietary and Food Kitchen Supervisor only on Thursdays. The dietary staff consisted of two employees. On 01/30/24 at 12:11 PM, the [NAME] verbalized the dishwasher used sanitizer to sanitize the dishes but did not know how to check the sanitizer levels because the Dietary and Food Kitchen Supervisor usually did it. The [NAME] confirmed the highest temperature the dishwasher had reached was 175 degrees Fahrenheit (F). On 01/31/24 at 9:12 AM, the [NAME] verbalized the dishwasher was a high temperature dishwasher for sanitizing. The [NAME] ran the dishwasher and…

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

Based on observation, interview, and document review, the facility failed to ensure the outside receptacles were sealed (lid closed) and free of debris on the surrounding pavement. Findings include: On 01/29/24 at 9:25 AM, the two garbage receptacles outside were filled over the top with garbage. The lids of both receptacle were not closed. To the right of the two garbage receptacles, on the ground, was a used enteral nutrition bag (bag for tube feeding) with tubes attached. On 01/29/24 at 9:28 AM, the [NAME] explained the outside trash receptacles needed to be closed at all times to avoid animals to getting inside. On 01/29/24 at 9:32 AM, the Administrator confirmed the receptacles did not have the lids closed, concealing the garbage inside. The Administrator confirmed the bag for tube feeding was on the ground, to the right of the receptacles and verbalized it was a bag of Glucerna for tube feeding. The Administrator confirmed the receptacles should have the lids closed and the area should be free of debris.

Based on interview and document review the facility failed to ensure quarterly payroll-based staffing (PBJ) requirements were submitted to Center for Medicare and Medicaid Services (CMS). The failure to submit PBJ data prevented CMS to analyze staffing patterns and populate the staffing component of the Nursing Home Compare website. Findings include Review of the facility Certification and Survey Provider Enhanced Reporting System (CASPER) Report revealed the facility had no submission of staffing data for the fourth quarter of 2023. On 01/31/24 at 2:23 PM, the Administrative Assistant indicated the facility had not submitted PBJ data for a couple of months due to a vacancy in the position. On 01/31/24 at 2:25 PM, the Administrator confirmed PBJ data was not submitted for a short period of time.