Kimes Nursing and Rehab LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, policy review, and review of Legionella prevention maintenance records, the facility failed to implement their infection prevention and control program (standard precautions, enhanced barrier precautions and Legionella prevention) to prevent the spread of infection. This affected three residents (#2, #21, #57) of 27 residents reviewed for infection control concerns and had the potential to affect all 56 residents residing in the facility. Findings include: 1.Review of the record for Resident #57 revealed an admission date of 09/03/25 and diagnoses including diabetes, hypertension, and cerebral palsy. Resident #57 had deep tissue pressure ulcers to the left and right heels with a treatment order 05/06/26 to cleanse areas with wound wash, pat dry, apply betadine to wound and leave open to air every day. Observation of the treatment to the heels on 05/19/26 at 7:15 A.M. revealed Licensed Practical Nurse (LPN) #105 to place the treatment supplies, including…

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

Based on review of personnel files and interviews, the facility failed to ensure facility staff received a minimum of 12 hours of in-services per year. This affected 56 of 56 residents living in the facility. Findings include:1.Review of the personnel file for Certified Nursing Assistant (CNA) #125 revealed she was hired on 10/12/23. Further review of her file revealed no evidence she had received at least 12 hours of in-service education annually. 2.Review of the personnel file for CNA #151 revealed she was hired on 08/14/23. Further review of her file revealed no evidence she had received at least 12 hours of in-service education annually. 3.Review of the personnel file for CNA #132 revealed she was hired on 09/16/21. Further review of her file revealed no evidence she had received at least 12 hours of in-service education annually. Interview on 05/27/26 at 9:07 A.M. with Human Resources (HR) #163 confirmed CNA #125, #151, and #132 had no evidence they had completed at least 12 hours of in-services annually.

Based on review of resident financial records, staff interview, and policy review, the facility failed to ensure residents had access to petty cash on an ongoing basis to include evenings and weekends. This could affect the seven residents whose personal funds were handled by the facility (#2, #6, #13, #25, #26, #27, and #43) of the seven residents reviewed for funds. The facility census was 56. Findings include: Review of resident personal funds records revealed the facility managed the personal funds for seven residents (Residents #2, #6, #13, #25, #26, #27, and #43). Interview with Business Office Manager #186 on 05/26/26 at 9:25 A.M. revealed residents, whose funds are handled by the facility, have access to petty cash at all times. She stated that business office staff are available Monday through Friday from 8:00 A.M. to 4:30 P.M. She stated that if a resident wanted money outside of those times, including weekends, there was a box behind the desk on the rehab unit that contained petty cash. She stated the rehab nurse had the key and would be able to get money out for 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, staff interview, and resident interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, to include the resident and resident representative and individuals who have knowledge of the resident and his/her needs, after each comprehensive and quarterly assessment. This affected four residents (#3, #5, #9, and #10) of 27 sampled residents reviewed for plans of care. The facility census was 56. Findings include:1.Review of the record for Resident #3 revealed an admission date of 03/07/24 and diagnoses including End Stage Renal Disease with dialysis, diabetes, and hypertension. An annual Minimum Data Set (MDS) assessment completed 03/14/26 documented a brief interview for mental status score of 15, indicating intact cognition. Interview with Resident #3 on 05/17/26 at 1:32 P.M. revealed he had not participated in a care plan meeting in the last six months. He stated he would like to have one and in previous meetings his daughter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs including drugs used without adequate indication for use. This affected four residents (#7, #22, #53, #72) of five residents reviewed for unnecessary medications. The facility census was 56.1.Review of the record for Resident #7 revealed an admission date of 01/13/26 and diagnoses including acute and chronic respiratory failure, hypertension, anxiety disorder, morbid obesity, and status post pneumonia. Record review revealed a physician's order 05/04/26 for Prednisone ( a steroid medication) 40 milligrams in the morning for seven days for cold symptoms. Review of the medication administration record for May 2026 revealed the Prednisone 40 milligrams was given daily from 05/05/26 to 05/20/26 (16 days instead of 7). Interview with the Director of Nursing (DON) on 05/20/26 at 10:35 A.M. confirmed the Prednisone was ordered for seven days. She stated a stop date was not put into the…

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

Based on observation, review of meal tickets, review of the facility's menu/ spreadsheet for specialty diets, review of diet orders, interview, and policy review, the facility failed to ensure all residents receiving a carbohydrate controlled diet (CCD) received the appropriate serving size of the dessert food item served during the lunch meal on 05/19/26. This affected two residents (Resident #58 and #65) and had the potential to affect 19 other residents (Resident #1, #3, #4, #5, #6, #13, #16, #21, #26, #27, #29, #31, #39, #40, #42, #50, #53, #56, and #57), who the facility identified as receiving a carbohydrate controlled diet. Findings include: On 05/19/26 at 11:10 A.M., an observation of the tray line for the lunch meal being served to the residents was completed to ensure diets were provided as ordered and appropriate serving sizes were served. The facility served regular diets, mechanically altered diets, pureed diets, CCD's, renal diets, and large portion diets. Two residents' meal tickets were observed during the tray line that identified those two residents (Resident #58…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and policy review, the facility failed to ensure documentation in the medical record was completed accurately to reflect residents' status. This affected four residents (#4, #5, #13, and #56) of 27 residents reviewed for accuracy of medical records. The facility census was 56. Findings include: 1.Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including multiple fractures of the ribs and muscle weakness. Review of a minimum data set (MDS) dated [DATE] revealed Resident #4's cognition remained intact, he had no behaviors, and he had skin tears. Review of a care plan dated 04/23/26 revealed Resident #4 was at risk for bruising related to bruising currently to bilateral upper extremities (BUE)and torso due to fall at home. The goal was for bruising to fade and disappear without any complications. Interventions included but were not limited to observe area and document any noted concerns, remind resident to alert staff if they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure a resident receiving an anti-depressant received education on the risks and benefits of taking that medication to allow them to provide informed consent. This affected one resident (#44) of five residents reviewed for unnecessary medications. Findings include:Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with mood disturbance, depression, and anxiety disorder. Review of Resident #44's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. Review of Resident #44's contact list on her admission Record (Face Sheet) revealed her emergency contact/ resident representative was an attorney that was appointed her legal guardian. Review of Resident #44's active physician's orders revealed she had an order in place to receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of resident financial records, record review, staff interview, and family interview, the facility failed to maintain a system that assured a full and complete accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. This affected one resident (#25) of seven residents whose funds were handled by the facility. The facility census was 56. Findings include:Review of the record for Resident #25 revealed an admission date of 01/30/23 and diagnoses including psychosis, paranoid personality disorder, delusional disorder, and Alzheimers disease. Review of a Minimum Data Set assessment completed 05/09/26 revealed a brief interview for mental status score of seven, indicating severe cognitive impairment. Review of financial records revealed the facility handled the resident's personal funds. Review of a Resident Statement Landscape for Resident #25 for the past three months revealed on 05/07/26 $970.00 was deducted from the resident's account for personal needs items. This left 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 record review and interview, the facility failed to ensure resident's medical provider was notified regarding change in condition. This affected two residents (#1 and #21) of two residents reviewed for change in condition. The facility census was 56. Findings include:1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia due to mycoplasma pneumoniae and acute posthemorrhagic anemia. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #1 had mildly impaired cognition, had no behaviors, and received continuous oxygen therapy. Review of a care plan dated 02/09/26 revealed Resident #1 required oxygen therapy related to chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute on chronic respiratory failure. The goal was for Resident #1 to have no signs or symptoms of poor oxygen absorption through the review date. Interventions included but were not limited to change resident's position frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure proper notices were given to residents when skilled services were ending. This affected three residents (#1, #4, and #69) of five residents reviewed for beneficiary notices. The facility census was 56. Findings include:1.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including other lack of coordination, muscle weakness, and chronic obstructive pulmonary disease. Review of a Beneficiary Protection Notification Review form revealed Resident #1's skilled stay at the facility began on 11/12/25 and his last covered day was 12/12/25. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. A Notice of Medicare Non Coverage (NOMNC) was not issued because resident's discharge plan was to go home. 2.Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, muscle weakness, and lack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, policy review, and staff interview, the facility failed to ensure the resident/resident representative was provided written notice, at the time of transfer for hospitalization, that specified the duration of the bed-hold policy. This affected one resident (#62) of one resident whose closed record was reviewed for hospitalization. The facility census was 56. Findings include:Review of the record for Resident #62 revealed an admission date of 02/09/26 and diagnoses including cerebral infarction with hemiplegia, diabetes, rheumatoid arthritis, and hypertension. Review of a Minimum Data Set assessment completed 02/15/26 revealed a brief interview for mental status score of 15, indicating intact cognition. Review of nursing progress notes on 02/09/26 revealed the resident arrived at the facility after a stay at a rehab hospital. On 03/04/26 it was documented that staff spoke with the resident and her husband about discharging to another facility by 03/10/26 or remaining in the facility for long term placement. The note stated wants to explore other options closer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the areas of vision/ corrective lenses and medications received during the assessment period. This affected three residents (#6, #7, and #44) of 27 residents reviewed for MDS assessments. Findings include:1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included adult- onset diabetes mellitus. Review of Resident #6's active physician's orders revealed he had orders to receive Mounjaro ( a GIP and GLP-1 receptor agonist used to treat adult-onset diabetes mellitus by triggering insulin release to lower blood sugar when it was high) 2.5 milligrams (mg)/ 0.5 milliliters (ml) with instructions to inject 2.5 mg subcutaneously in the morning once a week on Thursdays. The order had been in place since 02/24/26. The resident did not have an order to receive any insulin injections to manage her adult-onset diabetes mellitus.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure Pre-Assessment Screenings and Resident Reviews (PASARRs) were accurate and updated to reflect new mental health diagnoses. This affected three residents (#6, #40, and #53) of four residents reviewed for PASARRs. The facility census was 56. Findings include: 1.Record review revealed Resident #40 was to the facility on [DATE] with diagnoses including major depression and anxiety disorders. A new diagnosis of psychotic disorder was added on 03/28/24. Review of a PASARR completed 09/28/23 revealed no indications of Resident #40 having mental health diagnoses. Review of a care plan revised on 07/14/25 revealed Resident #40 had mood deficits related to the death of her son and grandson, psychotic disorder, depression, anxiety, insomnia, and Parkinson's disease. The goal was for the resident to not have any complications related to anxiety or depression through the review period. Goals included but were not limited to approach 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 record review, observation, and interview, the facility failed to ensure a resident with known edema to her bilateral lower extremities (BLE) had a care plan developed to address her edema and another resident's care plan for being at risk for falls was implemented. This affected two residents (#28, #44) of 27 residents reviewed for care plans. Findings include:1. Review of Resident #28's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with behavioral disturbances, neurocognitive disorder with Lewy Bodies, HTN, muscle weakness, and abnormalities of gait and mobility. Review of Resident #28's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She was usually able to make herself understood and was usually able to understand others. She was not noted to display any behaviors, nor was she known to reject care. She had limited range of motion (ROM) in her BLE. Review 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 record review, observations, interviews, and policy review, the facility failed to ensure residents requiring assistance with hygiene services received showers, facial hair removal, and nail care. This affected three residents (#13, #30, and #40) of five residents reviewed for activities of daily living (ADLs). The facility census was 56. Findings include: 1.Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including dementia and depression. Review of a care plan dated 07/15/25 revealed Resident #30 had a self-care and mobility performance deficit related to confusion, dementia, and muscle weakness. The goals were for risk for decline for ADL function to minimize through the review date and continue to have needs met on a daily basis through the review date. Interventions included but were not limited to assist as needed with shower twice weekly or per resident preference and personal hygiene assist: dependent with assistance from one helper. Review of a minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, staff interview, resident interview, and contract review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision abilities by assisting with making appointments and/or arranging for transportation to and from practitioner's offices. This affected two residents (#7, #13) of three residents reviewed for communication/sensory impairment. The facility census was 56.Findings include: 1.Review of the record for Resident #7 revealed an admission date of 01/13/26 and diagnoses including acute and chronic respiratory failure, schizoaffective disorder, hypertension, and anxiety disorder. Review of an admission Minimum Data Set (MDS) assessment 01/19/26 and a quarterly MDS assessment 04/21/26 revealed the resident's vision was adequate with no corrective lenses. The MDS on 04/21/26 had a brief interview for mental status score of 15, indicating intact cognition. Review of an ancillary services form revealed the facility provides in-house ancillary services for the residents. Resident #7 had agreed to receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, interview, and policy review, the facility failed to ensure a resident, who was at risk for falls and had a history of falls, had their fall prevention interventions implemented as per their plan of care and failed to ensure facility staff who are knowledgeable of resident transfers attended an appointment with a resident. This affected two residents (#21, #44) of two residents reviewed for falls. Findings include: 1 .Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including pericardial effusion and cardiac tamponade. Review of an MDS assessment dated [DATE] revealed Resident #21 had severely impaired cognition, had no behaviors, was dependent on staff for toileting hygiene, was dependent on staff for transfers, and was frequently incontinent of bowel and bladder. Review of a care plan dated 04/21/26 revealed Resident #21 was at risk for falls related to difficulty in walking and weakness. Goals were to minimize risk of falls and fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, and staff interview, the facility failed to ensure residents received necessary respiratory care and services. This affected two residents (#21, #56) of four residents reviewed for respiratory care. The facility census was 56. Findings include: 1.Review of the record for Resident #56 revealed an admission date of 02/06/24 and diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, diabetes, and bipolar disorder. Record review revealed a physician's order dated 07/09/25 to change oxygen tubing and set up weekly on dayshift on Thursday and as needed. Review of the oxygen administration record for Resident #56 revealed it was documented that the oxygen tubing and set up had been changed on 04/09/26, 04/16/26, 04/23/26, 04/30/26, 05/07/26, and 05/14/26. Observations on 05/17/26 at 9:10 A.M. revealed Resident #56 to have oxygen on per nasal cannula at two liters. The oxygen tubing was dated 04/02/26 and the humidifier bottle was dated 03/26/26.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure pharmacy recommendations that were generated from irregularities noted during residents' monthly medication regimen reviews were addressed and/ or responded to timely by the attending physician. This affected two residents (#6, #25) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, major depressive disorder, paranoid personality disorder, and delusional disorder. Review of Resident #6's monthly medication regimen reviews revealed the resident's medications were reviewed monthly for the past 12 months for irregularities. The monthly medication regimen reports showed irregularities were noted in the resident's medication regimen in September 2025 and again in April of 2026. Review of the pharmacy recommendation based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure lab results were obtained as ordered. This affected one resident (#1) of one resident reviewed for low hemoglobin. The facility census was 56. Findings include:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia due to mycoplasma pneumoniae and acute posthemorrhagic anemia. Review of orders revealed Resident #1 had an order in place dated 02/01/26 for albuterol sulfate inhalation aerosol solution 108 (90 base) micrograms (mcg)/ACT two puffs every four hours as needed for chronic obstructive pulmonary disease. Review of a minimum data set (MDS) dated [DATE] revealed Resident #1 had mildly impaired cognition, had no behaviors, and received continuous oxygen therapy. Review of a care plan dated 02/09/26 revealed Resident #1 required oxygen therapy related to chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute on chronic respiratory failure. The goal was 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 record review, staff interview, policy review, and review of infection surveillance reports, the facility failed to implement the antibiotic stewardship program to ensure the appropriate use of antibiotics. This affected three residents (#22, #40, and #72) of 27 residents reviewed for infection control concerns. The facility census was 56. Findings include: 1. Review of the record for Resident #72 revealed an admission date of 04/07/26. Review of the facility infection surveillance report for April 2026 revealed Resident #72 had been taken to the hospital by his family for reports of ongoing weakness, agitation, and hallucinations with difficulty urinating. No other symptoms voiced. Diagnosed with urinary tract infection by the hospital and started on an antibiotic. Review of hospital records revealed he presented with increased falls, confusion, and concern for urinary tract infection (did not mention difficulty urinating). The assessment and plan stated: urinary tract infection with urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, staff interview, and policy review, the facility failed to provide education for and then offer the influenza and pneumonia vaccines for a resident. This affected one resident (#6) of five residents reviewed for vaccines. The facility census was 56. Finding include:Review of the record for Resident #6 revealed an admission date of 01/13/26 and diagnoses including acute and chronic respiratory failure, morbid obesity, hypertension, and schizoaffective disorder. Record review revealed no evidence the resident had been provided education for or offered the influenza and pneumonia vaccines. There was no evidence the resident had received the vaccines previously. Interview with Assistant Director of Nursing #189 on 05/18/26 at 9:35 A.M. revealed Resident #6 should have been offered the influenza and pneumonia vaccines on admission and she could find no evidence that was done. Review of the facility policy dated 2001 and revised August 2008 titled Influenza Vaccine revealed between October 1st and March 31st each year, the influenza vaccine shall be offered 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.

Based on record review, policy review, and staff interview, the facility failed to provide education for then offer COVID-19 vaccines for a resident. The is affected one resident (#6) of five residents reviewed for vaccines. The facility census was 56. Findings include:Review of the record for Resident #6 revealed an admission date of 01/13/26 and diagnoses including acute and chronic respiratory failure, morbid obesity, hypertension, and schizoaffective disorder. Record review revealed no evidence the resident had been provided education for or offered the COVID-19 vaccines. There was no evidence the resident had received the vaccine previously. Interview with Assistant Director of Nursing #189 on 05/18/26 at 9:35 A.M. revealed Resident #6 should have been offered the COVID-19 vaccine on admission and she could find no evidence that was done. Review of the facility policy dated 05/13/21 and titled COVID-19 Vaccine revealed the COVID-19 vaccine shall be offered to residents, unless medically contraindicated or the resident has already been immunized. Prior to the vaccination, the…

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

Based on record review and interview, the facility failed to update the state agency regarding a change in administration. This affected all 59 residents residing in the facility. The facility census was 59. Findings include:Review of the enhanced information dissemination and collection (EIDC) website revealed the current Administrator and the interim Administrator from November (2025) through January (2026) were not listed. Interview on 03/04/26 at 1:01 P.M. with the Administrator confirmed the facility had failed to notify the state survey agency with changes in administrators including the current Administrator. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2735791

Based on record review and interview, the facility failed to maintain and effective training program for staff. This affected all 59 residents residing in the facility. The facility census was 59. Findings include:1.Review of personnel files revealed Certified Nursing Assistant (CNA) #183 was hired on 12/19/25.Further review of the file revealed CNA #183 did not having training for compliance and ethics, quality assurance program, effective communication, and behavioral health.2.Review of a personnel file revealed CNA #150 was hired on 10/08/25.Further review of the file revealed CNA #150 did not have training for compliance and ethics, quality assurance program, and behavioral health.Interview on 03/04/26 at 3:04 P.M. with Human Resources (HR) #158 confirmed required training was not completed for CNAs #183, #150.This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2735791.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure a resident's change in condition was timely identified, properly correlated to a suspected medication error, and promptly reported to the physician for necessary medical intervention. This affected one resident (#42) of three residents reviewed for medication administration errors. Findings include: Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, neurocognitive disorders with Lewy Bodies, unspecified mood disorder, major depressive disorder, anxiety disorder, congestive heart failure, hypertension, cirrhosis of the liver, muscle weakness, lack of coordination, difficulty walking, and insomnia. Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors and was not indicated to have received any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a grievance investigation, and interviews, the facility failed to ensure allegations of misappropriation were reported. This affected one resident (#10) of one resident reviewed for misappropriation. The facility census was 59. Findings include:Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscle weakness and hypertension.Review of the resident's care plan revealed no documented evidence of Resident #10 having impaired cognition or behaviors including making false allegations.Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #10's cognition remained intact and she had no behaviors.Review of a grievance report dated 02/24/26 revealed on the afternoon of 02/24/26, Resident #10's son reported he dropped off five lottery tickets to Resident #10 on 02/22/26, he was not able to come back on 02/23/26, so he came back to the facility on [DATE]. When he arrived to the facility, Resident #10 reported out 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 record reviews and interview, the facility failed to ensure residents who were not able to carry out of activities of daily living independently were provided with showers. This affected three residents (#35, #53, and #62) of five residents reviewed for showers. The facility census was 59. Findings include:1.Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including dementia and muscle weakness.Review of a care plan dated 08/27/25 revealed Resident #35 required assistance with self-care, activities of daily living (ADLs), and mobility related to dementia, weakness, diabetes, impaired mobility, and use of an assistive device. The goal was to continue to have needs met on a daily basis through the review date; remaining clean, dry, dressed, groomed, and free of odors. Interventions included but were not limited to showering assist: dependent with one helper.Review of a minimum data set (MDS) assessment completed on 11/18/25 revealed Resident #35 had no behaviors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure wound care treatments were completed as ordered. This affected one resident (#62) of one resident reviewed for non-pressure wound care. The facility census was 59. Findings include:Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including type II diabetes and hidradenitis suppurativa.Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #62 had moisture associated skin damage (MASD).Review of a care plan dated 10/13/25 revealed Resident #62 was at risk for skin impairment related to weakness, cognitive deficit, incontinence, impaired mobility, thin and fragile skin, falls, and autoimmune disease. The goal was to maintain or develop clean and intact skin by the review date. Interventions included but were not limited to keep skin clean and dry, use lotion on dry skin, do not apply on broken skin; monitor/document location, size, and treatment of skin injury, report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to ensure residents, who were at risk for falls, had their fall prevention interventions implemented as per their plan of care. This affected two residents (#6 and #19) of three residents reviewed for falls. Findings include:1.) Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included age related osteoporosis, essential hypertension, hypotension, chronic pain, senile degeneration of the brain, cognitive communication deficit, insomnia, difficulty in walking, abnormalities of gait and mobility, lack of coordination, and need for assistance with personal care. Review of Resident #6's Fall Risk assessment dated [DATE] revealed the resident was considered a high risk for falls. Her risk factors included a history of multiple falls, medications and diagnoses that predisposed her to falls, poor memory and recall, frequent bladder incontinence, and gait abnormalities. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to ensure a staff nurse donned appropriate personal protective equipment (PPE) before entering the room of a resident in transmission based precautions for Covid-19. This affected one resident (#30) of two residents reviewed for medication administration pass. Findings include:On 02/26/26 at 8:26 A.M., an observation during a medication administration pass for Resident #30 on the North hall noted Registered Nurse (RN) #154 to enter the room of the resident to give the resident her morning medications. While the nurse was in the room, Resident #30 had reported to the nurse that it was her last day of being in isolation for being positive for Covid-19. She further went on to tell the nurse that it was her tenth day of being in isolation and was looking forward to it ending. RN #154 entered the room only wearing a N-95 particulate mask all staff were wearing throughout the facility and a pair of gloves. She did not don 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 observations, staff interview, record review, and policy review, the facility failed to maintain an infection and prevention and control program designed to help prevent the development and transmission of communicable disease, including COVID-19. This affected 55 of 55 residents residing in the facility.Findings include: Observations on 01/15/26 at 5:00 A.M. revealed a sign on the entrance door to the facility that stated: Staff and visitors, due to current outbreak of COVID-19, N95 mask is required at all times in the facility. Observations on 01/15/26 between 5:01 A.M. and 5:30 A.M. revealed that four of the five staff on night shift (Licensed Practical Nurse (LPN) #73, LPN #105, Certified Nursing Assistant (CNA) #95, and CNA #81) were not wearing any mask in the facility. Interview with LPN #73 on 01/15/26 at 5:01 A.M. at the nursing desk on the skilled unit, confirmed she was not wearing any mask. She stated that she had one resident (Resident #42) on her unit that currently had COVID-19. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents received showers per their preferred shower schedule. This affected three (#5, #8 and #47) of four residents reviewed for showers. The facility census was 54.Findings include:1. Review of Resident #5's medical record revealed an admission date of 04/26/23 and diagnoses including but not limited to dementia, hypertension, anxiety and depression. Review of Resident #5's quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of one (1) indicating the resident had severe cognitive impairment. Further review revealed the resident was dependent on the facility staff for bathing/showering needs.Review of Resident #5's care plan revealed an activities of daily living care plan initiated on 09/16/25 that indicated the resident was dependent on one staff member for assistance with her shower. Further review of the care plan revealed the facility was to assist the resident with a shower twice a week.Review 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 medical record review, observation, staff interview, and review of the facility policy review, the facility failed to ensure residents with pressure ulcers received appropriate and timely treatment and services to promote wound healing. This affected two (Residents #22 and #58) of three residents reviewed for pressure ulcers. The facility census was 55 residents. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 02/11/25 with diagnoses of congestive heart failure, respiratory failure, diabetes, and stage four kidney disease. Review of readmission notes for Resident #22 dated 03/10/25 revealed the resident returned from the hospital on [DATE] with pressure ulcers to right and left heels. Review of the wound note for Resident #22 dated 04/01/25 revealed the pressure ulcer to the right heel was resolved. Review of the physician's orders for Resident #22 revealed an order dated 05/13/25 to cleanse the left heel with normal saline, apply skin prep, and leave open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, review of the facility Self-Reported Incident, review of facility witness statements, and review of facility policy, the facility failed to ensure an allegation of physical abuse was reported timely and appropriately. This affected one resident (#39) of the three residents reviewed for abuse during the complaint survey. The facility census was 55. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure, dementia with psychotic disturbance, and psychosis. Review of the 5-day Minimum Data Set (MDS) assessment, dated 11/15/24, revealed the resident was rarely/never understood and had long and short term memory problems. Review of the facility Self-Reported Incident (SRI), dated 12/01/24 and timed 11:44 A.M., revealed on 12/01/24 at 11:09 A.M. Activities Director #500 reported to the Administrator an allegation of abuse by Certified Nursing Assistant (CNA) #111…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of medical records, resident vaccination consent forms and staff interview the facility failed to offer each resident a pneumococcal immunization. This affected four (Residents #10, #36, #37 and #46) of five residents sampled for influenza, pneumococcal and COVID-19 immunization review. The census was 51. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 08/09/21 and diagnoses of atherosclerotic heart disease, diabetes, hypothyroidism, dementia of unspecified severity, anxiety, depression, hypertension and hyperlipidemia. Review of the immunization record revealed Resident #10 received a dose of an unknown type of pneumococcal vaccine on or around 07/10/19. Review of Resident #10's physicians orders revealed no orders for pneumococcal vaccine. Review of the facility form titled Vaccine Administration Record (VAR)/informed Consent for Vaccinations at LTCF Pharmerica revealed a line where the resident or responsible party could indicate if they wished to receive a COVID-19 vaccination, influenza vaccination or other vaccination.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and policy review, the facility failed to ensure a resident and or their resident representative was provided a bed-hold notice as required, when the resident was transferred out to the hospital. This affected one (Resident #32) of two residents reviewed for hospitalization. The facility census was 51. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbances, unspecified intellectual disability, generalized anxiety disorder, restlessness and agitation, and hypernatremia. Her face sheet indicated the resident's sister was listed as her emergency contact #1 and her mother was her emergency contact #2. Review of Resident #32's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was sometimes able to make herself understood and was sometimes able to understand others. She had short and long term memory impairment and her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview and record review the facility failed to to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected one (Resident #4) of one resident reviewed for PASARR documents. The census was 51. Findings include: Record review of Resident #4 revealed an admission date of 04/26/19 with pertinent diagnoses of: anxiety disorder on 07/30/21, schizoaffective disorder on 01/25/22 dementia, covid 19, type two diabetes mellitus, localized edema, hammer toe, cognitive communication deficit, macular degeneration, sensorineural hearing loss, reduced mobility, vitamin D deficiency, iron deficiency anemia, hypertension, hyperlipidemia, major depressive disorder, hypokalemia, and symbolic dysfunctions. Review of the 08/22/24 Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and used a walker to aid in mobility. The resident required partial moderate assistance to roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed 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 staff interview, and record review the facility failed to develop comprehensive care plans for Resident #36's anticoagulant use and Resident #10's anxiety care plan was not specific and patient centered. This affected two (Resident #10, and #36) of 20 residents reviewed for care plans. The facility census was 51. Findings include: 1. Record review of Resident #36 revealed an admission date of 03/07/24 with pertinent diagnoses of: end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, atherosclerotic heart disease of native coronary artery, congestive heart failure, acute embolism and thrombosis of right internal jugular vein, acute and chronic respiratory failure, disorder of kidney and ureter, noninfective gastroenteritis and colitis, hypertension, morbid obesity, disorders of lung, malignant neoplasm of prostate, anemia, polyneuropathy, hypoxemia, acquired absence of left leg above knee, and other malaise. Review of the 09/12/24 Minimum Data Set (MDS) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure hospice records were available for continuity of care for one resident. This affected one (Resident #109) of one resident reviewed for hospice. Additionally, the facility failed to ensure compression stockings were applied as physician ordered. This affected one resident (#32) of one resident reviewed for edema. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #109 revealed an initial admission date of 09/23/24 with the diagnoses including but not limited to fracture of head and neck of right femur, heart failure, dementia, atrial fibrillation, chronic obstructive pulmonary disease, gout, gastro-esophageal reflux disease and anxiety disorder. Review of the resident's comprehensive admission assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident's prognosis was less than six months and the resident received hospice services. Review of the plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure physician ordered pressure reduction devices were implemented as ordered. This affected two residents (#45 and #109) of four residents reviewed for pressure ulcers. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #109 revealed an initial admission date of 09/23/24 with the diagnoses including but not limited to fracture of head and neck of right femur, heart failure, dementia, atrial fibrillation, chronic obstructive pulmonary disease, gout, gastro-esophageal reflux disease and anxiety disorder. Review of the resident's admission nursing assessment dated [DATE] revealed the resident was admitted to the facility with a stage I pressure ulcer to the right outer ankle measuring 2.0 centimeters (cm) by 2.0 cm. The resident also had an abrasion to the right hip measuring 3.0 cm by 0.2 cm and an abrasion to the left buttocks measuring 2.0 cm by 0.2 cm. Review of the resident's Braden scale 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 record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as per the plan of care for residents who were at risk for and/ or had a history of falls. This affected two (Resident #33 and #38) of four residents reviewed for falls. The census was 51. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included a history of a left hip fracture and a left rib fracture secondary to a fall at home, difficulty walking, muscle weakness, and need for assistance with personal care. His diagnoses list was updated to reflect he had a right hip fracture on 08/19/24, after his admission to the facility. Review of Resident #33's care plans revealed he had an active care plan in place for being at risk for additional falls related to having a history of falls resulting in multiple fractures, a history of waking up through out the night confused and would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one resident (#37) identified by the facility as having PTSD/trauma. The facility census was 51. Findings include: Record review of Resident #37 revealed an admission date of 01/30/23 with pertinent diagnoses of: post traumatic stress disorder chronic 07/12/23, heart failure, morbid obesity, Alzheimer's disease, need for assistance with personal care, repeated falls, unspecified psychosis, hyperlipidemia, paranoid personality disorder, delusional disorders, abnormal posture, cognitive communication deficit, dementia, hypothyroidism, hypertension, tinea unguium, cardiomegaly, mood affective disorder, obstructive sleep apnea,anxiety disorders, major depressive disorder, and nightmare disorder. Review of the 09/11/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a walker to aid in…

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

Based on observation, record review, policy review, and staff interview the facility failed to follow infection prevention guidelines when they failed to wear appropriate personal protective equipment for enhance barrier precautions when doing would care for Resident #36. This affected one (Resident #36) of five residents reviewed for infection control. The facility census was 51. Findings include: Record review of Resident #36 revealed an admission date of 03/07/24 with pertinent diagnoses of: end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, atherosclerotic heart disease of native coronary artery, congestive heart failure, acute embolism and thrombosis of right internal jugular vein, acute and chronic respiratory failure, disorder of kidney and ureter, thrombocytopenia, gout, noninfective gastroenteritis and colitis, hypertension, morbid obesity, disorders of lung, malignant neoplasm of prostate, anemia, polyneuropathy, hypoxemia, acquired absence of left leg above knee, and other malaise. Review of the 09/12/24 Minimum Data Set (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 record review and interview, the facility failed to ensure one resident (#21) was not treated with an antibiotic prior to the return of the culture and sensitivity (C&S) results. This affected one (Resident #21) of two residents reviewed for urinary tract infection (UTI). The facility census was 51. Findings Include: Review of the medical record for Resident #21 revealed an initial admission date of 02/13/23 with the latest readmission date of 04/07/23 with the diagnoses including but not limited to neurocognitive disorder with Lewy bodies, repeated falls, anxiety disorder, dementia, Alzheimer's disease, mood disorder, hypertension, osteoarthritis, metabolic encephalopathy and osteoporosis. Review of the plan of care dated 03/05/23 revealed the resident had toileting deficits related to dementia, cognitive function fluctuates, short and long term memory deficits, sometimes understood and sometimes understands others, supervision to limited assist with toileting, frequently incontinent of bowel 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, staff interview, and facility policy review, the facility failed to serve food in a safe and sanitary manner. This affected 46 of 46 residents who utilized the kitchen for meals (Resident #249 received nothing by mouth). The census was 47. Findings Include: Observation on 07/06/23 at 12:36 P.M. revealed [NAME] #163 touching the cornbread from the pan three times with gloves and placed them on the meal plates. Also, she touched one breaded pork chop with the same gloved hand and placed it on the meal plate. In between touching the cornbread and pork chop with the same gloved hands, she touched the counter top, drawer handle for utensils, three different food utensils, multiple plates, and the plate warmer lid to lift it up. Observation on 07/06/23 at 12:44 P.M. revealed [NAME] #163 touching four pork chops with her gloved hand. After touching the pork chops, she took the gloves off, did not wash her hands, and then put a new pair of gloves on. Observation on 07/06/23 at 12:45 P.M. revealed [NAME] #163 touching stuffing after it was served onto the resident's…

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

Based on review of infection control records and infection control policies and procedures review the facility failed to appropriately monitor resident infections as per infection control policy and procedures for the month of July, August and September of 2022. In addition the facility failed to implement and perform their Legionella Precautionary Maintenance and Inspections per their Legionella Water Management Program. This affected all residents in the facility. The census was 47. Findings Include: 1. Review of the the facility monthly infection control logs from 07/2022 to 07/2023 revealed for the months of 07/2022, 08/2022 and 09/2022 the monthly infection control log form did not include the resident symptoms, indicate if the resident had a chest x-ray or culture done with results , any type of necessary treatments and if the resident required Isolation. Interview on 07/06/23 11:48 AM with Registered Nurse (RN) #142 confirmed the Monthly Infection Log for 07/2022, 08/2022 and 09/2022 was incomplete and did not include the necessary documentation needed to track the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's shower schedule, resident interview, staff interview, and policy review, the facility failed to ensure a resident's frequency in which they were showered was honored in accordance with their preference. This affected one (Resident #10) of one residents reviewed for choices. Findings include: A review of Resident #10's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, adult onset diabetes mellitus, major depressive disorder, muscle weakness, difficulty walking, and need for assistance with personal care. A review of Resident #10's baseline care plan initiated on 08/12/21 revealed the resident was indicated not to have a preference at that time regarding bathing activities and staff may choose for her. They indicated showers would be provided two times per week. A review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and 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 record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure a thorough investigation was competed for an alleged allegation of abuse. This had the potential to affect all 47 residents residing in the facility and specifically affected Resident #39. Findings Included: Review of the SRI dated 04/01/23 revealed Resident #39 reported Licensed Practical Nurse (LPN) #210, the agency nurse who worked through the night threw something and hit her in the nose with it and woke her up. The SRI indicated the resident was alert and oriented and was emotionally distressed at the moment, but no physical injuries were present. The Administrator immediately reported LPN #210 to the agency and banned the nurse from returning to the facility in any role. The SRI indicated residents were interviewed and statements were being collected from witnesses. Review of the medical record for Resident #39 revealed an initial admission date of 01/30/23 with the diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ,staff interview, policy and procedure review the facility failed to issue a bed hold notification letter to one resident (#47) out of one resident reviewed for hospitalizations. The census was 47. Findings Include: Review of Resident #47's medical record revealed an admission date of 4/28/23 with no cognitive deficits. Diagnoses include atherosclerosis, muscle weakness, surgical aftercare following surgery on the circulatory system, and atherosclerotic heart disease of natives coronary artery without angina pector. Resident #47 was discharged on 05/18/23 to the hospital. Review of Resident #47's medical record nurses progress notes from 05/01/23 to 05/18/23 confirmed resident was discharged to the hospital on [DATE] with no bed hold notification given. Interview on 07/05/23 at 4:09 P.M. with the Administrator verified Resident #47 or the designated resident representative was not issued a Bed Hold Notification Letter when transferred to the hospital . Review of the facility Hold 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete comprehensive assessments as required. This affected three (Residents #9, #250, and #40) of 17 resident assessments reviewed. The census was 47. Findings Include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, Alzheimer's disease, repeated falls, cognitive communication deficit, muscle weakness, heart failure, generalized anxiety disorder, congestive heart failure, osteoporosis, cerebrovascular disease, kyphosis, anemia, osteoarthritis, atherosclerosis, anemia, chronic kidney disease, major depressive disorder, dermatitis, insomnia, disorder of thyroid, hypertension, delirium, atrial fibrillation, hyperlipidemia, dysphagia. Review of her Minimum Data Set (MDS) assessment, dated 02/22/23, revealed she was cognitively intact. Review of Resident #9 MDS assessments revealed her most recent completed assessment was on 02/22/23. Review of her MDS assessments in 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 medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Record review revealed Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 05/18/23, revealed he had a severe cognitive impairment. Review of Resident #1's PASRR document, dated 09/17/18, revealed under Section C, the facility indicated he did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 05/18/23, revealed he had a severe cognitive impairment. Review of Resident #1 PASRR document, dated 09/17/18, revealed under Section C, the facility indicated he did not have a diagnosis of dementia or Alzheimer's disease. Also, under Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident's (#40) hospice continuity of care. This affected one of one resident reviewed for hospice. Findings Included: Review of the medical record for Resident #40 revealed an initial admission date of 02/22/23 with the admitting diagnoses including Alzheimer's disease, anxiety disorder, restlessness and agitation, chronic obstructive pulmonary disease, diabetes mellitus, anemia, insomnia, peripheral vascular disease, chronic kidney disease, hyperlipidemia and depression. Review of the resident's clinical admission assessment dated [DATE] indicated the resident was admitted to the facility with hospice services. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident received hospice services. Review of the plan of care revealed the resident had no care plan addressing the resident's hospice status. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement the physician ordered off-loading to one resident's (#15) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer. This affected one of one resident reviewed for pressure ulcers. Findings Included: Review of the medical record for Resident #15 revealed an initial admission date of 08/12/21 with the diagnoses including dementia, altered mental status, adult failure to thrive, nonrheumatic aortic valve insufficiency, cardiac murmur, generalized muscle weakness, schizoaffective disorder, metabolic encephalopathy, dysphagia, hypertension, disorder of kidney and ureter, gastro-esophageal reflux disease, insomnia and presence of cardiac pacemaker. Review of the plan of care dated 09/07/21 revealed the resident was at risk for skin integrity related to diagnoses of dementia with lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for a resident with a known history of falls and considered to be at risk for falls. This affected one (Resident #2) of two residents reviewed for accidents. Findings include: A review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a fracture of the distal end of her right femur following a fall on 06/09/23, repeated falls, difficulty walking, age related osteoporosis, muscle weakness, muscle wasting and atrophy, need for assistance with personal care, osteoarthritis, hypertension, memory deficit following stroke, and unspecified dementia. A review of Resident #2's fall risk assessment completed on 04/14/23 revealed the resident was assessed to be a moderate risk for falls. Her risk factors included having a history of one to two falls during the past six months, medications that increase the risk 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 and interview the facility failed to maintain a clean, sanitary homelike environment. This affected one (#40) of 15 sampled residents. Findings Included: On 07/03/23 at 9:57 A.M., observation of Resident #40's room revealed a strong odor of urine. The resident's bed side chair had peeling leather and a rip in the cushion. The resident's wall behind the headboard was also marred. On 07/05/23 at 1:20 P.M., observation of Resident #40 revealed the resident was quiet at bedrest with eyes closed. No signs of incontinence noted, however the resident's room continued to have a strong odor of urine. On 07/05/23 at 10:45 A.M., interview with Registered Nurse (RN) #142 verified the resident's room had a persistent strong odor of urine and the disrepair of the chair and wall. 07/06/23 at 8:00 A.M., observation of Resident #40's room revealed the room continued to have a strong odor of urine.