The Enclave at Barnesville

Based on observation, staff interview, and policy review, the facility failed to ensure a nurse followed appropriate hand hygiene practices after administering eye drops to one resident (Resident #31) and before preparing medications for another resident (Resident #11). The facility's census was 52. Findings include: On 05/06/26 at 8:15 A.M., a medication administration observation for Resident #31 noted her medications to be prepared and administered by Registered Nurse #227. Among the medications administered was Artificial Tears Opthalmic solution 0.2- 0.2-1%. The nurse was observed to enter the resident's room to give the resident her morning medications. She gave the resident her pills first, followed by the eye drops, administering one drop into both the resident's eyes before leaving the room. She was not observed to wash her hands with soap and water or to use hand sanitizer when leaving the room, or before returning to the medication administration cart to begin preparing Resident #11's medications for administration. On 05/06/26 at 8:24 A.M., an interview with RN #227…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit the required staffing information for the fourth quarter of July 1st 2024 through September 20th 2024 to the payroll based journal (PBJ) data. This had the potential to affect all residents. The census was 46. Findings included: Review of Payroll Based Journal (PBJ) staffing report for the fourth quarter (July 1st 20024 through September 30th 2024) revealed the facility failed to submit data for the quarter, one star staffing rating, excessively low weekend staffing, no registered nurse (RN) hours, and failed to have licensed nursing coverage 24 hours per day. Interview on 02/13/25 at 7:55 A.M. with the Administrator revealed that corporate submits the staffing data, she has reached out to cooperates a few times this week for their proof of submitting the staffing data for the fourth quarter (July 1st 2024 through September 30th 2024). She stated corporate had not given her proof of submission. Interview with Administrator on 02/13/25 at 11:33 A.M. confirmed corporate was unable to provide evidence the facility had…

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

Based on observation and interview, the facility failed to maintain infection control practices. This had the potential to affect 26 residents (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #15, #17, #18, #19, #21, #23, #25, #26, #28, #32, #35, #36, #44, #47, and #152) of 46 residents residing in the facility. Findings include: Observation on 02/11/25 at 2:53 P.M. revealed a male resident walked up to the ice chest next to the nurses' station and helped himself to some ice, with no evidence of practicing hand hygiene. The ice scoop was left inside the ice chest. Two aides were at the nurses' station at the time of the observation. Interview on 02/11/25 at 2:56 P.M. with Certified Nursing Assistant (CNA) #128 confirmed the observation and stated residents typically do not and should not help themselves to ice, but should ask for assistance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure Preadmission Screening and Resident Review (PASARR) were accurately completed. This affected three residents ( #3, #40, and #43) of three reviewed for PASARR. Findings include: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, post-traumatic stress disorder (PTSD), and dementia with other behavioral disturbance. Review of Resident current orders dated 02/2025 revealed the resident received Quetiapine (anti-psychotic) 25 milligrams (mg) at bedtime for major depressive disorder. The target behaviors included agitation and aggression. Review of Resident #40's PASARR dated 02/23/24 revealed the resident had no mental illness. Interview on 02/11/25 at 5:18 P.M., with the Director of Nursing (DON) confirmed the resident had major depressive disorder and PTSD that were not reflected on the PASARR on 02/23/24. 2. Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise a comprehensive, person-centered care plan with interventions for oxygen therapy and antipsychotic medication treatment. This affected two residents (#7, #46) of seven residents reviewed for respiratory care and unnecessary medications. The facility census was 46. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, malignant melanoma, heart failure, and acute respiratory distress syndrome. Review of Resident #7's physician order, dated 01/18/24, revealed the order for oxygen to be administered at four liters per minute via nasal cannula continuously for low oxygen saturation. Review of Resident #7's care plan revealed it was not individualized and did not reflect the resident's treatment order for oxygen therapy. Interview on 02/11/25 at 2:01 P.M., the Registered Nurse (RN)/Minimum Data Set (MDS) #101 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure Resident #33's blood glucose level reading was obtained prior to administering insulin and failed to timely identify Resident #26's edema. This affected two residents (#33, #26) of three residents reviewed for change in condition and edema. Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 11/15/24. Diagnoses included Alzheimer's disease, dementia, encephalopathy, angina, and diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment, dated 11/22/24, revealed a Brief Interview for Mental Status (BIMs) score of 04, which indicated severely impaired cognition. The MDS further revealed Resident #33 required staff assistance with activities of daily living (ADLs). Review of physician order, dated 12/20/24, revealed the order for Degludec Subcutaneous Pen-Injector 100 units/milliliter (ml) inject 20 units subcutaneously one time a day for diabetes mellitus. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview, the facility failed to ensure an order for an alternating air mattress was followed for a resident at risk for developing pressure ulcers. This affected one resident (#32) of four residents reviewed for pressure ulcers. The facility census was 46. Findings include: Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including stage three chronic kidney disease, hyperlipidemia, anxiety disorder, dementia, and osteoarthritis. Review of a care plan last updated on 08/19/22 revealed Resident #32 had the potential for impairment to skin integrity related to dermatitis, use of Plavix, neuropathy, edema, and obesity. Interventions included keeping body free of moisture, cut fingernails, follow facility protocols for treatment of injury, monitor for bruising related to Plavix, pressure reducing mattress to bed, and provide incontinence care after each incontinence episode. Review of an order dated 05/16/24 revealed Resident #32…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and interview, the facility failed to ensure an order for non-skid strips was followed. This affected one resident (#32) of one resident reviewed for falls. The facility census was 46. Findings include: Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including stage three chronic kidney disease, hyperlipidemia, anxiety disorder, dementia, and osteoarthritis. Review of an undated fall care plan revealed Resident #32 was at risk for falls related to confusion, gait/balance, unaware of safety needs, essential tremors, bilateral knee replacements, behaviors, medication use and a history of wandering. Interventions included but were not limited to call light in reach, ensure non-skid footwear is in use, and non-skid strips to right of bed. Review of an order dated 03/22/23 revealed Resident #32 should have non-skid strips in front of her bed. Review of a minimum data set (MDS) completed on 12/05/24 revealed Resident #32 had severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement interventions for weight loss after a significant weight loss in one month of 5.45%. This affected one resident (#19) of two residents reviewed for nutrition. The facility census was 46. Findings include: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia, urinary tract infection, and type II diabetes. Review of orders revealed Resident #19 had a consistent carbs diet with regular texture dated 12/13/24. There were no additional orders for nutrition. A nutritional assessment dated [DATE] revealed Resident #19 had good intakes of meals. Review of a care plan dated 12/16/24 revealed Resident #19 had altered nutrition and/or hydration status related to therapeutic diet, type II diabetes, dementia, gastro-esophageal reflux disease, above knee amputation, depression, psychotic disorder, and acute kidney injury. Interventions included administering medications per order, honor food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident's oxygen humidifier bottle was changed timely. This affected one resident (#7) of one resident reviewed for respiratory care. The facility identified six residents who received oxygen therapy. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, asthma, dementia, diabetes mellitus, congestive heart failure, and atrial fibrillation. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, malignant melanoma, heart failure, and acute respiratory distress syndrome. Review of Resident #7's physician order, dated 01/18/24, revealed the order for oxygen to be administered at four liters per minute via nasal cannula continuously for low oxygen saturation. Review of the quarterly 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 medical record review, interview, and policy review the facility failed to ensure a resident had a comprehensive assessment and plan of care for Post Traumatic Stress Disorder (PTSD). This affected one resident (#40) of one reviewed for behavioral/emotional. Findings included: Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, post-traumatic stress disorder (PTSD), and dementia with other behavioral disturbance. Review of Resident #40's admission assessment dated [DATE] revealed there was a section titled trauma. The first question was does the resident have a history of any of the following mental health diagnosis? Staff checked depression but did not check the box for PTSD. The second question of the assessment was Does the resident have a history of one or more of the following including all types of abuse, veteran, homeless, imprisonment, loss, trauma, or other. Staff indicated none. The next…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident did not receive an unnecessary antibiotic. This affected one resident (#44) of one resident reviewed for unnecessary antibiotic. The facility census was 46. Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina, chronic kidney disease stage 3A, urinary incontinence, and mild cognitive impairment. Review of a Urinary Tract Infection (UTI) Worksheet and Culture and Sensitivity dated 08/05/24 revealed Resident #44 had a culture revealing klebsiella in her urine and the culture and sensitivity showed the infection was resistant to Cipro (antibiotic). Review of a UTI Worksheet and Culture and Sensitivity dated 09/11/24 revealed Resident #44 had a culture revealing klebsiella and aerococcus urinae in her urine. The culture and sensitivity revealed the infection was resistant to Klebsiella. Resident #44 received Bactrim for treatment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of pharmacy recommendation, interview, and policy review the facility failed to ensure appropriate diagnoses for psychotropic medication and failed to have supporting evidence for declining gradual dose reduction recommendations and increasing dose of psychotropic medication. This affected two residents (#43 and #46) of six resident reviewed for unnecessary medication review. Findings included: 1. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, anxiety, major depressive disorder, and unspecified psychosis. Review of Resident #43's orders dated 06/04/24 to 02/1/25 revealed on 06/13/24 the resident was ordered Abilify 5 milligram (mg) daily for psychosis related to psychosis. The targeted behaviors were agitation and paranoia. On 10/17/24 the Abilify was increased to 7.5 mg daily for cerebrovascular disease and psychosis. The resident targeted behaviors were fearful and tearful.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 42 residents in the facility. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. with the Administrator revealed, at that time, there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date.…

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

Based on record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 42. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue was in addition to the identification of other vendors/suppliers with past due balances,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 41 residents in the facility. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 41. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. an interview with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue was in addition to the identification of other vendors/suppliers with past due…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 30 residents in the facility. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. an interview with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This…

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

Based on record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 30. Findings include: Review of the provided QAPI documentation, beginning 10/01/23, revealed an identified problem of vendors not being paid promptly. The root cause revealed invoices were not being entered electronically when received. Review of invoices and calls with the Administrator and Business Office Manager were to be completed weekly. The QAPI did not identify any type of ongoing systemic monitoring and mechanisms to ensure there was no disruption of employee payroll responsibilities and to ensure all staff were paid on the agreed payroll date. a. During the onsite investigation, the facility provided a list of nine employees who had paychecks returned from payroll on 01/19/24.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review and interview, the facility failed to establish an effective governing board, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care and maintenance. This had the potential to affect all 42 residents in the facility. Findings include: Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary duty, duty of care, and duty of loyalty to act in the best interests of the Facility. The governing body should be comprised of the operator (s), c-suite level executives, and other individuals who were legally responsible for the establishment and implementation of policies regarding management and operations of the facility. The Governing Body member responsibilities included to be active, engaged, and involved in the affairs of the facility and to have direct access to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure food was stored properly, kitchen equipment was clean, the kitchen environment was clean, kitchen staff's hair was properly restrained, kitchen staff washed hands after touching trash can lids and prior to donning (putting on) gloves, and the Robot Coup was sanitized and dried between uses. This had the potential to affect all 44 residents receiving food from the kitchen. The facility census was 44. Findings included: 1. Observation on 09/11/23 at 8:32 A.M. of bread on the bread rack revealed the following: three full loaves which were sealed but had no date on them, three partial loaves which were not sealed (the end of the bag was open) and did not have a date on them, one pack (eight count) of hotdog buns which were sealed but had no date on them, three packs (12 count) of hamburger buns which were sealed but had no date on them, one pack (nine count) of hamburger buns which were not sealed (the end of the [NAME] 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.

Based on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 44 residents residing in the facility. Findings included: Observation on 09/11/23 at 5:45 P.M. of the two dumpsters behind the facility revealed multiple pieces of trash (multiple straws, plastic spoons, rubber gloves, and container caps) on the ground. Observation on 09/12/23 at 4:24 P.M. of the two dumpsters behind the facility revealed multiple pieces of trash (multiple straws, plastic spoons, rubber gloves, and container caps) on the ground. Interview on 09/12/23 at 4:25 P.M. with the Regional Dietary Manager #465 verified there were multiple pieces of trash outside the two dumpsters behind the facility and trash around a dumpster wound tend to draw in pests and vermin. Review of the facility policy titled, Trash Handling, undated, revealed outside dumpsters and the surrounding area are to be kept clean and free of debris.

Based on observation and interview, the facility failed to ensure the ice machine drain had an air gap to prevent potential backflow of drain contents into the ice machine. This had the potential to affect all 44 residents residing in the facility. Findings included: Observation on 09/12/23 at 7:23 A.M. of the facility ice machine, which was located in the hallway outside of the kitchen, revealed there was no air gap between the ice machine and the drain. Interview on 09/12/23 at 7:25 A.M. with the Maintenance Director #432 verified there was no air gap between the ice machine and the drain. He verified that microorganisms could backflow into the ice machine since there was no air gap which could lead to contaminated ice and illness for the residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, MedScape online drug reference app review and staff interview, the facility failed to ensure resident assessments were completed accurately. This affected five (Resident #4, #5, #13, #26 and #27) of 15 residents reviewed for assessments. The facility census was 44. Findings include: 1. Review of Resident #5's medical record revealed an admission of 07/24/20 with diagnoses that include congestive heart failure, mitral valve prolapse, atherosclerotic heart disease, atrial fibrillation and peripheral vascular disease. Review of the quarterly minimum data set (MDS) 3.0 assessment with a reference date of 08/11/23 revealed bed rails used as a restraint. No other restraint use was indicated on the MDS assessment. Further review of the medical record including physician's orders and care plans revealed no evidence of any restraint use including bed side rails. Review of the physician's orders revealed no evidence of any type of current restraint use. Observation of 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, resident record review, and facility policy review, the facility failed to ensure residents received a written summary of their baseline care plan. This affected four Resident (#4, #11, #38 and #42) of four residents reviewed for baseline care plans. The facility census was 44. Findings included: 1. Review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic atrial fibrillation, hypothyroidism, unspecified dementia and essential hypertension. Review of Resident #4's admission Minimum Data Set (MDS), dated [DATE], revealed she was severely cognitively impaired. Review of Resident #4's Baseline Care Plan, dated 06/01/23, revealed it was developed to care for the immediate needs of the resident within 48 hours of admission. However, there was no documentation to support the resident/resident representative was educated on the baseline plan of care or provided a written summary. Interview on…

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

Based on observation, interview, spread sheet review, and facility policy review, the facility failed to ensure the spread sheet was followed and residents received the correct portion of food. This affected the 23 residents receiving the regular line meal (#1, #2, #5, #6, #7, #8, #9, #10, #15, #19, #23, #24, #25, #29, #31, #32, #35, #37, #39, #41, #43, #44, and #301) and the 11 residents receiving the mechanical soft meal (#4, #12, #17, #20, #26, #27, #28, #33, #34, #42, and #45) for the lunch meal observation. The facility census was 44. Findings included: Review of the documentation titled, Daily Production dated Tuesday 09/12/23, revealed for lunch, residents receiving the regular line meal were to receive four ounces of saffron rice, six ounces of pork and mushroom stir fry, and four ounces of oriental blend vegetables and residents receiving a mechanical soft diet meal were to receive four ounces of saffron rice with four ounces of mechanical soft pork and four ounces of green beans. Observation on 09/12/23 at 11:32 A.M. of [NAME] #483 plating food for lunch. During 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 and interview, the facility failed to prepare pureed food in the proper form. This had the potential to affect all seven residents (#3, #13, #16, #21 #22, #36, and #38) who were receiving pureed meals. The facility census was 44. Findings included: Observation on 09/12/23 at 10:04 A.M. of [NAME] #483 placing one cup of chicken broth in the Robot Coup bowl followed by seven servings of pork. [NAME] #483 started to Robot Coup and let it run for approximately two minutes. She looked at the pureed pork and reported it was ready to be served. This surveyor asked [NAME] #483 to taste the pureed pork to confirm the pork was the correct consistency and she did. [NAME] #483 reported it was the correct puree consistency to serve to residents. This surveyor then tasted the pork puree and had to chew the pork. Regional Dietary Manager #465 tasted the puree after this surveyor and confirmed the pork was not the correct consistency and needed to be chewed. [NAME] #483 then continued to puree the pork stopping two more times when Regional Dietary Manager #465 tasted the pureed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to ensure a resident's representative was notified of orders for laboratory tests. This affected one (Resident #101) of two residents reviewed for notification of change in condition. The census was 44. Findings include: Review of Resident #101's medical record revealed diagnoses including cerebral infarction, fracture of the right femur, anxiety disorder, ulcerative colitis, generalized muscle weakness, hypertension, heart disease, and chronic obstructive pulmonary disease. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was severely cognitively impaired. A nursing note dated 01/10/23 at 3:40 P.M. indicated Psychiatrist #450 visited and new orders were received for laboratory tests (B 12 level, folate, thyroid stimulating hormone, and rapid plasma [NAME]) to be obtained 01/13/23. There was no indication Resident #101's power of attorney/resident representative was notified. On 09/14/23 at 12:32 P.M., Clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a facility investigation, and interview, the facility failed to ensure allegations of abuse were reported to the State Survey Agency. This affected one (Resident #101) of three residents reviewed for abuse. Findings include: Review of Resident #101's closed medical record revealed diagnoses including cerebral infarction with paralysis affecting the left non-dominant side, anxiety disorder, generalized muscle weakness, heart disease, hypertension, osteoarthritis and osteoporosis. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was severely cognitively impaired. No behavioral symptoms or rejection of care was noted. Review of a skin assessment dated [DATE] revealed no documentation of impairment/bruises. A skin assessment dated [DATE] indicated Resident #101 had a group of five bruises measuring 6 centimeters (cm) x 6 cm x 0 cm to the right upper extremity. Review of progress notes for the period between 01/06/23 and 01/09/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of a facility investigation, and interview, the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one (Resident #101) of three residents reviewed for abuse. The census was 44. Findings include: Review of Resident #101's closed medical record revealed diagnoses including cerebral infarction with paralysis affecting the left non-dominant side, anxiety disorder, generalized muscle weakness, heart disease, hypertension, osteoarthritis and osteoporosis. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was severely cognitively impaired. No behavioral symptoms or rejection of care was noted. Review of a skin assessment dated [DATE] revealed no documentation of impairment/bruises. A skin assessment dated [DATE] indicated Resident #101 had a group of five bruises measuring 6 centimeters (cm) x 6 cm x 0 cm to the right upper extremity. Review of progress notes for the period between 01/06/23 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 medical record review and staff interview the facility failed to provide written transfer notification to the resident and/or representative when a resident was transferred to the hospital. This affected two (Resident #49 and #4) of three residents reviewed for hospitalization. The facility census was 44. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 07/12/23 with diagnoses that included congestive heart failure, atrial fibrillation and atherosclerotic heart disease. Further review of the medical record revealed on 07/22/23 Resident #49 was transferred to the local hospital and admitted on [DATE] for exacerbation of chronic obstructive pulmonary disease. Further review of the medical record found no evidence of written notification of transfer provided to the resident or resident representative following admission to the hospital. Interview on 09/13/23 at 10:45 A.M., with social services designee (SSD #406) revealed no written transfer notification 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 medical record review, policy review and staff interview the facility failed to ensure residents and/or resident representatives admitted to the hospital were provided bed hold notification. This affected one (Resident #49) of three residents reviewed for hospitalization. The facility census was 44. Findings include: Review of Resident #49's medical record revealed an admission date of 07/12/23 with diagnoses that included congestive heart failure, atrial fibrillation and atherosclerotic heart disease. Further review of the medical record revealed on 07/22/23 Resident #49 was transferred to the local hospital and admitted on [DATE] for exacerbation of chronic obstructive pulmonary disease. Further review of the medical record found no evidence of written notification of bed hold days remaining provided to the resident or resident representative following admission to the hospital. Interview on 09/13/23 at 10:45 A.M., with social services designee (SSD #406) revealed no notification of bed hold days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review and interview, the facility failed to ensure a Preadmission Screening/Resident Review (PAS/RR) assessment was accurate upon admission and failed to ensure an updated PAS/RR was submitted to determine if a resident would benefit from specialized services. This affected one (Resident #3) of one resident reviewed for PAS/RR. 16 residents were screened for need for PAS/RR reviews. The census was 44. Findings include: Review of Resident #3's medical record revealed an initial admission date of 01/21/13. Review of the medical diagnoses record revealed diagnoses relevant on admission included dysthymic disorder (mood disorder), dementia, and post traumatic stress disorder (PTSD). On 02/07/17 a diagnosis of psychotic disorder was added. On 01/13/18 a diagnosis of recurrent major depressive disorder was added. Review of the PAS/RR dated 01/18/13 indicated Resident #3 did not have a documented diagnosis of dementia, had no diagnosis of any mental disorders including mood disorders or other psychotic disorders. The assessment indicated Resident #3 had a severe,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's plan of care. This affected one (Resident #27) of two residents reviewed for accidents. The census was 44. Findings include: A review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a fracture of an unspecified part of the neck of the left femur (07/24/23), history of repeated falls, difficulty in walking, muscle weakness, unspecified intracapsular fracture of the right femur (02/21/22), presence of an artificial right hip joint, aphasia following CVA, HTN, and dizziness and giddiness. A review of Resident #27's quarterly fall risk assessment dated [DATE] revealed the resident was assessed as a moderate risk for falls. Her risk factors included cognitive impairment, the use of medications that increased her risk for falls, and diagnoses that predisposed her to falls. A 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.

Based on medical record review, inter-department email communication review and staff interview, the facility failed to ensure dietary recommendations were communicated effectively. This affected one (Resident #31) of four residents reviewed for nutrition. The facility census was 44. Findings include: Review of Resident #31's medical record revealed an admission date of 08/25/20 with diagnoses that included diabetes mellitus, chronic kidney disease, dementia and hypertension. Review of Resident #31's weights revealed a 6.6% weight loss in the last 30 days that was identified on 09/04/23. Review of the dietary progress revealed a progress note on 09/10/23 which indicated a significant weight loss that was identified on 09/04/23. The dietician recommended to increase Resident #31's nutritional supplement. Review of Resident #31's nutritional supplements revealed on 08/02/23 the resident was ordered the use of 8 ounce sugar free house supplement daily. No evidence was found of any increase as recommended by the dietician on 09/10/23 as indicated in dietary notes. Interview with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and resident record review, the facility failed to ensure a resident was assessed prior to the use of bed side rails and she was properly care planned for bed side rails. This affected one Resident (#38) of one resident reviewed for accidents. The facility census was 44. Findings included: Review of Resident #38's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, dysphagia, encounter for palliative care, cerebral infarction, and chronic obstructive pulmonary disease. Review of Resident #38's admission Minimum Date Set (MDS) 3.0 assessment, dated 05/23/22, revealed she was cognitively impaired and was totally dependent on the help of two persons to physically assist with bed mobility. Review of Resident #38's significant change MDS 3.0 assessment, dated 07/20/23, revealed she was rarely or never understood, was totally dependent on the help of one person to physically assist with 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 record review, review of hospital records, and staff interview, the facility failed to ensure medications were only used when there was an adequate indication for use and a resident did not receive antibiotics administered via an intramuscular (IM) injection unless warranted for the treatment of an infection. This affected one (Resident #4) of five residents reviewed for unnecessary medications. The census was 44. Findings include: A review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of dementia with behavioral disturbances, chronic pain syndrome, adult onset diabetes mellitus, and congestive heart failure. She was hospitalized on [DATE] and re-admitted to the facility on [DATE]. A review of Resident #4's physician's orders revealed there was an order for the resident to be sent to the hospital for an evaluation on 08/02/23. There was another physician's order dated 08/07/23 for the resident to receive ceftriaxone (Rocephin) 250 milligrams (mg)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, policy review, and interview, the facility failed to ensure anti-psychotic medications were utilized only when medically necessary. This affected one (Resident #3) of five residents reviewed for medication use. The census was 44. Findings include: Review of Resident #3's medical record revealed diagnoses including post traumatic stress disorder (PTSD), dementia, major depressive disorder, psychotic disorder, dysthmic disorder, and mood disorder with depressive features. Review of a psychiatrist note dated 03/14/23 indicated risperdal (antipsychotic) (order for 0.5 milligram at bedtime for repetitive behavior and delusions related to dementia) would be decreased 0.25 milligrams (mg). An order was written for risperdal 0.25 mg every day for delusions. A psychiatrist note dated 04/11/23 revealed the risperdal would be discontinued. A psychiatrist note dated 05/09/23 indicated Resident #3 was doing well with the discontinuation of the risperdal. A nursing note dated 05/14/23 at 9:41 A.M. indicated Resident #3 was yelling out all hell was breaking loose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, tray card review, menu review and facility policy review, the facility failed to ensure preferences were honored when providing beverages. This affected three Residents (#2, #15, and #23) of three residents reviewed for beverage of choice. The facility census was 44. Findings included: Observation on [DATE] at 8:42 A.M. of three and one half gallons of 2% white milk in the milk cooler. There were no other types of milk (whole or chocolate) noted in the cooler. An interview at the time with [NAME] #483 verified there was only one type of milk, 2%. Observation on [DATE] at 7:10 A.M. of one and one half gallons of 2% white milk in the milk cooler. There were no other types of milk (whole or chocolate) noted in the cooler. An interview at the time with Cook/Dietary Aide #479 revealed the chocolate milk had expired and the facility discarded it. She verified there was no chocolate milk for all three meals on [DATE] or breakfast on [DATE]. She reported the facility order was to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to follow appropriate infection control practices by not ensuring a resident's indwelling urinary catheter bag was kept off the floor. This affected one (Resident #13) of one residents reviewed for catheters. Findings include: A review of Resident #13's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic pain syndrome, heart failure, chronic kidney disease, urinary retention, and difficulty walking. A review of Resident #13's physician's orders revealed she had the use of an indwelling urinary catheter to continuous drain. The order originated on 09/10/23. A review of Resident #13's care plans revealed she had a care plan in place for the potential for complications related to the use of an indwelling urinary catheter for urinary retention. The care plan was initiated on 09/11/23. The goal was for the resident to be free from catheter-related trauma through the review date.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's infection control log, review of infection reports, staff interview, and policy review, the facility failed to maintain an effective antibiotic stewardship program to ensure antibiotics were not used unnecessarily. This affected two (Resident #4 and #42) of five residents reviewed for antibiotic use. Findings include: 1. A review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of dementia with behavioral disturbances, chronic pain syndrome, adult onset diabetes mellitus, and congestive heart failure. She was hospitalized on [DATE] and re-admitted to the facility on [DATE]. A review of Resident #4's physician's orders revealed there was an order for the resident to be sent to the hospital for an evaluation on 08/02/23. There was another physician's order dated 08/07/23 for the resident to receive Ceftriaxone (Rocephin) 250 milligrams (mg) IM every day until 08/13/23 for a diagnosis of a UTI and Diflucan…

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