Bethany Nursing Home, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review and policy review, the facility failed to ensure residents received timely assistance with meals and received showers per schedule. This affected three residents (Resident #22, #34 and #75) of five residents reviewed for assistance during mealtimes and one resident (Resident #37) of three residents reviewed for being offered showers per schedule. The facility census was 73. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date 07/01/21. Diagnosis included dementia, difficulty in walking, chronic kidney disease stage 3, anxiety, on hospice and solitary pulmonary nodule. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed impaired cognition. Resident #22 required substantial/maximal assistance for eating and dependent for all other activities of daily living (ADL's). Review of the meal intake for Resident #22 for the last 30 days revealed Resident #22 ate 26-50 % of meals from 02/15/26 to 02/25/26.…

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 observations, interviews, record review and policy review the facility failed to ensure residents were offered activities to meet their interests and support psychosocial well-being. This affected four residents (Resident #22, #30, #31 and #57) of four residents reviewed for activities. The facility census was 73. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date [DATE]. Diagnoses included dementia, difficulty in walking, chronic kidney disease stage 3, anxiety and solitary pulmonary nodule. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. Resident #22 required substantial/maximal assistance from staff for eating and dependent for all other activities of daily living (ADLs). Incontinence of bowel and had an indwelling catheter. Review of the care plan dated [DATE] revealed self-directed activities as Resident #22 preferred to participate in self-directed activities such as watching TV 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 staff interviews and record review, the facility failed to ensure the residents received nutritional supplements as physician ordered and failed to ensure the amount of fluid offered/consumed was documented when there was a physician order to encourage fluid intake for a resident. This affected two (Residents #4 and #37) of two residents reviewed for nutrition. This had the potential to affected an additional nine residents the facility identified who had physician orders to receive a nutritional supplement named Ensure. The facility census was 73.Findings include:1. Record review for Resident #4 revealed an admission date of 08/13/21. Diagnosis included Alzheimer's disease, mild protein calorie malnutrition, adult failure to thrive, and abnormal weight loss. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was severely cognitively impaired. Resident #4 had impairment to both sides of the upper extremities, and required partial/moderate assistance with eating.…

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 residents and/or responsible parties were informed of the risk of antipsychotic use prior to administration. This affected two (Residents #48 and #88) of six residents reviewed for medication use. The facility census was 73.Findings include: 1.Review of Resident #88's medical record revealed diagnoses including muscle wasting and atrophy of multiple sites, difficulty walking, urinary tract infection, cellulitis, chronic venous hypertension with an ulcer of bilateral lower extremities, and congestive heart failure. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was able to make herself understood and was able to understand others. Resident #88 was assessed as moderately cognitive impaired with a Brief Interview of Mental Status (BIMS) score of 11 (on a scale of 0-15). No behavioral symptoms were indicated but Resident #88 rejected care one to three days during the lookback period. 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 observations, medical record review, and interview, the facility failed to permit a resident to choose dining location and times. This affected one (Resident #31) of four residents reviewed for choices. The facility census was 73.Findings include: Observations on 03/11/26 revealed breakfast was served in the dining room for residents who needed assistance or supervision with eating between 9:30 A.M. and 9:48 A.M. Review of Resident #31's medical record revealed diagnoses included Alzheimer's disease, dementia, glaucoma, and macular degeneration. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 was usually able to make herself understood, was able to understand, and was severely cognitively impaired. The assessment indicated Resident #31's vision was moderately impaired. On 03/16/26 at 9:42 A.M., Resident #31's niece was observed propelling her in the hall and declaring it was ridiculous that residents did not get to eat breakfast until 10:00 A.M. Observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all resident funds were disbursed within 30 days of death. This affected one of one resident (#100) of one resident reviewed for disbursement of funds upon death. The facility identified nine residents with personal fund accounts residing in the facility. The facility census was 73.Findings include: Review of the closed medical record for Resident #100 revealed an admission date of [DATE]. Resident #100 expired in the facility on [DATE].Review of the resident funds account for Resident #100 revealed as of [DATE], Resident #100 had $4403.88 in her personal fund account that had not been disturbed after her passing on [DATE]. Interview on [DATE] at 11:03 A.M. with [NAME] Business Office Manager (BOM) #506 and the Administrator verified there had not been any BOM working at the facility since [DATE]. Regional BOM #506 verified funds are to be returned within 30 days upon death and this had not happened with Resident #100's funds.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to ensure residents' personal information was maintained in a manner to respect privacy related to personal and medical information. This affected two residents (#32 and #61) of 28 residents reviewed for privacy. The facility census was 73.Findings include: 1. Review of Resident #61's medical record revealed diagnoses including traumatic subdural hemorrhage and zoster ocular disease (shingles in the eye). Review of documentation confirmed Resident #61 had an appointment with the eye surgeon on 03/09/26. 2. Review of Resident #32's medical record revealed diagnoses including peripheral vascular disease, polyneuropathy, iron deficiency anemia, and generalized muscle weakness. An admission nursing assessment dated [DATE] indicated Resident #32 had an abrasion on the left buttock measuring 2 centimeters (cm) x 1.5 cm x 0.1 cm, a scab to the left heel measuring 3 cm x 2 cm x 0 cm and a surgical incision to the back neck (no measurements). No…

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 review of drug information from Medscape, the facility failed to ensure a resident had indications for use of an antipsychotic medication. This affected one (Resident #13) of three residents reviewed for psychotropic medication use. Findings include:Review of Resident #13's medical record revealed diagnoses including psychotic disorder with delusions and vascular dementia with anxiety. Orders included seroquel (antipsychotic) 12.5 milligrams every night at bedtime. Review of a nurse practitioner note dated 05/14/26 indicated Resident #13's daughter reported seroquel was started for insomnia. Due to concerns for QT prolongation (QT interval represents the time from the start of ventricular depolarization to the end of repolarization, reflecting the total duration of ventricular electrical activity) the Resident's daughter was informed to avoid seroquel upon discharge. Review of a discharge planning assessment dated [DATE] indicated Resident #13 was expected to stay in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure required notifications were provided to residents and/or representatives upon transfer to the hospital for two (Residents #37 and #88) of two residents reviewed for hospitalization, and failed to provide a discharge summary for one (Resident #90) of two residents reviewed for discharge. The facility census was 73. Findings include: 1. Review of Resident #88's medical record revealed diagnoses including muscle wasting of multiple sites, difficulty walking, cellulitis, chronic venous hypertension with ulcer of bilateral lower extremities, and congestive heart failure. A progress note by Nurse Practitioner (NP) #502 dated 01/02/26 revealed Resident #88 was noted to have increased agitation, severe paranoia and delusions, and was refusing all medications and care. Attempts had been made to initiate oral antipsychotic medication but none had been received due to refusal. Resident #88 received two doses of Haldol (antipsychotic) on 01/01/26…

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.

Based on closed medical record review and interview, the facility failed to ensure timeliness of completion and submission of Minimum Data Set (MDS) assessments. This affected one (Resident #18) of two residents reviewed for submission of MDS assessments. The census was 73.Findings include: Review of Resident #18's closed medical record revealed an admission date of 09/23/25 with diagnoses of osteoarthritis, osteoporosis, chronic obstructive pulmonary disease, depression, and generalized anxiety disorder. Resident #18 discharged from the facility on 10/15/25.Review of Resident #18's MDS assessments revealed an admission MDS assessment with an assessment reference date (ARD) of 09/30/25 was completed with a completion date of 10/08/25. A discharge MDS with an ARD of 10/15/25 was not completed.On 03/18/26 at 4:45 P.M., interview with Registered Nurse (RN) #434 verified Resident #18's discharge MDS with an ARD of 10/15/25 was not completed and was not submitted as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments. This affected two (Residents #10 and #32) of 27 residents whose assessments were reviewed for accuracy. The census was 73.Findings include: 1. Review of Resident #10's medical record revealed diagnoses including stage two chronic kidney disease, congestive heart failure, Alzheimer's disease, depression, anxiety disorder and restless leg syndrome. Review of a quarterly MDS assessment with an assessment reference date of 11/21/25 indicated Resident #10 received insulin injections seven of the last seven days.Review of Resident #10's November 2025 physician orders and the Medication Administration Record (MAR) from 11/14/25 to 11/21/25 revealed no evidence of insulin administrations.On 03/18/26 at 4:45 P.M., interview with Registered Nurse (RN) #434 verified the MDS dated [DATE] was inaccurate in regard to insulin administration.2. Review of Resident #32's medical record revealed 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 observation, medical record review and interview, the facility failed to ensure comprehensive care plans were developed for two (Residents #32, and #56) of 27 residents reviewed for comprehensive care planning. The census was 73.Findings include: 1. Review of Resident #32's medical record revealed diagnoses including pain, muscle wasting, chronic obstructive pulmonary disease, cirrhosis of the liver, peripheral vascular disease, iron deficiency anemia, and generalized muscle weakness. A nursing admission assessment dated [DATE] indicated Resident #32 had an abrasion on the left buttock, a scab on the left heel and a surgical incision on the back neck. On 02/09/26, orders were received to cleanse the abrasion to the left buttock with normal saline, pat dry, and cover with a foam dressing every day and as needed and to cleanse the surgical wound with normal saline, pat dry and cover with a dry dressing every day and as needed. A plan of care initiated 02/14/26 indicated Resident #32 was at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three residents (Resident #57, #64 and #84) of 30 residents reviewed were offered to participate in care plan meetings. The facility census was 73. Findings include: 1.Record review for Resident #57 revealed an admission date of 06/10/25. Diagnosis included muscle wasting and atrophy and neurocognitive disorder with Lewy bodies. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 had no impairment to the upper or lower extremity, used a walker for mobility, required set up or clean up assist for eating, and partial/moderate assist for walking 10 feet. Review of Resident #57's medical record revealed Resident #57 did not have a care plan for activities and there was no evidence Resident #57 ever was offered or participated in a care conference to determine his plan of care. Interview on 03/09/2026 at 1:14 P.M. with Resident #57 revealed he never had a care plan meeting while at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement a restorative nursing program as recommended for Resident #3 following the resident's discharge from therapy to assist the resident to maintain her functional ability. This affected one resident (#3) of eight residents reviewed for activities of daily living. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and difficulty walking.Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had severe cognitive impairment. The assessment revealed Resident #3 required (staff) supervision or touching assistance with eating and personal hygiene, partial/moderate (staff) assistance with oral hygiene, toileting hygiene, upper and lower body dressing, bathing, and transfers. Resident #3 used a walker and a wheelchair for mobility and required supervision or touch assistance for walking 150 feet.Review of the Modification 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 interviews, record review, observation and review of the facility policy, the facility failed to ensure Hospice documentation was in place for Resident #34 to ensure collaboration between the facility and Hospice services. This affected one Resident, Resident #34 of one resident reviewed for Hospice services. The facility also failed to ensure Resident #32 had routine assessments of a non-pressure skin impairment and failed to ensure Resident #56 had continued monitoring of a skin rash. This affected two residents (Resident #32 and #56) of two residents reviewed for non-pressure wounds of the skin. The facility census was 73.Findings include:1.Record review for Resident #34 revealed an admission date of 08/20/16. Diagnosis included cerebral atherosclerosis, atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs and adult failure to thrive. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was severely cognitively…

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 wound consultant notes, policy review, and interview, the facility failed to ensure routine skin assessments were completed for a resident with pressure ulcers. This affected one (Resident #32) of three residents reviewed for pressure ulcers The facility identified three residents with pressure ulcers. Findings include:Review of Resident #32's medical record revealed diagnoses including pain, muscle wasting and atrophy, abnormalities of gait and mobility, peripheral vascular disease, osteoarthritis, iron deficiency anemia and hypertension. An admission nursing assessment dated [DATE] indicated Resident #32 had pressure ulcers to the bottom of the left foot and right outer heel. There were no measurements or other descriptions of the pressure ulcers. Resident #32 was discharged to the hospital 02/02/26 for planned spinal surgery. Resident #32 was readmitted to the facility on [DATE]. An admission nursing assessment dated [DATE] indicated Resident #32 had an abrasion on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure a comprehensive, resident centered fall prevention program was implemented to prevent resident falls and to ensure staff have access to resident information. This affected one resident, Resident #57 of one resident reviewed for falls with serious injury. The facility census was 73. Findings include: Record review for Resident #57 revealed an admission date of 06/10/25. Diagnoses included muscle wasting and atrophy multiple sites, muscle weakness, neurocognitive disorder with Lewy bodies, and difficulty in walking. Review of the fall history form provided by Minimum Data Set (MDS) Coordinator #434 revealed Resident #57 had a fall on 06/11/25 and 06/12/25. Neither fall documentation was timed and both occurred while getting up unassisted. The documentation included Resident #57 had a skin tear from the fall on 06/11/25.Record review of the Fall Risk Assessment for Resident #57 dated 12/08/25 revealed no…

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, interview and policy review the facility failed to ensure Resident #30's urinary tract infection (UTI) was addressed timely and Resident #45 received timely incontinence care. This affected two residents (Resident #30 and #45) of two residents reviewed for bladder incontinence/urinary tract infection (UTI). The facility census was 73.Findings Include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/09/17. Diagnoses included cognitive impairment, muscle weakness, chronic pain and anxiety.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. Resident #30 was dependent on all activities of daily living (ADL's) and was incontinent of bowel and bladder.Review of the care plan dated 03/06/26 for incontinent of bladder and/or bowel related to severe cognitive impairment and severe physical impairment. Interventions included[SP1.1][TH1.2] keeping skin as clean and dry as possible.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 and physician and staff interviews, the facility failed to ensure medication was not received in an excessive dose for a resident. This affected one (Resident #88) of six residents reviewed for unnecessary medications. The facility census was 73.Findings include:Review of Resident #88's medical record revealed diagnoses included cellulitis (bacterial skin infection) and chronic venous hypertension (increased blood pressure in the veins) with ulcer of bilateral lower extremities. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was moderately cognitively impaired. Review of the December 2025 Medication Administration Record (MAR) revealed Resident #88 had an order with a start date of 12/09/25 for acetaminophen 500 milligrams (mg) two tablets before meals for pain. Administration was scheduled for 7:30 A.M., 11:00 A.M., and 4:00 P.M. Another order dated 12/09/25 indicated acetaminophen 500 mg two tablets three times a day with medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the manufacturer instructions, the facility failed to ensure a medication error rate of less than five percent (%). Two errors were observed in 25 opportunities resulting in an 8.0% error rate. This affected one (Resident #83) of four residents observed for medication administration. The facility census was 73.Findings include: Record review for Resident #83 revealed an admission date of 11/03/25. Diagnosis included type two diabetes mellitus (DM). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was moderately cognitively impaired and received insulin injections daily. Review of the physician orders revealed on 12/13/25, Resident #83 had an order for insulin lispro 100 units per milliliter (ml) inject subcutaneously (SQ) as per sliding scale. The order included if the blood sugar was 301 to 350 inject eight units. Medications also included insulin lispro 26 units SQ one time a day for DM, give half dose if 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 observation, interview, record review and review of the manufacturer instructions, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #83) of one resident observed for insulin administration. The facility identified there were six residents who receive insulin. The facility census was 73.Findings include:Record review for Resident #83 revealed an admission date of 11/03/25. Diagnosis included type two diabetes mellitus (DM). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was moderately cognitively impaired and received insulin injections daily. Review of the physician orders revealed on 12/13/25, Resident #83 had an order for insulin lispro 100 units per milliliter (ml) inject subcutaneously (SQ) as per sliding scale. The order included if the blood sugar was 301 to 350 inject eight units. Medications also included insulin lispro 26 units SQ one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, observation and record review, the facility failed to ensure a resident was offered to see a dentist. This affected one (Resident #1) of three residents reviewed for dental services. The facility census was 73. Findings include:Findings include:Record review for Resident #1 revealed an admission date 01/14/25. Diagnoses included spinal stenosis, thoracolumbar region and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired and was dependent on staff for oral hygiene. Resident #1 had no dental care plan. There was no evidence Resident #1 was offered and/or seen by a dentist since admission to the facility in the resident's medical record.Interview on 03/09/26 at 9:28 A.M. with Resident #1 revealed she was concerned because she had not seen a dentist since admission to the facility.Observation and interview on 03/11/26 at 3:54 P.M. revealed Resident #1 was sitting up in her chair and stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review and policy review, the facility failed to honor food preferences of the residents. This affected one (Resident #84) of three residents reviewed for meal preferences. The facility census was 73.Findings include:Review of the medical record for Resident #84 revealed an admission date 01/15/26. Diagnoses includes dysphagia (difficulty swallowing), kidney disease and chronic pain.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had intact cognition and was on mechanically altered diet.Interview on 03/10/26 at 8:37 A.M. with Resident #84 stated the facility used to send a staff member around and ask the residents what they wanted to eat for their next meal, but the facility quit doing that. Resident #84 stated she does not like green beans and since staff don't come around and ask, she gets green beans even though she does not like them. After you receive the meal, she can ask for something else, but then you have 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 interviews and record review, the facility failed to ensure medical records were accurate. This affected one (Resident #45) of 30 residents reviewed for accurate medical records. The facility census was 73.Findings include: Review of the medical record for Resident #45 revealed an admission date 02/27/23. Diagnoses included colostomy and inability to control bowel or bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition and had an ostomy. Review of the physician orders dated 12/14/25 revealed an order to change ostomy bag every three days, cleanse surrounding skin with normal saline, ensure dry and apply nystatin powder prior to applying new ostomy bag/wafer and as needed. Review of the Treatment Administration Record (TAR) for March 2026 revealed on 03/03/26, 03/09/26 and 03/12/26, the treatment for changing ostomy bag was signed off by Licensed Practical Nurse (LPN) #508. On 03/06/26, the treatment was marked refused by LPN #508. 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 and policy review, the facility failed to provide a dignified dining experience for Resident #68. This affected one resident (#68) of one reviewed for dignity. The facility census was 78. Findings include: Review of the medical record for Resident #68 revealed an admission date of 04/27/23 with diagnoses including non-traumatic subarachnoid hemorrhage, muscle weakness, hereditary motor and sensory neuropathy, Alzheimer's disease, hemiplegia affecting right dominant side, dysphagia (difficulty swallowing), and personal history of transient ischemic attack and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/18/24, revealed Resident #41 had severe cognitive impairment and was dependent on staff for eating assistance. On 04/01/24 at 11:34 A.M., Resident #68 was observed sitting in a chair in the common area by the nurses' station with her lunch tray on a table in front of her. Resident #68 did not attempt to feed herself and no staff attempted to assist her with the meal at that time. On 04/01/24 at 11:47 A.M.,…

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 provide Residents #72 and #73 with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) informing them of the financial liability for continuation of skilled services not covered by Medicare. This affected two residents (#72 and #73) of three residents reviewed for beneficiary notification. The facility census was 78. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 09/19/23 with diagnoses including non-traumatic chronic subdural hemorrhage, difficulty in walking, muscle weakness, other symptoms involving the musculoskeletal system, breast cancer, asthma, protein-calorie malnutrition, and weakness. Review of the Notice of Medicare Non-Coverage (NOMNC) form, dated 10/30/23, for Resident #72 revealed the last covered day for skilled services was 11/03/23. Resident #72 remained in the facility until her discharge on [DATE]. On 04/02/24 at 9:12 A.M., 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.

Based on medical record review, interview, and policy review, the facility failed to ensure psychotropic medications which were ordered on an as necessary basis had a specific duration for use. This affected two (Resident #26 and #335) of six residents reviewed for the medical necessity of medication use. The facility census was 78. Findings include: 1. Review of Resident #26's medical record revealed diagnoses including depression and anxiety disorder. Review of physician orders revealed an order dated 03/08/24 for trazodone (an anti-depressant) 12.5 milligrams (mg) at bedtime as needed (prn). There was no time limit on the order or documentation regarding when the next re-evaluation of its continued use would be completed. Review of the March 2024 and April 2024 Medication Administration Record (MAR) revealed Resident #26 was administered the trazodone on an as necessary basis 13 times. During an interview on 04/03/24 at 12:10 P.M., the Director of Nursing (DON) verified the order for trazodone did not have specific orders for the duration of use. 2. Review of Resident #335'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 record review, interview and policy review, the facility failed to monitor prophylactic antibiotic use. This affected one resident (#23) of two residents reviewed for antibiotic use and one resident (#36) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 11/16/23 with diagnoses including type two diabetes mellitus, anemia, vascular dementia without behavioral disturbances, granulomatous disorder of the skin and congestive heart failure. Review of the physician's orders for April 2024 identified orders for minocycline hydrochloride (HCl) 50 milligrams (mg) twice daily for skin. Further review of the medical record identified no active infections of the skin. On 04/03/24 at 2:30 P.M., interview with the Director of Nursing (DON), who also served as the facility's Infection Preventionist, stated the facility does not monitor or track antibiotics for prophylactic use. She stated any residents who had orders for prophylactic antibiotics were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to timely report allegations of abuse as required to the State Agency. This affected one resident (Resident #3) of one resident reviewed for abuse. The facility census was 81 residents. Findings include: Review of Resident #3's medical record revealed an admission date of 07/01/21 and diagnoses including unspecified dementia without behaviors, hypertension, chronic obstructive pulmonary disease, Alzheimer's disease, anxiety and constipation. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was cognitively impaired, had no limitations to range of motion and did not display behaviors. Review of a nurses' note for Resident #3 on 06/01/23 at 4:22 P.M. written by Executive Director of Quality (EDQ)/Registered Nurse (RN) #614 revealed a skin assessment was completed to back and upper arms. Resident #3 was calm and no complaints were noted. Resident #3's daughter and provider were updated. 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 and interview, the facility failed to ensure assessments were accurately completed. This affected two (Residents #44 and #75) of 21 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 81. Findings include: 1. Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including Alzheimer's Disease, congestive heart failure and chronic kidney disease. Review of the significant change MDS 3.0 assessment dated [DATE] for Section G for Resident #44 revealed he needed extensive assistance of two staff members for bed mobility, transfers and toileting. Resident #44 needed extensive assistance of one staff member for dressing, personal hygiene and eating. There was no daily documentation from staff to show the resident's functional status. Interview on 06/07/23 10:31 A.M. with Registered Nurse (RN) #614 verified she had documented and completed Resident #44's MDS dated for 04/10/23. She verified she was unable to provide 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.