Deupree Cottages

Based on observation, staff interview, review of facility documents, and review of the facility policy, the facility failed to store and prepare food in a sanitary manner and the facility failed to ensure the facility dishwashers maintained a proper temperature to ensure sanitization. This had the potential to affect all of the residents residing in the facility. The facility census was 22 residents.Findings include: 1.Observation on 07/15/25 at 9:20 A.M. with Household Coordinator (HHC) #103 of kitchen #1 revealed the refrigerator contained the following unlabeled and undated items: a container of mashed potatoes, an bag containing an uncooked hamburger patty, a container of chicken salad, a half of a lemon pie, a large open container of ham lunch meat, a purple onion that had been cut wrapped in plastic, a container of cheese, a large opened container of macaroni salad, a container of opened chicken salad. The freezer contained the following unlabeled and undated items: two bowls of ice cream covered in plastic, a large bag of rolls Interview on 07/15/25 at 9:23 A.M. with HHC #103…

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, staff interview, and review of the facility policy, the facility failed to complete an updated Preadmission Screening and Resident Reviews (PASARRs) for residents experiencing significant changes and new diagnoses. This affected three (Residents #3, #14, #16 of four residents sampled. The facility census was 22 residents. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 04/06/21 with diagnosis including cerebral atherosclerosis, dementia with mood disturbance, and depression. Review of the progress note for Resident #3 dated 03/18/25 revealed the resident was admitted to hospice services. Review of the medical record for Resident #3 revealed the updated PASARR to reflect the resident's change in status was not completed until 07/17/25. Interview on 07/17/25 at 11:03 A.M. with Social Worker (SW) #102 confirmed Resident #3 admitted to hospice on 03/18/25 and the required updated PASARR was not completed until 07/17/25. 2. Review of the medical record for Resident #14 revealed an admission date of 6/19/24…

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.

Based on medical record review, observation, staff interview, review of online guidelines for enhanced barrier precautions (EBP) per the Centers for Disease Control (CDC), and review of the facility policy, the facility failed to display proper signage on the door for residents in EBP and failed to provide a proper receptacle located inside the door of the room for staff to doff personal protective equipment (PPE). This affected one Resident (#6) of one resident reviewed for EBP. The facility census was 22 residents. Findings include: Review of the medical record for Resident #6 revealed an admission date of 02/29/24 with diagnoses including dementia, hypertension, and myalgia. Review of the physician's orders for Resident #6 revealed an order dated 05/06/24 for the resident to be on EBP related to an ostomy. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 05/24/25 revealed the resident was cognitively impaired and required maximum staff assistance with activities of daily living (ADLs.) Review of the Medication Administration Record (MAR) for Resident #6 dated…

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

Based on observations, staff interview, and policy review, the facility failed to ensure storage of food was stored in a safe manner. This had the potential to affect all 20 residents residing in the facility who received food from the kitchen. Findings include: Observations during the initial tour on 11/07/22 from 10:05 A.M. to 10:35 A.M. with Household Coordinator #109 revealed the following: • Observation on 11/07/22 at 10:09 A.M. revealed the Colonial Kitchen refrigerator had two bags of cheddar cheese opened, unlabeled and undated, one container of cantaloupe sealed, but unlabeled and undated, and one container of chicken salad, sealed, but unlabeled and undated. • Observation on 11/07/22 at 10:13 A.M. revealed the Colonial Kitchen freezer revealed one bag of cheese biscuits opened, unlabeled and undated, one bag of frozen peaches opened, unlabeled and undated, one bag of regular biscuits opened, unlabeled and undated. • Observation on 11/07/22 at 10:25 A.M. revealed the Craftsmen Kitchen freezer had two bags of frozen turkey burgers opened, unlabeled and undated, one bag 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 staff interview, review of the facility's policy, and record review, the facility failed to ensure residents were accurately assessed for mental illnesses on Pre-admission Screening and Resident Reviews (PASARR). This affected two (Resident #3 and #8) of three residents reviewed for PASARR. The facility census was 20. Findings include: 1. Review of Resident #8's records revealed an admission date of 07/11/21 with diagnoses including dementia, anxiety disorder, delusional disorders, and vascular dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. Review of the care plan for behavioral symptoms including packing belongings, misplaces items, and accusing staff of hiding and stealing related to psychotic disorder; psychotropic drug use, psychiatrist/psychologist as needed/ordered, causal factors of behavior, monitor behaviors, disorders, decline in mood, document and notify physician of negative findings.…

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 routinely assess a resident's dialysis access site for patency or complications. This affected one (Resident #13) of one resident reviewed for dialysis. The facility identified one resident who receives dialysis. The facility census was 20. Findings include: Review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment, required extensive assistance with all Activities of Daily living (ADL). The MDS assessment indicated the resident received dialysis treatments. Review of Resident #13's November 2022 physician orders revealed the resident has orders to receive dialysis treatments weekly on Mondays, Wednesdays, and Fridays. Resident #13 had orders for no blood pressures or blood draws…

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 staff interview, the facility failed to store food in accordance with professional standards by having a hand-held scooper in the bread crumbs container and expired food items in the refrigerators. This had the potential to affect all residents that resided in the facility. The facility census was 23. Findings included: During the initial observation of the Colonial kitchen on 08/19/19 at 8:30 A.M., revealed a container of cottage cheese inside the commercial refrigerator that was undated and expired on 07/31/19. Observations of the Colonial kitchen also revealed a clear plastic hand-held scooper inside the portable bread crumb container. Observations of the Craftsman kitchen on 08/19/19 at 8:35 A.M. revealed two containers of cottage cheese inside the commercial refrigerator that were undated and expired on 07/31/19. Interview with versatile worker (VW) #238 on 08/19/19 at 8:32 A.M. verified the cottage cheese container inside the commercial refrigerator was undated and expired on 07/31/19. VW #238 also verified the clear plastic hand-held scooper inside…

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 upon record review, observation, staff interview, review of facility policy, review of manufacturer's recommendations, and review of online medication resources, the facility failed to date multi-use containers and vials of medication in order to determine when they should be discarded, failed to discard expired medication, and failed to store medication appropriately by storing oral medications next to externally administered medications. This had the potential to affect 8 (#1, #2, #3, #5, #7, #18, #21, #123) of 23 residents residing in the facility. Findings include: 1. Review of record for Resident #2 revealed an admission date of 11/15/17 with a diagnosis of glaucoma. Review of the record for Resident #2 revealed a revealed an order dated 11/15/17 for dorzolamide eye drops to the right eye three times daily. Review of manufacturer's insert for dorzoloamide revealed no recommendations for when to discard opened medication. Review of for Resident #2 revealed an order dated 06/14/19 for erythromycin…

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 upon record review and staff interview, the facility failed to accurately assess resident status regarding the provision of hospice services. This affected one (#11) of two residents reviewed for hospice and end of life care. The census was 23. Findings include: Review of record for Resident #11 revealed an admission date of 01/04/18, with diagnoses which included Parkinson's disease and Alzheimer's disease. Review of record for Resident #11 revealed an order dated 04/20/18 for hospice services for end-stage Alzheimer's disease. Review of care plan for Resident #11 revealed a care plan dated 04/20/18 for resident to receive hospice service for end stage Alzheimer's disease. Interventions included the following: activity as tolerated, call hospice with change in condition, hospice nurse to visit one to two times per week, pain management, offer religious support/counseling. Review of Minimum Data Set (MDS) Section O, dated 05/29/19 for Resident #11 revealed resident was coded negative for the provision of hospice services. Interview on 08/21/19 at 2:45 P.M., with the Director…

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, resident and staff interview, the facility failed to ensure an order was obtained for oxygen. This affected one resident (#20) of the three residents whom the facility identified as being on oxygen. The facility census was 23. Findings included: Review of the medical record for the Resident # 20, revealed an admission date of 07/15/19. Diagnoses included: syncope and collapse major depressive disorder, hypertension, hypothyroidism, acute kidney failure, hypokalemia and heart block. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/29/19 revealed resident was cognitively intact. Resident # 20 had no behaviors, did not reject care, and did not wander. Resident was a one-person physical assist, required extensive or limited assistance for activities of daily living (ADLs). MDS section 0 (special treatments) was silent for Resident #20 being on oxygen Interview with Resident #20 on 08/19/19 at 11:03 A.M., indicated she was started on oxygen when she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the failed to ensure a residents antipsychotic medication (Risperdal) was limited to 14 days and when given, no careplanned or non-pharmacological approaches were attempted prior to Risperdal being administered. This affected one (#6) of the five residents reviewed for unnecessary medications. The facility census was 23. Findings included: Review of the medical record for the Resident #6, revealed an admission date of 11/08/19. Diagnoses included: Alzheimer's disease, dementia, cataracts, and delusional disorders. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. Resident #6 had no behaviors, did not want wander but rejected care. MDS section N indicated an antipsychotic was used 7 days. Resident #6 was a one-person physical assist, required extensive assistance or limited assistance for activities of daily living (ADLs). Review of plan of care dated 11/08/18 was silent for any indication…

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 upon record review, observation, resident and staff interview, the facility failed to assist the resident in obtaining timely routine dental care. This affected one (#1) of one residents reviewed for dental concerns. The census was 23. Findings include: Review of record revealed Resident #1 was admitted on [DATE] with a diagnosis of unspecified dementia with behavioral disturbance. Review of Minimum Data Set (MDS) for Resident #1 dated revealed resident was cognitively impaired and was coded as negative for dental concerns. Review of record for Resident #1 revealed resident's representative had signed a consent for resident to receive dental services from the dentist who visited the facility dated 05/31/18. Review of social service progress note for Resident #1 dated 11/26/18 revealed resident's representative inquired about resident's teeth and that arrangements would be made for resident to examined by the the in-house dentist. Review of social service progress note for Resident #1 dated 02/25/19…

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.