Roscoe Gardens Skilled Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a safe environment. This affected one resident (#4) of four sampled for environment. The facility census was 59.Findings Include: Review of Resident #4's medical record revealed an admission date of 07/20/22, a re-entry date of 07/07/24 and diagnoses including but not limited to diabetes, dysphagia, heart failure, chronic obstructive pulmonary disease, osteomyelitis, schizoaffective disorder, schizophrenia, peripheral vascular disease, anxiety disorder, major depressive disorder and hypertension. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the MDS revealed the resident was independent or required set up assistance with eating, bed mobility, transfers and wheelchair mobility, required partial/moderate assistance with toilet hygiene and showering or bathing, had an indwelling…

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 record review, staff interview, and review of facility policy, the facility failed to provide a bed hold letter to a resident and failed to notify the Ombudsman when the resident discharged to the hospital. This affected one resident (Resident #3) out of three residents reviewed for discharges. The facility census was 59 residents.Findings Include:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia, and displaced fracture of neck of right femur. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was assessed as having a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognitive status. Review of Resident #3's nursing progress notes dated 08/20/25 revealed that he had a fall and was discharged to the hospital for an evaluation. Review of Resident #3's medical record revealed that he was hospitalized from [DATE] to 08/24/25. There was no documented…

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, interview, and policy review, the facility failed to ensure Resident #7's fingernails were trimmed and cleaned. This affected one (Resident #7) out of three reviewed for activities of daily living. Facility census was 59.Findings included:Review of the medical record revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, displaced fracture of right femur, severe-protein-calorie malnutrition, and anxiety.Review of Resident #7's plan of care dated 08/06/25 revealed Resident #7 had an activity of daily living (ADL) self-care performance deficit. Interventions included to assist the resident with activities of daily living such as dressing, grooming, personal hygiene, locomotion, and oral care. Review of Resident #7's physician order dated 10/21/25 at 3:47 P.M. revealed Resident #7 was admitted to hospice with diagnosis of hypertensive heart disease with heart failure. Review 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 observation, record review, interviews, and policy review, the facility failed to ensure timely care and services were provided to Resident #8 who had a fall which resulted in a fracture. This affected one resident (#8) out of five reviewed for accidents. Additionally, the facility failed to ensure appropriate catheter care was provided for Resident #7 when the resident's indwelling urinary catheter drainage bag was not properly positioned or secured in accordance with facility policy and accepted catheter care standards. This deficient practice affected one resident (#7) of two residents reviewed for catheter care. The facility reported ten residents with indwelling urinary catheters. Facility census was 59.Findings include: 1. Review of Resident #8's medical record revealed an admission date of 09/16/22 with diagnoses including, but not limited to dementia without behavioral disturbances, anxiety, major depressive disorder, and unspecified intellectual disabilities. Review of Resident #8's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of resident diet slips, interview, and observation, the facility failed to ensure timely initiation of nutritional supplement recommendations and failed to ensure nutritional supplements were available and received as ordered. This affected two residents (#3 and #8) of three residents reviewed for nutrition.Findings include:1. Review of Resident #8's medical record revealed an admission date of 09/16/22 with diagnoses including, but not limited to dementia without behavioral disturbances, anxiety, major depressive disorder, and unspecified intellectual disabilities. Review of Resident #8's care plan dated 01/03/25 revealed the resident was at risk for altered nutritional status related to dementia, anxiety, communication problems, and on 11/07/25 it was updated to include an altered diet texture, unplanned weight loss and poor intakes. Interventions included provide feeding/dining assistance as needed and provide nutritional supplements as ordered by the physician. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interviews and review of a facility policy, the facility failed to have parameters in place for as needed pain medications. This affected one (Resident #3) out of two residents reviewed for pain management. The facility census was 59.Findings include:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of vascular dementia and displaced fracture of the base of the neck of the right femur.Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that he was assessed as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of intact cognitive status.Review of Resident #3's physician orders dated 08/24/25 revealed that he had an order for Tylenol, a non-narcotic analgesic oral tablet 325 milligram (mg), give 650 mg by mouth every four hours as needed for pain. There were no specified parameters in place for the medication.Review of Resident #3's physician orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement pharmacy recommendations signed by the provider in a timely manner. This affected one resident (#49) of five reviewed for unnecessary medications. The facility census was 59.Findings include:Review of Resident #49's medical record revealed an admission date of 07/27/23 and diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction on the right dominant side, chronic pain, hyperlipidemia, hypertension, mood disorder due to know physiological condition, and alcohol abuse uncomplicated.Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed Resident #49 required a wheelchair for mobility and was independent with wheelchair mobility, was continent of both bladder and bowel, had occasional pain of five out of ten on the pain scale (zero was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility investigations, interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected three residents (#28, #50, and #69) out of nine residents reviewed for medication administration. Facility census was 59. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included mononeuropathy of the right lower leg, pain in right knee, and type two diabetes. Review of Resident #28's physician order dated 11/24/25 revealed Resident #28 was ordered Pregabalin (a medication used to treat nerve pain) 150 milligrams (mg) capsules three times a day, due at 6:00 A.M., 2:00 P.M., and 10:00 P.M. Review of Resident #28's controlled drug record revealed on 11/26/25 at 4:00 A.M. Licensed Practical Nurse (LPN) #96 signed out five Pregabalin 150 mg capsules. Review of Resident #28's Medication Administration Record (MAR) revealed on 11/26/25 at…

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

Based on observation, staff interviews, review of the menu spreadsheet, and review of facility policy, the facility failed to provide and serve pureed bread as planned on the menu. This affected two out of two residents (Resident #8 and #13) who received pureed diets in the facility. The facility census was 59 residents.Findings include: Review of the planned pureed diet spreadsheet for 12/18/25 revealed that a #16 scoop of pureed bread was to be served with the lunch meal on 12/18/25. Observations of the preparation of the pureed diets on 12/18/25 from 10:02 A.M. to 10:17 A.M. revealed that no pureed bread was prepared for the pureed diets. An interview with [NAME] #117 on 12/18/25 at 11:51 A.M. confirmed that no pureed bread was made for the pureed diets on 12/18/25 for lunch, and no pureed bread substitute was served. [NAME] #117 stated that it does not work well. An interview with Registered Dietitian #300 on 12/18/25 at 12:22 P.M. revealed that if bread was unable to be prepared properly, she would expect a pureed bread substitute to be served instead.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident #42's call light was within reach. This affected one (Resident #42) out of 28 residents observed for call lights within reach. Facility census was 59. Findings include:Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses that included dementia, atrial fibrillation, asthma, and generalized anxiety disorder.Review of Resident #42's care plan dated 02/20/25 revealed the resident was at risk for falls related to impaired cognition and the use of psychotropic medications. Interventions included to maintain the call light within reach.Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 02 which indicated severe cognitive impairment. The MDS also revealed Resident #42 was independent with mobility. An observation on 12/15/25 at 3:03 P.M. revealed Resident #42's call light was between the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, and facility policy review the facility failed to maintain sanitary conditions in the kitchen during meal service by not wearing facial hair covering and handling food with bare hands. This affected one resident (Resident #5) and had the potential to affect all residents residing in the facility. The facility census was 54. Findings Include: A review of the medical record for Resident #5 revealed an admission on [DATE] with diagnoses including but not limited to dementia, weakness, and indigestion. Resident #5 required assistance from staff to complete activities of daily living (ADL) tasks and was independent with eating. A review of Resident #5's physician orders revealed an order dated 05/15/25 for a regular, mechanical soft texture, thin liquids consistency diet and preferred small portions. A review of Resident #5's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section K - Swallowing/Nutritional Status was marked as…

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 staff interview the facility failed to ensure weekly skin inspections were completed as indicated in the resident's comprehensive care plan. This affected one (Resident #54) of three residents reviewed for skin impairment. The facility census was 53. Findings include: Review of the Resident #54's closed medical record revealed an admission date of 01/07/25 with diagnoses that included fall with nasal fracture, influenza A, cerebrovascular accident and traumatic brain injury. Further review of the medical record including weekly skin inspections revealed inspections completed upon admission and again on 01/15/25. No further skin inspections were completed. Resident #54 discharged home from the facility on 02/01/25. Review of the care plan titled potential for altered skin integrity indicated an intervention of weekly skin inspections to be completed. On 04/07/25 at 1:10 P.M. interview with the Director of Nursing verified weekly skin inspections were not completed for Resident #54 on 01/22/25 and 01/29/25 as indicated in the care plan. 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 review of invoices, review of alternative menu, review of the contract, observation, and interviews the facility failed to ensure alternate menu items were available. This had the potential to affect all 57 residents residing in the facility. Findings included 1. Interview on 10/07/24 at 9:45 A.M., with Resident #24 revealed the facility doesn't honor food alternatives ordered. Interview on 10/07/24 at 1:17 P.M., with Resident #46 revealed the facility was always out of menu and alternative food items. The other day the facility was out of lettuce and orange juice. The facility quit providing cottage cheese as well, which was on the alternative menu. Interview and observation on 10/08/24 at 8:48 A.M., with Resident #20 revealed he was told the facility was no longer providing residents with cottage cheese and he would have to buy his own. The resident reported he loved cottage cheese and had been purchasing his own. Interview on 10/08/24 at 8:48 A.M. with State Tested Nurse's Aide (STNA) #176 revealed he was told the facility was out of cottage cheese last week, but he 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 and interview the facility failed to ensure the ice machine was maintained and cold air-vents were cleaned. This had the potential to affect all 57-resident residing in the facility. Findings included Observation on 10/09/24 at 12:12 P.M., of the kitchen with revealed the three cold air ducts and one duct no longer used were visibly dusty. Additional observations revealed the bottom drainpipe for the ice machine was running into the floor drainpipe. There was no gap between the ice machine drainpipe and floor drainpipe. The floor drainpipe was clogged and filled with stagnant water filling, backing into the ice machine drainpipe. Findings confirmed during observation with District Manager #129. Review of the food service contract 04/25/21 revealed the contracted company was responsible for providing labor to perform menu and recipes development, procuring, handling, inventorying and storing food and related supplies, preparing, staging, and transporting meals to resident dining areas, and cleaning and sanitizing.

Based on self-reported incident review, medical record review, interview and policy review the facility failed to ensure allegations of abuse were reported to the state survey agency in a timely manner. This affected one (Resident #26) of one residents reviewed for abuse. The facility census was 57. Findings include: Review of Resident #26's medical record revealed an admission date of 03/29/22 with admission diagnoses that included anoxic brain injury, schizoaffective disorder and bipolar disorder. Review of Resident #26's Minimum Data Set (MDS) 3.0 assessment with a reference date of 08/28/24 revealed the resident had an independent and intact cognition level. Review of the facility on-line self reported incidents (SRI) revealed on 09/30/24 the facility created an SRI for Resident #26 for an allegation of physical abuse. Review of the facility investigation revealed the abuse allegation was reported to staff by Resident #26 on 09/27/24. Review of progress notes for Resident #26 revealed on 09/27/24 the resident made an allegation of physical abuse related to her family hitting her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication and pertinent diagnosis. This affected two residents (#6 and #9) of five residents reviewed for unnecessary medications. Findings include: 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, dysphagia, chronic kidney disease, low back pain, and muscle wasting and atrophy. Review of a physician order, dated 07/30/24, revealed the order for Tramadol 50 milligrams (mg), one tablet every six hours, as needed for pain. Review of the August and September 2024 Medication Administration Records (MAR) revealed Resident #6 received Tramadol 50 mg, one tablet, on 08/30/24, 09/02/24, and 09/03/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/05/24, revealed that Resident #6 received an opioid for zero days during the seven day look-back period. Interview on 10/08/24 at 3:24…

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 medical record review and staff interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) document accurately reflected diagnoses. This affected two (Resident #6 and Resident #9) of three residents reviewed for PASRR documents. The census was 57. Findings Include: 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, dysphagia, chronic kidney disease, low back pain, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/05/24, revealed the resident had intact cognition and a diagnosis of anxiety disorder. Review of Resident #6's PASRR document, dated 08/24/23, revealed under Section E, there was no check mark selected to indicate the diagnosis of anxiety. Review of the resident's diagnosis list revealed the diagnosis of anxiety on 08/13/20. Review of a physician order, dated 01/03/24, revealed the order for Clonazepam 0.5 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 record review, and staff interview, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. This affected one (Resident #52) of one resident reviewed for dialysis. Resident #52 was the only resident in the facility receiving dialysis treatments. The facility census was 57. Findings include: Review of the medical record for Resident #52 revealed an admission date of 07/12/24. Diagnoses included end stage renal disease, essential hypertension, and type two diabetes mellitus with diabetic nephropathy. Review of Resident #52's October 2024 Physician orders revealed orders for the resident to receive outpatient dialysis on Monday, Wednesday and Friday every weekly. The resident has been receiving dialysis three times a week since his admission to the facility. Review of Resident #52's Care Plan dated 08/30/24 revealed the resident has a diagnosis of chronic renal failure and has the potential for complications from hemodialysis. Interventions included outpatient dialysis 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 interview, record review, and pharmacy recommendations the facility failed to timely address pharmacy recommendation related to Resident #3's pain medication and lab work. This affected one (#3) of five residents reviewed for unnecessary medications. The facility census was 57. Findings include: Review of the medical record for Resident #3 revealed an admission date of 07/20/22. Diagnoses included type two diabetes mellitus, pain in left hip, and non-pressure chronic ulcer of other part of left foot. Review of Resident #3's Pharmacy Recommendation dated 01/05/24 stated to please evaluate the following as needed medications and assess proper parameters (i.e. pain scale 1-10) to identify which medication to administer or consider discontinuation of one of the agents. The agents listed were acetaminophen 325 mg take two every six hours as needed for pain and tramadol 50 mg as need for pain. Review of Resident #3's Pharmacy Recommendation dated 08/04/24 stated to please be sure the following lab results are posted in the chart as they were unavailable during the of review. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and policy review the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #13) of five residents reviewed for unnecessary medication use. The facility census was 57. Findings included: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, subsequent encounter, acute Infection, infection following a procedure, other surgical site, subsequent encounter, and pain. 1. Review of Resident #13's admission orders dated 08/21/24 revealed the resident was ordered vancomycin 2,000 milligrams (mg) intravenous (IV) twice daily for a spinal surgical wound infection. The wound culture grew Enterococcus Faecalis, Candida Albicans, and Staph Haemolyticus . Additional orders for the central line (special access to administer intravenous medication) included to…

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

Based on medical record review, observation, interview, and policy review revealed the facility failed to ensure medications were stored appropriately. This had the potential to affect all 57 residing in facility. Findings included: 1. Observation on 10/07/24 at 2:04 P.M. revealed the Sycamore Valley medication cart was left unlocked and unattended. The nurse (Licensed Practical Nurse (LPN) #158) was observed in a room with a resident, which was at the other end of the hall. Interview on 10/07/24 at 2:04 P.M., with State Tested Nurse's Aide (STNA) #162 confirmed the medication cart was unlocked and unattended. Review of the facility's policy tilted Medication Administration dated 09/2018 revealed the medication cart is kept closed and locked when out of sight of the medication nurse. 2. Observation 10/08/24 at 7:40 A.M. revealed the facility's Director of Nursing (DON) administered medication to Resident #7. While in the room, whom she shares with Resident #35, a pill cup with several pills on Resident #35's bedside table. The DON asked the resident what the pills were doing there,…

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 a resident received dental services timely. This affected one (Resident #11) of one reviewed for dental services. Findings included: Record review revealed Resident #11 was admitted to the facility on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gastro-esophageal reflux disease without esophagitis, and need for assistance with personal care. Review of Resident #11's face sheet revealed the resident's primary insurance was Medicaid. Review of Resident #11's progress notes revealed on 09/04/24 the Social Worker (SW) #132 was notified Resident #11 needed to see a dentist related to losing a bottom right filling. Review of Resident #11's progress note dated 09/05/24 revealed the resident had voiced complaints of right-sided mouth pain due to a filling lost from a tooth. The resident requested as needed Tylenol. The medication was administered and effective.…

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 provide an appropriate assistive device to maintain/improve the ability to eat independently. This affected one (Resident #5) of two residents reviewed for mobility/restorative. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, muscle wasting and atrophy, lack of coordination, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 08/21/24, revealed Resident #5 was cognitively intact. There were no behaviors or rejection of care. The resident was receiving hospice services. Review of the Care Plan, dated 01/30/24, revealed Resident #5 was limited in ability to eat and drink related to weakness, cerebral infarction with left-sided hemiplegia, and dysphagia with interventions including to provide diet as ordered and eating assistance.…

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 policy review the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for Resident #261 who was admitted with a chronic venous ulcer. This affected one (Resident #261) of one residents reviewed for wounds. The facility census was 57. Finding include: Review of the medical record for Resident #261 revealed an admission date of 09/11/24. Diagnoses included unspecified venous ulcer, cellulitis, morbid obesity, and peripheral vascular disease. Review of Resident #261 wound assessment dated [DATE] revealed the resident had a right ankle unspecified venous ulcer measuring three centimeters (cm) length by three cm width and 0.1 cm deep. The wound was noted to have light exudate of serosanguineous (pale red to pink, thin and watery) drainage. Review of Resident #261 October 2024 physician orders revealed the resident did not have an order in place for EBP. Observations on 10/07/24 at 9:29 A.M. and 03:43 P.M. revealed the Resident #261 did not…

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 with staff, and review of the facility policy the facility failed to ensure three medication carts were locked when unattended. This had the potential to affect 12 residents (#1, #5, #18, #22, #24, #32, #33, #42, #46, #51, #55, and #56) who were cognitively impaired and independently mobile residents. The facility census was 54. Findings include: Observation of the Buckeye Unit on 06/29/24 at 7:50 A.M. revealed three medication carts (#2, #3 and #4) were sitting outside the nurse's station unlocked and unattended. On 06/29/24 at 8:05 A.M. an interview with Nurse #101 confirmed she had left the medication carts unlocked while she went to the restroom. Review of the facility policy titled, Medication Storage-Storage of Medication, dated 01/23, revealed medications and biologicals were stored properly, following manufacturers or providers pharmacy recommendations, to maintain their integrity and to support safe effective drug administrations. The medication supply would be accessible only to licensed nursing personnel, pharmacy personnel or staff members…

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 review of the medial record, review of the facility investigation, interview with the staff, and facility policy review the facility failed to ensure Resident #58 was administered the correct medication. This affected one resident (#58) of three residents reviewed for medication errors. The facility census was 54. Findings include: Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses include cellulitis of the left upper limb, urinary tract infection, cognitive communication deficit, dysphagia, hypertension, dementia, atherosclerotic heart disease, chronic kidney disease, and atrial fibrillation with pacemaker. She was discharged against medical advice on 06/23/24. Further review of the medical record revealed Resident #58 was allergic to caffeine, chocolate flavoring, codeine sulfate, and meclizine. There was no Minimum Data Set information available. Review of the vital signs for Resident #58 revealed on 06/12/24 her baseline vital signs were blood…

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

Based on observations and interview with staff the facility to ensure staff used proper hand hygiene during medication administration. This affected three residents (#25, #51, and #54) of eight residents reviewed for medication administration. The facility census was 54. Findings include: Observations of medication administration on 06/29/24 at 11:07 A.M. revealed Nurse #101 administered medication to Resident #51, left her room, went to the medication cart in the hallway, and hugged a visitor in the hallway. She went down the hall to another unit, and she stopped at a resident's room and shook hands with a resident's family member then she went out to the medication cart and started to set up medication for Resident #54 without washing her hands. She removed a capsule of gabapentin from the card with her bare hand and put it into the medication cup and started to walk towards the resident's room. She was stopped by the surveyor to administer a new capsule of gabapentin. Nurse #101 stated she did not even realize she used her hands to pop the capsule out of the medication card. 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.

Based on record review, review of the Administrator and Director of Nursing (DON) Job Descriptions, review of a facility self-reported incident (SRI) and investigation, and interviews the facility failed to maintain effective administrative services to provide a comprehensive abuse prohibition program to prevent, timely identify and investigate situations of resident-to-resident physical abuse. This affected one resident (#2) and had the potential to affect all residents residing in the facility. The census was 58. Findings include: Review of the Administrator Job Description, Version 03.2021 revealed the position was to lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Review of the Director of Nursing (DON) Job Description, version 03.21, revealed the position was to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices…

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

Based on review of a facility Self-Reported Incident (SRI) and investigation, review of the facility's abuse policy titled, Abuse, Neglect, and Misappropriation of Property, and interviews the facility failed to ensure a complete and thorough investigation following an allegation of physical abuse. This affected one (Resident #2) of six residents reviewed for abuse. The facility census was 58. Findings include: Review of the facility Self-Reported Incident (SRI), tracking number 24658, discovery and submission date of 04/21/24, revealed an allegation/suspicion of physical abuse with the initial source of the allegation being a resident victim and a resident witness. The SRI indicated on 04/21/24 at 7:45 A.M. in the dining room, Resident #2 alleged Resident #3 attacked her. There were no staff present during the alleged attack. The only witness was Resident #6. Facility interview with Resident #3 revealed Resident #2 attacked her by pulling her oxygen off and saying, I'm gonna kill you {expletive}. Facility interview with Resident #2 revealed she didn't do anything, and Resident #2…

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

Based on record review, policy review, and interview, the facility failed to implement interventions to prevent further potential abuse after allegations of staff being rough and making inappropriate comments were reported to staff. This affected one resident (Resident #7) of 11 residents interviewed regarding abuse. The census was 41. Findings include: Review of Resident #7's medical record revealed diagnoses including major depressive disorder, multiple sclerosis, contractures of both hands, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder, spondylolisthesis of the lumbar region, and intervertebral disc disorders of the thoracic region. Review of a nursing note dated 01/01/23 at 5:12 P.M. revealed Resident #7's daughter spoke to Registered Nurse (RN) #18. Resident #7 had informed her daughter a STNA told Resident #7 she needed to be repositioned in bed for safety. Resident #7 reported when she refused the STNA said well fall on the floor then. RN #18 documented she explained all care was provided by two staff at all times. Resident #7'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, policy review, and interview, the facility failed to report allegations of rough handling by staff, inappropriate intimidating remarks made to residents, and allegations of misappropriation of property. This affected one resident (Resident #7) of 11 residents interviewed regarding abuse and missing items. The census was 41. Findings include: Review of Resident #7's medical record revealed diagnoses including major depressive disorder, multiple sclerosis, contractures of both hands, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder, spondylolisthesis of the lumbar region, and intervertebral disc disorders of the thoracic region. Review of a nursing note dated 01/01/23 at 5:12 P.M. revealed Resident #7's daughter spoke to Registered Nurse (RN) #18. Resident #7 had informed her daughter a STNA told Resident #7 she needed to be repositioned in bed for safety. Resident #7 reported when she refused the STNA said well fall on the floor then. RN #18 documented she explained all care was provided by two staff at all times.…

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

Based on record review, policy review, and interview, the facility failed to investigate allegations of staff being rough and making inappropriate comments toward residents. This affected one resident (#7) of 11 residents interviewed regarding abuse. The census was 41. Findings include: Review of Resident #7's medical record revealed diagnoses including major depressive disorder, multiple sclerosis, contractures of both hands, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder, spondylolisthesis of the lumbar region, and intervertebral disc disorders of the thoracic region. Review of a nursing note dated 01/01/23 at 5:12 P.M. revealed Resident #7's daughter spoke to Registered Nurse (RN) #18. Resident #7 had informed her daughter a STNA told Resident #7 she needed to be repositioned in bed for safety. Resident #7 reported when she refused the STNA said well fall on the floor then. RN #18 documented she explained all care was provided by two staff at all times. Resident #7's daughter requested the STNA not care for Resident #7. RN #18…

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 the Minimum Data Set (MDS) assessment accurately reflected opioid medication use and significant weight loss. This affected two residents (#28 and #29) of five residents reviewed for unnecessary medications. Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included unspecified open wound of vagina and vulva, colostomy, chronic obstructive pulmonary disease, muscle wasting and atrophy, chronic pain. Review of the admission Minimum Data Set (MDS) assessment, dated 06/30/23, inaccurately revealed that Resident #29 received opioid medication for zero days during the look-back period. Review of a physician order, dated 06/28/23, revealed an order for Dilaudid (opioid pain medication) eight milligrams (mg), one tablet every four hours, as needed for pain. Review of a physician order, dated 06/24/34, revealed an order for Methadone (opioid pain medication) 10 mg, 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 medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected two residents (Resident #35 and #40) of three residents reviewed for PASARR documents. The census was 41. Findings Include: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including sepsis, pressure ulcers, depression, bipolar disorder, and paraplegia. Review of Resident #40's PASARR document, dated 05/30/23, revealed under Section E, there were no diagnosis listed. Review of the resident's diagnoses list revealed bipolar disorder and depression were added on 06/09/23. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/15/23, revealed the resident was cognitively intact, and had diagnoses of depression and bipolar disorder. During interview on 07/25/23 at 11:25 A.M., Social Services Director (SSD) #19 confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure Resident #7 and/or her representative was provided an opportunity to participate in the development and revisions of the plan of care. This affected one resident (Resident #7) of 11 residents interviewed regarding participation in planning care. The census was 41. Findings include: Review of Resident #7's medical record revealed diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, major depressive disorder, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder neuromuscular dysfunction of the bladder, and insomnia. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #7 was able to make herself understood and was able to understand others. Resident #7 was assessed as cognitively intact. There was no documentation indicating Resident #7 nor her family were invited to participate in the care planning process or review of the care plan for…

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

Based on observation, record review and interview the facility failed to maintain Resident #7's respiratory equipment in a clean manner and ensure the equipment was inspected and air filter exchanged annually as appropriate. This affected one (Resident #7) of one residents reviewed for environmental concerns. The facility identified six residents (Residents #5, #7, #13, #22, #23 and #25) currently utilizing oxygen concentrators. The census was 41. Findings include: Review of Resident #7's medical record revealed an admission date of 12/14/22 with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus type II and lupus. Further review of Resident #7's medical record revealed a quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 06/16/23 which indicated the resident had an intact cognition level. Physician's orders indicated Resident #7 was to utilize supplemental oxygen at two liters per minute (lpm) by nasal cannula. Interview with Resident #7 on 07/24/23 at 9:58 A.M. revealed that her oxygen machine needed cleaned. On 07/26/23 at 10:10…

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 policy review the facility failed to ensure antibiotics were assessed for appropriate indication for use prior to initiating antibiotic therapy. This affected one resident (Resident #4) of five residents reviewed for medication use. The facility census was 41. Findings include: Review of Resident #4's medical records revealed an admission date of 04/21/23 with diagnoses that included dementia, atrial fibrillation, hypertension and chronic obstructive pulmonary disease. Further review of the medical record including nursing notes revealed on 06/14/23 at 2:22 P.M. Resident #4 advised nursing staff he was having trouble breathing with coughing and white sputum. The nurse notified the physician at this time who orders Pro-BNP (lab test to determine congestive heart failure (CHF)) and a chest x-ray. Results of the chest x-ray revealed patchy modest bilateral airspace disease. Pneumonia should be considered in the appropriate clinical setting. Recommend follow-up examination to confirm resolution of findings. On 06/15/23 at 7:06 A.M. 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.