Rae Ann Geneva

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and facility policy review, the facility failed to complete and submit Minimum Data Set (MDS) assessments within the required timeframes. This affected 11 (Residents #11, #20, #21, #22, #26, #29, #41, #42, #60, #62 and #70) out of 11 residents reviewed for MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 07/31/11 and diagnoses included Parkinsonism, dementia and diabetes mellitus (DM) type two. Review of the quarterly MDS assessment for Resident #11 with an ARD (assessment reference date) of 12/31/24 revealed it was completed on 02/13/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 12/31/24. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #11's assessment was not completed timely. 2. Review of the medical record for Resident #20 revealed an admission date of 01/09/16 and diagnoses included chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, interviews and facility policy review, the facility failed to revise care plans for Residents #3 and #25 to include the use and monitoring of seat belts and alarms as restrictive devices and failed to complete comprehensive care plans within the required timeframe (within 21 days after admission) for Residents #60 and #70. This affected four (Residents #3, #25, #60 and #70) out of four residents reviewed for comprehensive care plan completion and revision. The facility census was 66. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 08/28/03 with diagnoses of hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, speech and language deficits following cerebrovascular disease, chronic kidney disease and vascular dementia. Review of a physician order dated 09/17/24 indicated Resident #3 had a Velcro seat belt to the wheelchair for positioning and safety. Review of the quarterly Minimum Data…

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 insulin manufacture guidelines, observation, interview and review of facility policy, the facility failed to ensure insulin was dated after opening and failed to ensure insulin was disposed of per manufacture guidelines. This affected four (Residents #8, #11, #63, and #131) out of nine (Residents #5, #8, #11, #12, #41, #47, #63, #129, and #131) that had their insulin on the East and/or North medication cart. This had the potential to affect 12 (Residents #5, #8, #10, #11, #12, #41, #46, #47, #63, #129, #131, and #179) that had orders for insulin. The facility census was 66. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 12/09/14 with diagnoses including dementia, diabetes and hypertension. Review of the May 2025 physician's orders revealed Resident #11 had an order dated 11/22/24 for Lantus solution (insulin) 100 units per milliliter (ml) inject eight units subcutaneously (SQ) once a day due to diabetes. Review of the care plan revealed Resident #11 had the potential for hypoglycemia and/or…

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, review of the facility self-reported incident (SRI) and review of the facility policy, the facility failed to ensure Primary Care Physician (PCP) #600 was notified of Resident #9's unknown injury. This affected one (Resident #9) out of one resident reviewed for notification of change in condition. The facility census was 66. Findings included: Review of the medical record for Resident #9 revealed an admission date of 10/10/20 with diagnoses including congestive heart failure, muscle weakness, cirrhosis of liver, diabetes, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had impaired cognition. She required substantial to maximum assistance with toileting hygiene and lower dressing. She required partial to moderate assistance with transfers. Review of the nursing note dated 04/28/25 authored by Licensed Practical Nurse (LPN) #404 revealed Resident #9 had scattered discoloration noted during her shower. She had large…

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 facility policy review, the facility failed to ensure as needed (PRN) psychotropic medication was reviewed by a practitioner after 14 days for necessity and appropriateness. This affected one (Resident #33) out of five residents reviewed for psychotropic medications. The facility census was 66. Findings include: Review of the medical record for Resident #33 revealed an admission date of 03/20/19 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder recurrent, adjustment disorder with anxiety, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 had severe cognitive impairment. Review of the care plan last reviewed on 03/12/25 revealed Resident #33 had potential for adverse effects from antianxiety medications and used PRN antianxiety medications for anxiety. Interventions included administering medications as ordered by 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, interview and facility policy review, the facility failed to complete an annual Minimum Data Set (MDS) assessment in the required timeframe (within 366 days from the previous comprehensive assessment) for Resident #22. This affected one (Resident #22) out of 11 residents reviewed for comprehensive MDS assessments. The facility census was 66. Findings include: Review of the medical record for Resident #22 revealed an admission date of 05/13/20 with diagnoses including chronic obstructive pulmonary disease and diabetes mellitus type two. Review of the MDS assessments for Resident #33 revealed the last comprehensive assessment completed was an annual MDS assessment dated [DATE]. There was no comprehensive assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #22 had no comprehensive assessment completed since 04/01/24 within the required timeframe. Review of the facility policy, Comprehensive Assessments, revised March…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and facility policy review, the facility failed to provide residents and representatives with a written summary of the baseline care plan. This affected two (Residents #76 and #77) of two residents reviewed for baseline care plans. The facility census was 66. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 02/18/25 and discharge date of 03/07/25. Diagnoses included nonrheumatic aortic valve stenosis, nonrheumatic mitral valve insufficiency, pulmonary hypertension, nonrheumatic tricuspid valve insufficiency, chronic obstructive pulmonary disease, atrial fibrillation, and congestive heart failure (CHF). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was rarely or never understood. The baseline care plan dated 02/18/25 included Resident #76's use of antibiotics for a urinary tract infection, diuretics due to CHF, cognitive status and needs for activities of daily living 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 record reviews, interviews and facility policy review, the facility failed to implement a comprehensive care plan to include trauma-informed care for Residents #25 and #140. This affected two (Residents #25 and #140) out of two residents reviewed for trauma-informed care. The facility reported two (Residents #25 and #140) who had trauma related diagnoses. The facility census was 66. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of the quarterly MDS assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Review of the physician orders effective May 2025 revealed no orders related to trauma-informed care other than to consult psychotherapies. Review of the assessments for Resident #25 revealed no trauma screening or assessments completed since admission. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews and facility policy review, the facility failed to properly monitor and maintain safety interventions which were in place for Resident #25. This affected one (Resident #25) out of two residents reviewed for safety interventions. The facility census was 66. Findings include: Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type two, dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Review of a physician order dated 09/17/24 indicated Resident #25 had an alarming Velcro seat belt to the wheelchair for positioning and safety. Another physician order dated 03/17/25 specified an additional pressure alarm was applied to the wheelchair for safety. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, observation and review of the facility policy, the facility failed to clean Resident #10's Continuous Positive Airway Pressure (CPAP) (machine used to treat sleep apnea) equipment and mask as recommended. This affected one (Resident #10) out of one resident reviewed for use of CPAP. This had the potential to affect two (Residents #9 and #10) who had orders for CPAPs. The facility census was 66. Findings include: Review of the medical record for Resident #10 revealed an admission date of 11/03/21 with diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, diabetes and hypertension. Review of the undated care plan revealed Resident #10 had diagnoses of COPD and obstructive sleep apnea. Resident #10 utilized a BiPap (Bilevel positive airway pressure) with oxygen every night. Interventions included oxygen therapy as ordered, head of bed elevated as tolerated, and monitor for difficulty breathing. There was nothing in the care plan regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and facility policy review, the facility failed to adequately train staff on trauma related care and provide trauma-informed care to Residents #25 and #140. This affected two (Residents #25 and #140) out of two residents reviewed for trauma-informed care. The facility reported two (Residents #25 and #140) who had trauma-related diagnoses. The facility census was 66. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. The resident had depression, anxiety, and a history of alcohol abuse, who demonstrated behaviors related to…

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

Based on record review, interviews, review of facility policy, observation, the facility failed to ensure accurate documentation on the medication administration record (MAR) for Resident #43 and the treatment administration record (TAR) for Resident #25. The facility also failed to routinely assess seat belts and alarms for necessity, appropriateness and least restrictive. This affected two (Residents #25, and #43) out of 21 medical records reviewed for accuracy, and two (Residents #3 and #25) out of two residents reviewed for restraints. The facility identified 13 residents (#4, #5, #9, #11, #16, #25, #26, #29, #33, #38, #52, #64 and #135) who had seat belts or alarms as restrictive devices. The facility census was 66. Findings included:1. Review of the medical record for Resident #43 revealed an admission date of 12/20/21 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, indwelling urethral catheter, and neuromuscular dysfunction of the bladder. Review of the May 2025 physician's orders revealed Resident #43 had an order dated 05/16/25 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 observation, interview, record review, review of the memorandum QSO-24-08-NH and facility policy review, the facility failed to utilize enhance barrier precautions (EBP) when indicated for Residents #9 and #34. This affected two residents (#9 and #34) out of three residents reviewed for the donning of EBP. The facility reported 11 residents (#9, #10, #16, #18, #34, #36, #46, #48, #51, #53, and #54) who were identified on EBP. The facility census was 65. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 04/01/25 with diagnoses including osteomyelitis (a bone infection, typically caused by bacteria) of vertebra, chronic ulcer of right foot, and diabetes. Review of the April 2025 physician orders revealed Resident #34 had an order to access and flush her Med Port (a device implanted under the skin to provide long-term access to a large vein near the heart for possible intravenous access) with normal saline 0.9 percent intravenously 10 milliliters (ml) prior 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 observation, interview and policy review, the facility failed to serve food at appropriate temperatures. This had the potential to affect 61 residents who eat food prepared by the facility (all residents except Resident #21, #28, and #62). The total census was 64. Findings include: Interview with Resident #56 on 12/26/24 at 8:27 A.M. revealed the food was often served cold. Observation of a test tray for breakfast on 12/26/24 at 9:22 A.M. revealed it contained scrambled eggs, toast, and canned pears. The toast tasted unpalatably cool. The eggs tasted unpalatably lukewarm and had a temperature of 123 degrees Fahrenheit. No concerns were noted with the pears. The food was served on a room temperature plate and covered with a clear plastic lid. Interview with Dietary Director #301 on 12/26/24 at 9:25 A.M. confirmed the above findings. She said residents had raised past concerns with the food temperature. The facility did not have a plate warmer and only had five rubber dish containers to maintain heat. Review of the facility's food and nutrition services policy dated 10/2017…

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 interviews, review of the call light detail report, call light policy, nursing staff schedules, payroll based journal (PBJ), nursing staff punch detail, the staffing tool and the facility assessment, the facility failed to respond to call lights in a timely manner for Resident #8, #32, #50 and #221, and failed to meet the minimum staffing requirement for all quarters of fiscal year 2023. This affected four residents (#8, #32, #50, and #221) of five residents reviewed for sufficient staffing and call light response times, and had the potential to affect all residents living in the facility. The facility census was 67. Findings include: 1. Interview on 12/11/23 at 11:09 A.M with Resident #14 stated sometimes there were not enough staff and call light response times were 20 minutes. Interview on 12/11/23 at 11:12 A.M. with Resident #221 stated call light response times were anywhere between 30 minutes to one hour and half. Interview on 12/11/23 at 2:17 P.M. with Resident #50 revealed she felt they were not enough staff because the call light response times were sometimes 30…

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

Based on record review and interview, the facility failed to obtain proper written authorization to open resident accounts for Resident #40, #51 and #56. This affected three residents (#40, #51 and #56) of the five residents reviewed for resident funds. The facility census was 67. Findings include: 1. Record review for Resident #40 revealed an admission date of 09/03/21 with diagnoses including chronic obstructive pulmonary disease and vascular dementia. The daughter of Resident #40 was listed as financial power of attorney (POA). Review of Resident #40's resident fund account on 12/14/23 revealed the authorization form was unsigned by the resident or financial POA.The signature line titled Signature of Legal Representative was signed by an employee of Resident Fund Management Service the company managing resident funds for the facility. 2. Record review for Resident #51 revealed an admission date of 10/12/22 with diagnoses including anxiety, spinal stenosis, and post-traumatic stress disorder. Resident #51 was listed as their own financial representative. Review of Resident #51'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to exercise reasonable care for the protection of Resident #50's personal property from loss or theft. This affected one resident (#50) of one resident reviewed for personal property. The facility census was 67. Findings include: Review of the medical record for Resident #50 revealed an admission date of 12/30/21. Diagnoses included congestive heart failure (CHF), legal blindness, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had intact cognition. Review of the Resident Grievance/Concern Log dated October 2023 through December 2023 revealed no missing items reported by Resident #50. Interview on 12/11/23 at 2:14 P.M. with Resident #50 revealed she had a black sweater with her name written on it, and the sweater went missing about a month ago. Resident #50 stated she reported it to staff, had not heard anything else about it and it was not replaced. Interview on 12/13/23 at 4:50 P.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 interview and record review, the facility failed to ensure a complete and accurate care plan for Resident #7. This affected one resident (#7) of 27 residents reviewed for care plans. The facility census was 67. Findings include: Review of Resident #7's medical record revealed an admission date of 08/01/22. Diagnoses included aphasia following cerebrovascular disease, spastic hemiplegia, peripheral vascular disease, benign prostatic hyperplasia with lower urinary tract symptoms and urinary tract infection Resident #7 was prescribed anticoagulant therapy of apixaban five milligram tablet two times a day by mouth for a diagnoses of cerebrovascular disease and peripheral vascular disease. Review of Resident #7's nurse progress notes indicated he was resistant to care including incontinence care. Review of Resident #7's physician's orders indicated Resident #7 had been prescribed antibiotic therapy on two occasions since admission for urinary tract infections. Review of Resident #7's Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed at least weekly for Resident #8 and #47 who were receiving oxygen therapy. This affected two residents (Residents #8 and #47) of the 22 residents (Residents #5, #6, #8, #9, #10, #14, #15, #19, #20, #23, #24, #28, #29, #30, #31, #35, #46, #47, #59, #66, #221, and #273.) the facility identified as receiving oxygen therapy. The facility census was 67. Findings include: 1. Review of Resident #8's medical records revealed an admission date of 10/02/23. Diagnoses included obstructive sleep apnea, morbid obesity, chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. Review of the December 2023 physician orders revealed an order for oxygen at four liters/minute via nasal cannula (a tube with two prongs inserted in nasal openings to deliver oxygen). continuously to maintain…

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 did not ensure residents were treated in a dignified respectful manner. This affected three residents (#9, #32 and #40) out of five residents reviewed for resident's rights and had the potential to affect all 66 residents residing at the facility. Findings include: 1. Review of medical record for Resident #9 revealed an admission date of 10/12/22 with diagnoses including aftercare following surgery of the digestive system, panic disorder, spinal stenosis, post-traumatic stress disorder (PTSD), major depression, and anxiety disorder. Review of undated care plan revealed Resident #9 had PTSD related to sexual abuse as a child. She experienced anxiety and does not sleep well at night. Interventions included encourage the resident to discuss feelings and provide reassurance that she in a safe environment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had impaired cognition. She had no behaviors and required extensive…

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, record review, and review of the facility policy the facility did not ensure allegations of potential staff to resident abuse were reported to the state agency. This affected one resident (Resident #32) out of five residents reviewed for abuse and had the potential to affect all 66 residents residing at the facility. Findings include: Review of the medical record for Resident #32 revealed an admission date of 08/07/23 with diagnoses including surgical aftercare following surgery due to neoplasm to the nervous system, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, hypertension, and major depression. Review of the Admission/ Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and no behaviors. He required extensive assist of staff with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of a witness statement dated 08/16/23 at 3:00 P.M. and completed by 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 interview, record review, and review of the facility policy the facility did not ensure allegations of potential staff to resident abuse were thoroughly investigated in a timely manner. This affected one resident (Resident #32) out of five residents reviewed for abuse and had the potential to affect all 66 residents residing at the facility. Findings include: Review of the medical record for Resident #32 revealed an admission date of 08/07/23 with diagnoses including surgical aftercare following surgery due to neoplasm to the nervous system, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, hypertension, and major depression. Review of the Admission/ Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and no behaviors. He required extensive assist of staff with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of a witness statement dated 08/16/23 at 3:00 P.M. 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.