Jamestown Place Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure a dental care plan was created timely. This affected one (Resident #04) of three residents reviewed for dental services. The facility census was 30.Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included type II diabetes mellitus (DM II), atrial fibrillation, major depressive disorder, and peripheral vascular disease (PVD).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. This resident was assessed to require setup with eating, dependent with toileting and transfers, partial assistance with bathing, and substantial assistance with dressing.Review of the physician order dated 07/10/25 revealed Resident #04 was ordered to see podiatrist, dentist, audiologist, and ophthalmologist. Interview on 01/21/26 at 3:55 P.M. with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interviews, observations, and policy review, the facility failed to ensure dressing changes were changed as ordered. This affected one (Resident #04) of three residents reviewed for skin concerns. The facility census was 30. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included type II diabetes mellitus (DM II), atrial fibrillation, major depressive disorder, and peripheral vascular disease (PVD).Review of the physician order dated 11/25/25 revealed Resident #04 was ordered a continuous wound vacuum-assisted closure (Wound Vac) (therapeutic technique using a suction pump, tubing, and a dressing [usually foam] to apply sub-atmospheric pressure to a wound) at 125 millimeters of mercury (mmHg) to be changed every Monday, Wednesday, and Friday every shift.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to thoroughly assess a resident's pressure wound upon admission and readmission. This affected one (Resident #32) of one resident reviewed for wound assessment. The facility total census was 30. Record review of Resident #32 revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. Diagnoses for Resident #32 included Stage IV pressure ulcer, respiratory failure with atrial fibrillation, hypoxia and hypercapnia, incontinence, and obesity. Review of the census information for Resident #32 revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and was readmitted to the facility on [DATE].Review of the Admissions Data Collection document for Resident #32 dated 12/19/25 (admission) revealed the resident had an open area on the sacrum. The document had no measurement of the pressure wound. Review of the Resident #32 readmissions…

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 interviews, the facility failed to implement and execute physician orders to ensure maintenance of acceptable nutrition status parameters. This affected one (Resident #25) out of five residents (#25, #02, #19, #07, and #29) reviewed for weight loss. The facility census was 30. Review of the medical record for Resident #25 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of orbital floor on the right side, fracture of other specified skull and facial bones on the right side, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, generalized anxiety disorder, oropharyngeal dysphagia (difficulty swallowing), muscle weakness, seizures, and underweight status.Review of the weight summary for Resident #25's revealed the resident weighed 164.4 pounds (lbs.) on 07/15/25 (admission). The resident experienced a weight loss of 45 pounds (27 percent [%] weight loss) in less than six months when the resident'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 medical record review, staff interview, review of the dialysis contract, and policy review, the facility failed to ensure pre/post dialysis communication forms were completed consistently and thoroughly and failed to ensure pre/post dialysis vital signs and weights were obtained as per physician orders. This affected one (Resident #02) resident who received dialysis. The facility census was 30. Review of the medical record for Resident #02 revealed an admission date of 11/05/2020 with medical diagnoses of end stage renal disease (ESRD) with dependency on dialysis, congestive heart failure (CHF), anxiety disorder, hypertension (HTN), and dementia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, which indicated Resident #02 had severe cognitive impairment and required substantial/maximum staff assistance for showers, bed mobility, and transfers and was dependent upon staff for toilet hygiene. The MDS indicated Resident #02 received dialysis. Review of the physician orders for Resident #02 dated 10/29/25 revealed the resident was ordered to receive…

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, family interview, and staff interview, the facility failed to ensure care conferences were completed as required. This affected three (#07, #22, and #29) of three residents reviewed for care conferences. The facility also failed to ensure care plans were updated in a timely manner. This affected one (Resident #06) of one resident reviewed for advanced directives. The facility census was 30. 1) Review of the medical record for Resident #04 revealed an admission date of 07/10/25 with medical diagnoses of diabetes mellitus (DM), morbid obesity, hypertension (HTN), chronic kidney disease Stage III, and depression. Review of a physician order for Resident #04 dated 07/10/25 revealed the resident was ordered to receive Trulicity pen-injector (used to improve blood sugar levels) 0.75 milligram (mg) per 0.5 milliliter (ml) to inject 0.5 ml subcutaneously (SQ) one time weekly on Sunday and an order dated 09/09/25 for insulin glargine (long acting insulin) SQ pen-injector 100 units per ml…

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 medical record, observations, staff interviews, and policy review, the facility failed to ensure medication error rate was less than five percent (%) during medication administration pass. This affected two Residents (#31 and #33) of four residents observed for medication administration. The facility census was 30. 1) Review of the medical record for Resident #33 revealed an admission date of 12/09/24. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and emphysema. Review of the physician order dated 07/15/25 revealed Keppra 500 milligrams (mg), give one tablet by mouth two times a day for seizures. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. This resident was assessed to require setup with eating, toileting, and transfers, and partial assistance with bathing and dressing.Observation on 01/21/26 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed to notify the physician of abnormal laboratory (lab) results/values. This affected one (Resident #29), of one resident reviewed for labs. The total facility census was 30. Record review of Resident #29 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #29 included diabetes, dysfunction of heart disease, chronic kidney disease, malnutrition, and coronary graft. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed Resident #29 had intact cognition and required set-up assistance for eating and partial assistance for mobility. The resident received a carbohydrate controlled and no added salt diet.Review of physician orders dated 02/19/25 revealed the Resident #29 had orders for weekly potassium levels drawn every Wednesday and to fax the results to a designated nephrology practice physician. Review of potassium level lab tests dated 12/24/25, 12/31/25 and 01/14/26, revealed 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, observation, staff interview, and review of the facility policy, the facility failed to ensure dental services were provided as required. This affected one (Resident #04) of three residents reviewed for dental services. The facility census was 30 residents.Findings include: Review of the medical record for Resident #04 was admitted on [DATE] diagnoses including diabetes mellitus, atrial fibrillation, major depressive disorder, and peripheral vascular disease (PVD).Review of the medical record for Resident #04 revealed the resident was seen by a dentist in August 2024. There were no subsequent dental visits.Review of the physician's orders for Resident #04 revealed an order dated 07/10/25 for the resident to receive dental services.Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 12/16/25 revealed the resident had moderate cognitive impairment and required assistance with activities of daily living (ADLs.)Interview on 01/21/26 at 2:45 P.M. with Regional…

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, resident interview, staff interview, and review of the facility policy, the facility failed to follow therapeutic diets as ordered by the physician. This affected three (Residents #02, #29 and #32) of three residents reviewed for therapeutic diets. The facility census was 30 residents.Findings include: 1.Review of the medical record for Resident #02 revealed an admission date of 11/05/20 with diagnoses including end stage renal disease, congestive heart failure, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 12/17/25 revealed the resident had severely impaired cognition and required maximum assistance with activities of daily living (ADLs.)Review of the physician's orders for Resident #02 revealed orders for dialysis three times a week and a renal diet. Review of the physician's orders for Resident #02 revealed an order dated 01/21/26 for a fluid restriction of 1500 cubic centimeters (cc) of fluid per…

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 ensure residents were provided education on benefits and risks of the Coronavirus (COVID-19) vaccination. This affected two (Residents #02 and #25) of five residents reviewed for vaccinations. The facility census was 30 residents.Findings include:1.Review of the medical record for Resident #02 revealed an admission date of 11/05/20 with diagnoses including end stage renal disease (ESRD), congestive heart failure (CHF), anxiety disorder, hypertension (HTN), and dementia. Review Minimum Data Set (MDS) assessment for Resident #2 dated 12/17/25 revealed the resident had severe cognitive impairment and required substantial/maximum staff assistance with activities of daily living (ADLs.) Review of the medical record for Resident #02 revealed the resident had refused COVID-19 vaccination. The medical record did not include documentation regarding resident education on the risks and benefits of the vaccination. Interview on 01/22/26 at 12:09 P.M. with Regional Clinical Nurse #160…

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, staff interview, and facility policy review, the facility failed to maintain safe clean environment. This had the potential to affect all 30 residents. The facility census was 30.Findings Included: Observation on 10/30/25 at 2:23 P.M. in [NAME] hallway there was staining on the ceiling tile around the water sprinkler which was located close to the nurse's station.Interview on 10/30/25 at 2:23 P.M. with Certified Nurse Assistant (CNA) #135 verified there was staining on the ceiling around the water sprinkler down [NAME] hallway.Observation on 10/30/25 at 2:27 P.M. in Summer hallway the air vents in the ceiling were observed, the second and third air vents from the entrance to the hallway had dust, dirt and debris in them, the sixth air vent was observed with staining on the ceiling around the air vent which had visible dust and debris hanging in the air vent.Interview on 10/30/25 at 2:27 P.M. with Physical Therapy Assistant #192 verified the condition of the air vents in Summer hallway 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 observation, record review, staff and resident interview, and policy review the facility failed to ensure there was a homelike environment. This affected 11 (# 20, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) out of 11 reviewed for the environment. The facility census was 34.Findings Included: Observation of Resident #13's room on Winter Hall on 09/15/25 at 8:16 A.M., revealed the bathroom light made a loud screeching noise, the faucet leaked in the sink, and the hot water temperature was 82.7 degrees Fahrenheit. Interview with Resident #13 on 09/15/25 at 8:17 A.M., revealed the light in her bathroom had been screeching for about five or six days, and an aide knew about it, however the resident could not remember her name. Resident #13 reported the water in her bathroom had not been hot for about three weeks and the aides would give her washcloths that were lukewarm, and they would apologize for it when they had to provide care when the washcloth wasn't hot. Review of the following resident's rooms on Winter Hall on 09/15/25 at 8:30 A.M., revealed:Resident #9's bathroom…

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, staff and resident interviews, and policy review the facility failed to ensure residents received two showers a week. This affected five (#25, #29, #20, #8 and #3) of five residents reviewed for bathing. The facility census was 34. Findings Included:1.Medical record review revealed Resident #25 was admitted on [DATE]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired. Her functional status was dependent for eating, toileting, bathing and bed mobility. She was non-applicable for transfers. Review of the shower sheets for Resident #25 revealed out of eight shower opportunities the resident received one on 08/21/25 and 09/08/25. The resident had not been out to the hospital. 2.Medical record review for Resident #29 revealed an admission date of 04/03/24. Medical diagnoses included aftercare following joint replacement surgery,…

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, staff and resident interview, observation, and policy review the facility failed to ensure fresh water was passed out during the day. This affected four Residents (#26, #19, #24, #29) out of four residents reviewed. The facility identified residents who received nothing by mouth. In addition, the facility failed to ensure a resident with significant weight loss was given his ordered supplement. This affected one resident (#3) of two residents reviewed for weight loss. The facility census was 34. Findings Included:1.Medical record review for Resident #26 revealed an admission date of 05/27/21. Medical diagnoses included quadriplegia, neurogenic bladder, diabetes, and cerebrovascular attack.Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. Her functional status was dependent for eating, toileting, bed mobility, and non-applicable for transfers. She was always incontinent for bowel and bladder. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure dignity and respect were shown to residents who needed help to eat. This affected three (#25, #26, #7) of three residents reviewed for assistance with eating. The census was 34.Findings Included:1.Medical record review for Resident #25 was admitted on [DATE]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired. Her functional status was dependent for eating, toileting, bathing and bed mobility. She was non-applicable for transfers. 2.Medical record review for Resident #26 revealed an admission date of 05/27/21. Medical diagnoses included quadriplegia, neurogenic bladder, diabetes, and cerebrovascular attack.Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. Her functional status was dependent for eating, toileting, bed…

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

Based on review of the resident council minutes, staff and resident interviews, and policy review the facility failed to ensure resident council concerns had a resolution. This affected two (#13 and #29) of two residents reviewed for resident council. The facility identified not all of the residents were able to attend resident council. The facility census was 34.Findings Included:Review of Resident Council Minutes revealed:On 06/23/25 there was a complaint noted about the facility driveway needed the cracks fixed.On 07/21/25 there was a complaint noted about the facility driveway still needed fixed. On 08/25/25 there was a complaint noted a resident's wheelchair got stuck in a hole out front and the resident could hardly get out of the hole. The resident's voiced in this resident council meeting they felt like nothing was done about their concerns when the administration was made aware of the concerns. Interview with the Resident Council President #13 on 09/15/25 at 10:32 A.M., revealed the resident council does not receive timely answers to their complaints, if they even answer…

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 revealed the facility failed to ensure a resident elopement was reported to the state agency. This affected one (#20) of two residents reviewed for elopement. The facility census was 34.Findings Included: Medical record review for Resident #20 revealed an admission date of 10/13/23. Medical diagnoses included non-Alzheimer's dementia, seizure disorder, and schizophrenia.Review of the progress notes dated 05/01/24 revealed Resident #20 had a history of eloping from home.Review of the care plan dated 04/03/25 revealed Resident #20 was identified as an elopement risk and would be wearing a wander guard alarming device. Interventions to prevent elopement included: to monitor placement and function of the wander guard alarming device every shift, provide redirection from the lobby area when visitors were leaving, and redirect the resident from the doors.Review of the medical record dated 04/12/25 revealed Resident #20 eloped from the facility at approximately 7:45 A.M., went to a gas station 0.2 miles away, got into 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 review of the activity calendar, observation, staff and resident interview, medical record review, and policy review the facility failed to ensure meaningful activities were provided as scheduled. This affected three (#13, #16, #26) of three residents reviewed for activities. This had the potential to affect all of the residents who participated in activities. The facility census was 34. Findings Included:Review of the activity calendar dated 09/01/25 through 09/30/25 revealed on 09/11/25:10:30 A.M. pass mail11:30 A.M. lunch1:30 P.M. bingo 3:30 P.M. manicuresFurther review of the activity calendar for the month of September 2025 revealed every day at 10:30 A.M., was mail and 11:30 A.M., was lunch. Observation on 09/11/25 at 10:30 A.M., revealed no one was passing mail to the residents. At 11:30 A.M., lunch was served to the residents. At 1:30 P.M., bingo was held by a resident who called out the numbers for the game. The Activity Director (AD) #38 walked around the bingo area for a while and then sat…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the facility investigation statements, staff interview and policy review the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopement did not elope from the facility. This affected one (#20) of three residents reviewed for elopement. The facility census was 34. Findings Included:Medical record review for Resident #20 revealed an admission date of 10/13/23. Medical diagnoses included non-Alzheimer's dementia, seizure disorder, and schizophrenia.Review of the progress notes dated 05/01/24 revealed Resident #20 has a history of eloping from home.Review of the physician orders dated 05/28/24 revealed to place a wander guard alarming device to alert staff of attempt to elope. Check function and placement every shift.Review of the physician orders dated 08/09/24 revealed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the daily staffing, observation and staff interview the facility failed to ensure there was enough staff to assist residents to eat. This affected three (#25, #26, and #7) of three residents reviewed for staffing. The facility census was 34. Findings Included:Review of the daily staffing dated 09/11/25 revealed there were two nurses, and three Certified Nursing Assistants (CNA)'s to take care of 34 residents. There was one CNA who was out of the facility taking a resident to dialysis. The affected three (#25, #26, and #7) of three residents reviewed for assistance with eating.1.Medical record review for Resident #25 was admitted on [DATE]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired. Her functional status was dependent for eating, toileting, bathing and bed mobility. She was non-applicable for transfers. 2.Medical record review for Resident #26 revealed…

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 interviews, the facility failed to ensure the appointed Infection Preventionist had proper infection prevention and control training and certification. This had the potential to affect all the residents in the facility. The facility census was 40. Finding include: Record review revealed the Director of Nursing (DON) was the Infection Preventionist for the facility. Further record review revealed the DON had not completed specialized training in infection prevention and control. Interview on 09/29/22 at 9:33 A.M. with DON confirmed she was the appointed Infection Preventionist in the facility to manage the Infection Prevention Control Program (IPCP). The DON confirmed she had not completed specialized training in infection prevention and control. Interview on 09/29/22 at 10:02 A.M. with Regional Nurse #150 confirmed DON was the appointed Infection Preventionist for the facility and DON had not completed specialized training for infection prevention and control.

Based on record review and staff interview, the facility failed to ensure advance directives were dated when signed. This affected one (Resident #32) out of four residents reviewed for advance directives. The facility census was 40. Findings include: Review of the medical record for Resident #32 revealed an admission date of 02/14/15. Diagnoses included cellulitis of right lower limb, peripheral vascular disease, type two diabetes mellitus with other circulatory complications, major depressive disorder, chronic obstructive pulmonary disease, atrial fibrillation, iron deficiency anemia, hyperlipidemia, hypertension, and angina pectoris. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 08/14/22, revealed this resident had intact cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. The resident was able to eat independently. Review of the current physician orders revealed an order dated 07/17/18 for Do Not Resuscitate (DNR) Comfort Care. Review of the completed DNR form revealed the…

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

Based on record review and staff interview, the facility failed to ensure an advanced beneficiary notice of non-coverage was completed. This affected one resident (Resident #36) out of three residents reviewed for beneficiary notice. The facility census was 40. Findings include: Review of the medical record for Resident #36 revealed an admission date of 02/25/22. Diagnoses included major depressive disorder, dementia, squamous cell carcinoma, pressure ulcer of sacral region, stage four, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/01/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance with transfers, dressing, and toileting as well as supervision for eating. Review of form titled CRI Notification for Discharge of Therapy Services, dated 04/19/22, revealed Resident #36 was discharged from therapy services effective 04/21/22 because the resident achieved all goals and was not expected to make further progress. Interview on 09/29/22 at 2:50 P.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and medical record review, the facility failed to complete comprehensive person-centered care plans for two (Resident #14 and Resident #19) out of the four residents sampled. The facility census was 40. Findings include: 1. Review of medical record for Resident #14 revealed an admission date of 05/28/21. Review of the medical record revealed medical diagnoses of protein calorie malnutrition, major Depression, syncope and collapse, atrial fibrillation, anemia, hypertension and unspecified injury of head. Review of the medical record revealed the Minimum Data Set (MDS) dated [DATE] which stated Resident #14's Brief Interview for Mental Status (BIMS) score was three indicating Resident #14 had severely impaired cognition. The MDS revealed the resident required extensive staff assistance of two staff members for bed mobility and transfers and extensive assist of one staff member for toileting. The MDS revealed Resident #14 was dependent upon staff for personal cares. Further 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, interviews, and policy review, the facility failed to complete quarterly care conferences for residents and family. This affected one (#39) of two residents reviewed for care plans. The facility census was 40. Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/01/19. Diagnoses included dementia, Alzheimer's disease, fracture of right wrist and hand, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment. This resident was assessed to require two-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and two-person total dependence with bathing. Review of the care conferences for the last 12 months revealed Resident #39 had a care conference on 08/30/21, 06/28/22 and 09/06/22. Interview on 09/28/22 at 11:46 A.M. with social services director #350 revealed care conferences were to be completed quarterly. Social services…

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, staff interview, and medical record review, the facility failed to provide fingernail care to one (Resident #14) out of the four residents sampled. This had the potential to affect all the residents in the facility. The facility census was 40. Findings include: Review of medical record for Resident #14 revealed an admission date of 05/28/21. Review of the medical record revealed medical diagnoses of protein calorie malnutrition, major Depression, syncope and collapse, atrial fibrillation, anemia, HTN and unspecified injury of head. Review of the medical record revealed the Minimum Data Set (MDS) dated [DATE] which stated Resident #14's Brief Interview for Mental Status (BIMS) score was three indicating Resident #14 had severely impaired cognition. The MDS revealed the resident required extensive staff assistance of two staff members for bed mobility and transfers and extensive assist of one staff member for toileting. The MDS revealed Resident #14 was dependent upon staff for personal care.…

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, interviews, and policy review, the facility failed to accurately monitor weights per nutritional parameters. This affected three (#8, #20, and #28) out of three residents reviewed for nutrition. The facility census was 40. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 01/25/22. Diagnoses included Parkinson's disease, Alzheimer's disease, major depressive disorder, pneumonia, COVID-19, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. This resident was assessed to require two-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and two-person total dependence with bathing. Review of the care plan dated 06/20/22 revealed Resident #8 had potential for inadequate food/beverage intake due to depression and parkinson's. Interventions included assist feed as tolerated and indicated. Staff to give diet as ordered.…

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 clinical record review, observation and staff interview, the facility failed to provide to dignity during dining for a resident. This affected one (#11) of 10 residents observed who required assistance/dependence with eating. The facility census was 39. Findings include: Clinical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment revealed the resident had severely impaired cognition and required the extensive assist of one staff for feeding at meals. Observation on 09/03/19 at 5:27 P.M. revealed State Tested Nursing Assistant (STNA) #53 standing while feeding Resident #11 her meal. There were five resident who received feeding assistance from the staff. Interview at that time of observation with the Director of Nursing (DON) verified STNA #53 was standing and should be sitting in a chair next to the resident when assisting a resident with her meal.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the resident fund accounts, staff interview and policy review, the facility failed to provide the resident's funds within 30 days from discharge from the facility. This affected one (Resident #194) of two residents reviewed for a closed fund account. The facility identified eight residents who had a fund accounts with the facility. The facility census was 39. Findings include: Review of the resident's fund account information revealed Resident #194 was admitted to the facility on [DATE]. The resident discharged to a different facility on [DATE]. A check for a balance of $516.74 was sent to the resident on [DATE]. Interview with Business Office Manager (BOM) #51 on [DATE] at 11:45 A.M. verified that Resident #194 discharged to a different facility on [DATE]. BOM #51 verified a check for a balance of 516.74 dollars was sent to the resident/responsible party on [DATE] which was 66 days after discharge. Review of the facility's undated policy titled Patient Resident Trust Fund Policy revealed the…

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

Based on medical record review, staff and family interview and review of the facility policy, the facility failed to ensure a 48-hour baseline care plan was reviewed with the resident and their representative, and a copy of the care plan given to the resident or their representative. This affected one (Resident #15) out of 12 residents reviewed for baseline care plans. The facility census was 39. Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/03/19. Diagnoses included malignant neoplasm of the hard palate, dysarthria and anarthria, dysphagia, blindness left eye, chronic hepatitis, benign prostatic hyperplasia, obstructive and reflux uropathy weakness and severe calorie malnutrition. Review of the 48-hour baseline care plan for Resident #15, dated 07/03/19, revealed the care plan was completed and signed by the Registered Nurse (RN). Further review of the care plan revealed no documentation that the plan had been reviewed with the resident or his representative. Review of the nursing progress notes dated 07/03/19 through 07/10/19,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, family and staff interviews and facility procedure review, the facility failed to provide timely and appropriate foot care a resident. This affected one (Resident #22) of one resident reviewed for activities of daily living care. The facility census was 39. Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses including a stroke resulting in left sided hemiplegia and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 07/04/19, revealed the resident was non-verbal with moderately impaired cognition. S he required the extensive assistance of one staff for hygiene. The resident's daughter was the responsible party. Review of a Health Care Services Consent Form, dated 08/12/19, revealed the resident's daughter signed a consent for audiology, optometry and podiatry services with a visiting mobile care group. Observation on 09/03/19 at 3:47 P.M. revealed Resident #22 was in bed with…

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, medical record review and staff and family interview, the facility failed to ensure Resident #15 received the prescribed amount of enteral nutrition. This affected one (Resident #15) out of one resident reviewed for enteral feeding. The facility identified four residents received tube feedings. The facility census was 39. Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/03/19. Diagnoses included dysarthria and anarthria, dysphagia and severe calorie malnutrition. Review of the 30-day Medicare Minimum Data Set (MDS) assessment, dated 07/31/19, revealed Resident #15 to have moderate cognitive impairment. He was also assessed to be totally dependent upon staff for his eating and nutrition and his weight loss was assessed as unknown. Review of Resident #15's nutritional assessment, dated 07/11/19, revealed Resident #15 was currently receiving Jevity one point two calories at 55 ml/hr., with 30 ml. of water flush every hour. Nutritional summary documented by Licensed Dietitian (LD) #97, revealed the current rate 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.