Luxe Rehabilitation And Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide notice to the office of the state long-term care Ombudsman for resident transfers or discharges. This affected two (Residents #144 and #146) of three closed records reviewed. The facility census was 148. 1. Review of the closed record for Resident #146 revealed an admission date of 02/17/26 with diagnoses including alcoholic cirrhosis, peptic ulcer, hepatic encephalopathy, and protein/calorie malnutrition. The resident was at the facility for two days before being transferred to the hospital on [DATE]. The resident did not return to the facility. (The family requested the resident go to a different facility). Review of an email dated 03/03/26 at 5:48 P.M. from Human Resources Director #274 revealed it stated please find the February transfers and discharges notice from the facility. Resident #146's name was on the list. The email was sent to the State legal department. There was no evidence the State long-term care Ombudsman office 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 medical record review and staff interview, the facility failed to ensure resident assessments accurately reflected the number of pressure wounds present upon admission to the facility. This affected one (Resident #11) for wound care out of the 36 total sampled residents reviewed for accurate assessments. The facility census was 148. Findings include:Review of the medical record for Resident #11 revealed an admission date of 12/19/2025. Diagnoses included generalized anxiety, dementia, and wedge compression fracture of the thoracic vertebra. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Per this assessment, Resident #11 was noted to have three stage III pressure ulcers (full-thickness skin loss forming a deep, crater-like wound where subcutaneous fat is visible, but muscle, tendons, or bone are not) where two of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) was completed accurately for a resident. This affected one (#8) of five residents reviewed for PASARR. The facility census was 148.Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension, and post-traumatic stress disorder (PTSD). Diagnoses of major depressive disorder and generalized anxiety were added 01/22/26 by the nurse practitioner. Review of the most recent PASARR documentation dated 01/26/26 revealed diagnoses of generalized anxiety and PTSD were not listed for Resident #8.Interview with Social Services Director #366 on 03/25/26 at 11:10 A.M. verified the PASARR dated 01/26/26 was missing additional diagnoses.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) was completed timely for a resident. This affected one (#8) of five residents reviewed for PASARR. The facility census was 148. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension and post-traumatic stress disorder (PTSD). Medical record review indicated Resident #8 had diagnosis of PTSD upon admission to facility. The PASARR was completed 10/31/25.Interview with Social Services Director #366 on 03/26/26 at 12:10 P.M. verified the PASARR dated 10/31/25 was not completed within 30-day timeframe from admission to the facility.

Based on record review, observations, family interview, and staff interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care for each resident in the area of pain. This affected one (Resident #155) of four residents reviewed for pain. The facility census was 148.Review of the record for Resident #155 revealed an admission date of 03/17/26 and diagnoses including osteoporosis, chronic kidney disease, hypertension, depression, and anxiety disorder. A brief interview for mental status assessment conducted on 03/18/26 indicated a score of 15, intact cognition. Review of hospital records revealed the resident had a hospital stay from 03/03/26 to 03/17/26. The discharge summary stated the resident was admitted after a fall. She presented with a head hematoma, altered mental status, and left sided weakness. She was diagnosed with an acute traumatic subarachnoid hemorrhage enhanced by aspirin and an acute traumatic glenoid fracture (an injury to the shoulder socket). At the time of discharge to 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 and staff interview, the facility failed to develop and implement a person-centered comprehensive care plan. This affected one (#8) of 36 residents reviewed for care planning. The facility census was 148. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension, and post-traumatic stress disorder (PTDS). Diagnoses of major depressive disorder and generalized anxiety were added 01/22/26 by the nurse practitioner. Medical record review of the most recent Minimum Data Set (MDS) assessment dated [DATE] validated diagnoses of major depressive disorder, generalized anxiety and PTSD. Recent care plan dated 03/11/26 revealed anxiety, depression and PTSD were not addressed in plan of care. Interview with Social Services Director #366 on 03/26/26 at 12:10 P.M. verified the care plan did not address anxiety, depression and PTSD for Resident #8.

Based on record review, resident interview, and staff interview, the facility failed to develop a comprehensive care plan for a resident in the area of constipation. This affected one (Resident #78) of 36 residents whose care plans were reviewed. The facility census was 148.Review of the record for Resident #78 revealed an admission date of 08/08/22 with diagnoses including constipation (dated 02/15/22), diabetes, convulsions, panic disorder, and chronic kidney disease. Interview with Resident #78 on 03/24/26 at 9:14 A.M. revealed that she has a problem with constipation. She stated she thinks it is due to the narcotic pain pills she takes for her back pain. She stated the pain medication is taken as needed but she usually asks for and takes it twice daily. She stated she has been taking different medications for her constipation but they were not working so the nurse practitioner just ordered a new medication to take. She stated she had x-rays to check her bowels about a month ago. She stated she sometimes has to digitally remove her stool as it won't come out. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy, the facility failed to provide blood pressure medication as needed according to the physician ordered parameters. This affected one resident (#7) of five sampled for unnecessary medications. The facility census was 148.Findings include:Review of Resident #7's medical record revealed an admission date of 05/30/25, a re-entry date of 02/11/26 and diagnoses including cerebral infarction, anxiety disorder, chronic kidney disease stage four, major depressive disorder, diabetes, dementia, unspecified protein-calorie malnutrition, and abdominal aortic aneurysm without rupture.Review of Resident #7's admission minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #7's physician's orders revealed an order dated 02/11/26 for clonidine 0.2 milligrams (MG) give one tablet by mouth every six hours as needed for hypertension. Give if blood pressure is greater than 140. Review of Resident #7's Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview and facility policy review, the facility failed to ensure indwelling urinary catheter collection bags were positioned below the bladder. This affected one resident (#108) of two residents reviewed for catheters. The facility census was 148. Findings Include:Review of the medical record for Resident #108 revealed an initial admission date of 08/23/23 with the latest readmission date of 03/02/26 with the diagnoses including but not limited to chronic kidney disease, , paraplegia, retention of urine, diabetes mellitus, mild intellectual disabilities, chronic pain, end stage renal disease, paranoid schizophrenia, major depressive disorder, benign prostatic hyperplasia, bladder neck obstruction, obstructive and reflux uropathy, kidney transplant status, spinal stenosis, need for assistance with personal care and chronic obstructive pulmonary disease. Review of the plan of care dated 12/18/24 revealed the resident had an indwelling suprapubic catheter size 16…

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, observations, and facility policy review, the facility failed to address significant weight loss. This affected three residents (Resident #17, #29, #90) of the 6 residents reviewed for an adequate nutritional status. The facility census was 148. Findings include: 1 Review of the medical record for Resident #90 revealed an admission date of 03/29/2023. Diagnosis included Alzheimer's disease, diverticulosis of the large intestines, and abnormal weight loss. Review of the plan of care dated 09/17/2024 revealed Resident #90 had nutritional problem or potential nutritional problem related to the diagnosis of Alzheimer's dementia, diverticulosis, prostate cancer, dysphagia, diet, mechanically altered, edentulous, variable intake, prefers almond milk. Interventions include to assist residents with meals as needed, encourage fluid intakes, provide supplements as ordered, provide diet as ordered, monitor intake and record every meal, Registered Dietitian to evaluate and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure a physician or practitioner order for supplemental oxygen was in place for a resident that used it continuously. This affected one (Resident #4) of three residents reviewed for respiratory care. The facility census was 148 residents.Findings include:Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] and readmitted [DATE]. Resident #4 had diagnoses that included other specified chronic obstructive pulmonary disease, unspecified open wound of unspecified front wall of thorax without penetration into thoracic cavity, chronic obstructive pulmonary disease with (acute) exacerbation, personal history of pulmonary embolism, pleural effusion, emphysema, shortness of breath, acute and chronic respiratory failure unspecified whether with hypoxia or hypercapnia, and obstructive sleep apnea.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, family interview, staff interview, record review, and policy review, the facility failed to recognize, evaluate, and manage acute pain for a resident. This affected one (Resident #155) of four residents reviewed for pain. The facility census was 148. Review of the record for Resident #155 revealed an admission date of 03/17/26 and diagnoses including osteoporosis, chronic kidney disease, hypertension, depression, and anxiety disorder. Review of hospital records revealed the resident had a hospital stay from 03/03/26 to 03/17/26. The discharge summary stated the resident was admitted after a fall. She presented with a head hematoma, altered mental status, and left sided weakness. She was diagnosed with an acute traumatic subarachnoid hemorrhage enhanced by aspirin and an acute traumatic glenoid fracture (an injury to the shoulder socket). At the time of discharge to the facility she was afebrile, hemodynamically stable, breathing comfortably, eating a regular diet with oral pain medication,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor medications by completing physician order laboratory work for residents. This affected two (Resident #2 and #3) of five residents sampled for unnecessary medications. The facility census was 148.1.Review of Resident #2's medical record revealed an admission date of 11/01/23 and diagnoses including schizophrenia, drug induced subacute dyskinesia, diabetes, dementia, hypothyroidism, hyperlipidemia, and normal pressure hydrocephalus. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] indicating the resident had severe cognitive impairment. Review of Resident #2's physician's orders revealed an order dated 01/25/24 for simvastatin 40 milligrams (MG) one tablet one time a day for hyperlipidemia. Review of Resident #2's pharmacy review recommendation dated 10/30/25 revealed a recommendation to get a fasting lipid panel (to monitor effectiveness of the medication) and liver function tests (to monitor for liver toxicity) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents' medical records were complete and accurate to reflect correct information on the location and origin of a pressure ulcer and treatments were properly documented in the medical record when completed. This affected two (#58 and #135) of eight residents reviewed. Findings include: 1.Review of Resident #58's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a non-traumatic subarachnoid hemorrhage, acute and chronic respiratory failure, tracheostomy status, and gastrostomy status. Review of Resident #58's physician's orders revealed he had orders in place to receive tracheostomy care every shift and prn. He was also to receive a treatment to his peg tube site cleaning it with normal saline, patting dry, and applying a split gauze every shift. Review of Resident #58's treatment administration record (TAR) for December 2025 revealed the nurse working night shift did not document any treatments…

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, staff interview, and policy review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn during tracheostomy care of a resident in enhanced barrier precautions (EBP's) for a medically invasive device. They also failed to ensure staff performing tracheostomy care and treatment of a peg tube site performed proper hand hygiene, after removing disposable gloves, and before touching environmental surfaces in the resident's room. This affected one (#58) of one resident reviewed for tracheostomy care. Findings include: Review of Resident #58's medical record revealed he was admitted to the facility on [DATE]. He had diagnoses that included acute and chronic respiratory failure, tracheostomy (an artificial airway established by surgically placing a plastic tube through the front of the neck) status, and gastrostomy (surgical placement of a tube through the abdomen and into the stomach for the administration of a liquid nutritional supplement 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 review of facility open payables log, review of Administrator job description, and interviews, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently including compliance with all financial obligations for the delivery of care to attain and maintain the highest practicable well being of each resident. This affected 133 of 133 residents residing in the facility. Findings include: 1. Review of information received from two anonymous complaints on 06/11/25 revealed: 1: The facility did not get the food truck because they did not pay the bill and 2: Food service was cut off until payment was made as the facility owed $86,000.00. a. Interview with Dietary Aide #294 on 06/16/25 at 9:35 A.M. revealed the food delivery truck did not come on Friday 06/06/25 to deliver the facility food supply. She stated they had to change the menu over the weekend but the facility had sufficient food. She stated the food delivery truck then came on Tuesday 6/10/25 with a food delivery. b. Interview with Dietary…

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, self-reported incident (SRI) review, and interview, the facility failed to complete thorough investigations after allegations of abuse. This had the potential to affect one resident (#131) of two residents reviewed for allegations of abuse. The facility census was 133. Findings include: Record review revealed Resident #131 admitted to the facility on [DATE] with diagnoses including seizures and other specified disorders of the brain. Review of a care plan last revised on 11/14/24 revealed Resident #131 did not have any behaviors. Review of a SRI investigation dated 05/11/25 revealed resident questionnaires were completed and Resident #131 indicated he had been mistreated. There was no evidence of any follow-up questions to determine how or when Resident #131 had been mistreated. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #131's cognition remained intact and he had no behaviors. Interview on 06/18/25 at 3:00 P.M. with the Director of Nursing (DON)…

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, policy review, and guardian interview, the facility failed to have evidence that a transfer from the facility was necessary for the resident's welfare and the resident's needs could not be met in the facility. This affected one resident (#135) of three residents reviewed who were transferred to other nursing facilities. The facility census was 133. Findings include: Review of the closed medical record for Resident #135 revealed an admission date of 01/04/25 and diagnoses including Schizophrenia, hypertension, benign neoplasm of cranial nerves, and hearing loss. His brother was his legal guardian. Review of a Minimum Data Set (MDS) assessment completed 04/01/25 revealed he had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. It also indicated he was independent with mobility. An elopement assessment completed 01/04/25 indicated the resident was not at risk for elopement. Review of nursing progress notes revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, policy review, and guardian interview, the facility failed to provide notice before transfer to another facility to include the reason for the transfer and include appeal rights This affected one resident (#135) of three residents reviewed who were transferred to other nursing facilities. The facility census was 133. Findings include: Review of the closed medical record for Resident #135 revealed an admission date of 01/04/25 and diagnoses including Schizophrenia, hypertension, benign neoplasm of cranial nerves, and hearing loss. His brother was his legal guardian. Review of a Minimum Data Set (MDS) assessment completed 04/01/25 revealed he had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. It also indicated he was independent with mobility. An elopement assessment completed 01/04/25 indicated the resident was not at risk for elopement. Review of nursing progress notes revealed no evidence of any attempts to elope…

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 2. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and hypertension. Review of a quarterly MDS 04/01/25 revealed Resident #18 had moderately impaired cognition and had no behaviors. Review of a care plan updated on 06/14/25 revealed Resident #18 was at risk for falls related to cognitive function, decreased mobility, current hospital stay, weakness, acute chronic encephalopathy, hypertension, hypocalcemia, cognitive impairment, and self-care deficit with a goal to be free from injury. Interventions included but were not limited to keep urinal at bedside (06/14/25), place a bedside toilet in room (06/04/25), and a please call don't fall sign in room (02/23/25). Observation on 06/18/25 at 12:34 P.M. revealed Resident #18 was sitting in his bed, eating. Resident #18 did not have a urinal at bedside, a bedside toilet, or a please call don't fall sign in his room. Interview on 06/18/25 at 1:28 P.M. with DON confirmed the fall interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of facility policy, the facility failed to provide clean and sanitary resident equipment, such as bedrails and wheelchairs. This affected one (Resident #1) of six residents reviewed for cleanliness of resident equipment. The facility census was 130 residents. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, mood affective disorder, heart transplant, cardiomyopathy, and frontotemporal neurocognitive disease. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed that he utilized a wheelchair. Review of Resident #1's nursing progress notes revealed that on 04/14/25, Resident #1 stated that he was turning over in bed and hit his face on the bedrail and he had a skin tear to his left eyelid. Padding made of white cloth bandage wraps was placed on the bedrail's as an intervention. Observations of Resident #1's bed on 04/17/25 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 medical record review and staff interview, this facility failed to ensure residents responsible party participated in care planning. This affected one (Resident #279) of the five residents reviewed for care planning. The facility census was 134. Findings include: Review of the medical record for Resident #279 revealed an admission date of 11/27/24 and a discharge date of 03/13/25. Diagnoses included heart disease, acute and chronic respiratory failure, seizures, and chronic obstructive pulmonary disease. Review of Resident #279's comprehensive baseline care plan which was developed with admission to this facility, revealed this care plan had not been reviewed with Resident #279 or this residents Power of Attorney(POA) as required. Interview on 04/01/25 at 2:30 P.M. with the Medical Records Director #262 confirmed the facility did not have a care plan on file indicating Resident #279's POA was informed or involved in the initial care planning. Medical Records Director #262 and the Director of Nursing both confirmed a signature is usually obtained when each care plan is…

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, fall investigation review, staff interview, and facility policy review, this facility failed to ensure the appropriate resident representative was notified of a fall incident when it occurred. This affected one (Resident #285) of the five residents review for notification of change. The facility census was 134. Findings include: Review of the medical record for Resident #285 revealed an admission date of 03/14/23 and a discharge date of 03/07/25. Diagnoses included dementia with behavioral disturbances, cognitive communication deficit, and schizoaffective disorder bipolar type. Resident #285's Power of Attorney (POA) was noted to be his wife. Review of the plan of care dated 03/27/23 and revised 03/19/25 revealed Resident #285 was at risk for falls related to dementia, reduced mobility, intermittent confusion, self care deficit, and difficulty walking. Interventions included to encourage to use urinal at bedside, encourage to attend activities that minimize the potential for falls while providing diversion and distraction, gripper socks to be worn…

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, medication administration observation, and facility policy review, this facility failed to ensure their medication error rate was less than 5% when there was noted 5 medication errors of the 43 medication that was administered resulting in a 11.9% error rate. This affected three (Resident #33, #147, and #143) of the four resident observed for medication administration. The facility census was 134. Findings include: 1. Observation on 04/01/25 from 8:40 A.M. through 8:45 A.M. of Licensed Practical Nurse (LPN) #8 administering medication to Resident #33 revealed the medication Aspirin (non-inflammatory drug) 81 milligrams (mg) chewable was administered with all other medications that were to be administered whole. Interview on 04/01/25 at 8:45 A.M. with LPN #8 confirmed Resident #33 was supposed to receive Aspirin 81 mg chewable tablet but this medication was not separated from other medications and consumed whole. 2. Observation on 04/01/25 from 9:00 A.M. through 9:20 A.M. of LPN #300 administering medication to Resident #147 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 medication administration observation, staff interview, and facility policy review this facility failed to ensure infection control measures were maintained while administering medication. This affected three (Resident #33, #147, and #143) of the four residents observed for medicating administration. The facility census was 134. Findings include: Observation on 04/01/2025 from 9:10 A.M. through 9:40 A.M. of Licensed Practical Nurse (LPN) #300 revealed after checking Resident #143's blood pressure, hand hygiene was not completed prior to starting to pull medication for the next resident. LPN #300 was then observed dropping medication for Resident #147 on the medication cart and then picking up the medication with an un-gloved hand and placing it back into the medication cup for administration. LPN #300 was then observed using un gloved hand to pull medication out of the cup prior to crushing this medication for administration. Interview on 04/01/2025 at 9:45 A.M. with LPN #300 confirmed she had checked Resident #143's blood pressure without completing hand hygiene 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility personnel and criminal background check records review, medical record review, review of the new hire application form, interview, and facility policy review, the facility failed to complete criminal background checks as required for all new employees. This had the potential to affect all 139 residents residing in the facility. Additionally, the facility failed to implement their abuse policy regarding reporting, ensuring resident safety, and thoroughly investigating alleged incidents as required. This affected one resident (Resident #8) of three residents reviewed for abuse. Findings Include: 1. Review of facility bureau of criminal investigation (BCI) log, dated 09/01/24 to 01/15/25, revealed no indication whether federal background checks had been completed for any new hires that had not lived in this state for the last five years prior to hire at the facility. Review of facility personnel records of all new staff hired, dated 09/01/24 to 01/15/25, revealed a total of nine new hires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, review of training records, review of meal monitoring records, and staff interview, the facility failed to ensure there was sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services. This could affect 137 of 139 residents in the facility (Residents #61 and #122 receive nothing by mouth). Findings include: The facility consisted of two buildings ([NAME] and [NAME]) connected by a therapy wing in the center. [NAME] had 92 beds on four hallways and [NAME] had 83 beds on four hallways. Observations on 01/09/25 at 9:20 A.M. revealed the breakfast meal cart sitting in the hallway on 400 hall [NAME] Wing. Interview with Licensed Practical Nurse (LPN) #254 on 01/09/25 at 9:20 A.M. revealed they had received the meal cart to the hallway at 9:10 A.M. The last tray was served at 9:55 A.M. LPN #254 stated there was not a real set schedule for meal delivery and it could be anywhere from 8:15 A.M. to 8:45 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, and review of meal monitoring records, the facility failed to ensure meals were served at regular times and in accordance with resident needs and preferences. This could affect 137 of 139 residents in the facility (Residents #61 and #122 do not receive nutrition by mouth). Findings include: The facility consisted of two buildings ([NAME] and [NAME]) connected by a therapy wing in the center. [NAME] had 92 beds on four hallways and [NAME] had 83 beds on four hallways. Observations on 01/09/25 at 9:20 A.M. revealed the breakfast meal cart sitting in the hallway on 400 hall [NAME] Wing. Interview with Licensed Practical Nurse (LPN) #254 on 01/09/25 at 9:20 A.M. revealed they had received the meal cart to the hallway at 9:10 A.M. The last tray was served at 9:55 A.M. LPN #254 stated there was not a real set schedule for meal delivery and it could be anywhere from 8:15 A.M. to 8:45 A.M. Interview with Dietary Manager #221 on 01/09/25 at 10:15 A.M. 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 interview and personnel file review the facility failed to ensure employment of a full-time, qualified social worker. This had the potential to affect all 139 residents residing in the facility. Findings include: Review of Social Service Director #146's personnel file revealed she was hired on 07/22/22 as the social service director. She had a bachelor's degree in business administration dated 07/01/22. There was no evidence of a required bachelor's degree in social work or a human services field. Review of the termination form undated, revealed the last licensed social worker had been employed from 09/23/24 to 12/06/24. Interview on 01/16/25 at 1:17 P.M. with Social Service Director #146 verified she did not have a required degree. She reported the facility had previously employed a licensed social worker but she was no longer employed at the facility. Interview on 01/16/25 at 1:30 P.M. with the Administrator verified the facility did not currently have a licensed social worker employed. This deficiency is an incidental finding discovered during the complaint investigation.

Based on observations, medical record review, interview, and facility activity calendar review, the facility failed to schedule activities to meet the needs of the residents on the memory care unit. This affected 21 of 21 memory care residents (Residents #9, #13, #27, #30, #32, #40, #41, #46, #49, #76, #78, #84, #86, #92, #96, #98, #129, #136, #139, #141) and Resident #107 who was not in the memory care unit. The facility census was 139. Findings Include: Review of Memory Care Activity Calendars, dated November 2024 to January 2025, revealed there were no activities scheduled for the weekends. Observations on 01/15/25 from 9:10 A.M. to 9:30 A.M. found no activities occurring in the memory care unit. Staff were assisting residents with their breakfast and morning hygiene routines; there were no activity staff in the memory care unit. Review of Memory Care Unit January Activity Calendar revealed the activity starting at 9:00 A.M. was to be AM Chats. Observations on 01/15/25 from 9:30 A.M. to 9:50 A.M. found no activities were occurring in the non-memory care unit areas. Staff were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to ensure a resident received adequate treatment and care and the physician was notified at the time of a change in condition. This affected one of 17 sampled residents (Resident #145). The facility census was 139. Findings include: Review of the closed medical record for Resident #145 revealed the resident was admitted from the hospital on [DATE]. The resident had been in the hospital from [DATE] to 12/09/24 and was treated for systolic heart failure with coronary artery bypass graft surgery and permanent pacemaker (arrested during surgery twice), right pneumothorax, left pleural effusion, pulmonary edema, periodontal abscess, diabetes, dysphagia with gastrostomy tube placement, acute pulmonary embolism, and anemia. Review of physician's orders on admission revealed the resident received nothing by mouth and had a continuous tube feeding. She had physician's orders on admission for two types of insulin: Glargine (long acting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview, and facility policy review, the facility failed to ensure all residents followed safe smoking provisions and failed to assess residents for safe smoking prior to smoking while residing in the facility. This affected five (Residents #4, #5, #6, #11, and #94) of five residents reviewed for smoking. The facility identified Resident #4, #5, #6, #11 and #94 as the only residents who smoked. The census was 139. Findings Include: 1. Observations on 01/14/25 at 1:30 P.M. and 1:40 P.M., there were used cigarette butts found in the trash can of each building's front porch. The trash cans were not safe for smoking materials to be disposed in. Also, the trash cans were lined with plastic trash bags. This was confirmed by Licensed Practical Nurse (LPN) #131 and the Administrator. Observation on 01/14/25 at 1:40 P.M. found Resident #4 on the front porch, smoking a cigarette. There were no ash trays or proper cigarette disposal devices on the front porch. The front porch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of menus/spread sheets, and staff interview, the facility failed to ensure menus were followed. This affected 11 of 137 residents (Residents #9, #25, #27, #30, #40, #49, #86, #92, #98, #129, and #136) residing in the facility and receive nutrition from the kitchen. The facility identified two residents (Resident #61 and #122) who received nothing by mouth. Findings include: 1. On 01/09/25 at 9:00 A.M. the surveyor requested to review menus with serving sizes for the week (spread sheets). The facility provided copies of recipes for the food items being prepared for the lunch meal. The recipes did not include the specific food items or serving sizes for the various diets provided by the facility including mechanical soft, pureed, and finger foods. The recipes stated to provide one, three ounce steak patty, four ounces of mashed potatoes, and four ounces of peas and carrots. Interview with [NAME] #145 on 01/09/25 at 11:31 A.M. revealed he had only worked at the facility for one month…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, meal test tray, staff interview, policy review, and resident interview, the facility failed to ensure meals were palatable, appetizing and served at appropriate temperatures. This affected six of six residents interviewed regarding food temperatures/palatability (Residents #1, #8, #63, #67, #70, and #116). The facility census was 139. Findings include: Observations on 01/09/25 at 9:20 A.M. revealed the breakfast meal cart sitting in the hallway on 400 hall [NAME] Wing. Interview with Licensed Practical Nurse (LPN) #254 on 01/09/25 at 9:20 A.M. revealed they had received the meal cart to the hallway at 9:10 A.M. The meal cart was a closed, unheated cart. Observations revealed LPN #254 and one nursing assistant were delivering the meal trays to the 24 residents on the 400 hall on [NAME] Wing. Another nursing assistant was observed on the hallway during breakfast but she was assisting residents with getting weighed and she was not observed to deliver any meal trays. Further observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interview, the facility failed to ensure a resident received food prepared in a form to meet their individual needs. This affected one (Resident #86) of ten residents observed during the lunch meal service. The facility census was 139. Findings include: Review of the medical record for Resident #86 revealed an admission date of 03/01/23 with diagnoses including hypertension, major depressive disorder, dementia, and chronic obstructive pulmonary disease. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had severely impaired cognition. Review of physician's orders revealed on 01/01/05 the resident was changed to a pureed texture diet due to pocketing food. The plan of care dated 09/17/24 stated to serve diet as ordered. Observations on 01/09/25 between 11:40 A.M. and 12:05 P.M. revealed [NAME] #145 to prepare Resident #86's lunch tray. He placed pureed meat, mashed potatoes, and a bowl of tomato soup on the tray. A bowl of regular…

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, staff interview and policy review, the facility failed to notify resident representatives when there was a significant change in resident condition. This affected two (Resident #86 and #145) of 17 sampled residents. The facility census was 139. Findings include: 1. Review of the closed medical record for Resident #145 revealed the resident was admitted to the facility from the hospital on [DATE]. The resident had been in the hospital from [DATE] to 12/09/24 and was treated for systolic heart failure with coronary artery bypass graft surgery (heart surgery) and permanent pacemaker (arrested during surgery twice), right pneumothorax (a collapsed lung) , left pleural effusion (a build-up of fluid between the tissues that line the lungs and the chest), pulmonary edema (build up of fluid in the lungs), periodontal abscess (bacterial infection that occurs alongside a tooth), diabetes, dysphagia with gastrostomy tube placement, acute pulmonary embolism (blood clot), and anemia. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, facility investigation review, and policy review, the facility failed to report an allegation of abuse to the state survey agency. This affected one (Resident #8) of three residents reviewed for abuse. The census was 139. Findings Include: Resident #8 was admitted to the facility on [DATE]. Her diagnoses included acute and subacute hepatic failure, type II diabetes, major depressive disorder, cirrhosis of liver, morbid obesity, heart failure, chronic hepatic failure, history of falling, toxic liver disease, altered mental status, hepatic encephalopathy, and unspecified severe protein calorie malnutrition. Review of her minimum data set (MDS) assessment, dated 11/07/24, revealed she was cognitively intact. Review of Resident #8 medical records found she changed rooms on 12/23/24. There was no documentation to support as to why this change occurred. Review of facility Concern form, dated 12/23/24, revealed a concern given to the nursing staff stating that multiple…

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 facility medical record review, resident interview, staff interview, facility investigative documents review, and facility policy review, the facility failed to complete a thorough investigation of an abuse allegation. This affected one (Resident #8) of three residents reviewed for abuse. The census was 139. Findings Include: Resident #8 was admitted to the facility on [DATE]. Her diagnoses included acute and subacute hepatic failure, type II diabetes, major depressive disorder, cirrhosis of liver, morbid obesity, heart failure, chronic hepatic failure, history of falling, toxic liver disease, altered mental status, hepatic encephalopathy, and unspecified severe protein calorie malnutrition. Review of her minimum data set (MDS) assessment, dated 11/07/24, revealed she was cognitively intact. Review of Resident #8 medical records found she changed rooms on 12/23/24. There was no documentation to support as to why this change occurred. Review of facility Concern form, dated 12/23/24, revealed a concern…

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, record review, and interview, the facility failed to provide pharmacy services to ensure medications were available to be administered per physician orders. This affected two (Residents #39 and #71) of five residents observed for medication administration The facility census was 139. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 07/13/22. There was a physician's order dated 08/01/24 for ergocalciferol (Vitamin D2) 1.25 milligrams one tablet once daily every Monday related to Vitamin D deficiency. Observations on 01/13/25 at 8:05 A.M. revealed Licensed Practical Nurse (LPN) #127 prepare medications to administer to Resident #39. LPN #127 stated that Vitamin D that was ordered to be given at that time was not available. She stated she did not know why it was not available. Interview with the Director of Nursing on 01/13/25 at 8:20 A.M. revealed the ergocalciferol comes from the pharmacy but was not available for administration. 2. Review of the medical record for Resident #71 revealed an admission date 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.

Based on observations, record review, and staff interview, the facility failed to ensure a resident's drug regimen was free from unnecessary medications when his blood pressure was not adequately monitored. This affected one (Resident #7) of five residents observed during medication administration. The facility census was 139. Findings include: Review of the medical record for Resident #7 revealed an admission date of 04/29/24 and a readmission date of 12/29/24 with diagnoses including hypertension (high blood pressure), syncope (fainting), hypotension (low blood pressure) due to drugs, and dementia. A Minimum Data Set assessment completed 01/06/25 indicated the resident had severe cognitive impairment. Resident #7 had a physician's order dated 12/29/24 for Midodrine 2.5 milligrams one tablet twice daily for hypotension (low pressure). The physician's order stated to hold the medication if the systolic blood pressure was greater than 140 millimeters of Mercury (mmHg) or the diastolic blood pressure was greater than 80 mmHg. Observations on 01/13/25 at 9:07 A.M. revealed Licensed…

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, record review, and interview, the facility failed to ensure medications were properly stored. This affected one (Resident #71) of five residents observed for medication administration. The facility census was 139. Findings include: Review of the medical record for Resident #71 revealed an admission date of 08/08/22. A Minimum Data Set assessment on 12/20/24 indicated the resident had intact cognition. There was a physician's order dated 07/26/24 for Breo Ellipta inhalation 100-25 micrograms one puff daily and a physician's order dated 04/17/23 for Flonase nasal spray 50 micrograms two sprays in each nostril daily. Review of the medication administration record for January 2025 revealed the nurses were documenting that the Breo Ellipta inhaler and Flonase nasal spray were administered daily. There was no evidence of a physician's order to self administer medications. Observations on 01/13/25 at 9:35 A.M. revealed Agency Licensed Practical Nurse (LPN) #301 prepared medications to administer to Resident #71. LPN #301 stated she was unable to find a Breo Ellipta…

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, insulin pen needle user guide review, facility policy review and interview, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 14.8% and included 4 medication errors of 27 medication administration opportunities. This affected two residents (#17 and #61) of two residents observed during medication administration. The facility census was 137. Findings include: 1. Review of the medical record for Resident #17 revealed an initial admission date of 11/03/2022 with an re-entry date of 12/21/2023. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and seasonal allergies. Review of Resident #17's physician orders for October 2024 revealed an active order for Fluticasone Propionate HFA, Inhalation Aerosol 110 microgram (mcg)/actuation (ACT), Two puffs inhale orally two times a day for chronic obstructive pulmonary disease. Observation on 10/07/2024 at 8:10 A.M. of Licensed Practical Nurse (LPN) #310 completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure residents received oral fluids between meals. This affected three residents (#10, #33, and #41) out of three residents reviewed for hydration. The facility also failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range when Resident #130's weekly weight were not completed as ordered after having weight loss. This affected one (Resident #130) of eight residents reviewed for nutrition The facility census was 140. Findings include: 1.Review of the medical record for Resident #10, revealed an admission date of 06/25/19. Diagnoses included but were not limited to chronic obstructive pulmonary disease, altered mental status, unspecified dementia and other reduced mobility. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of the resident is rarely/never understood. 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 observation, interview, and facility policy review, the facility failed to ensure pureed foods were prepared to the correct texture. This had the potential to affect nine (#7, #10, #18, #23, #40, #41, #94, #115, and #391) of nine residents who received pureed texture diets. The facility census was 140. Findings included: Observations made continuously on 08/21/24 at 9:59 A.M. to 10:45 A.M. during the preparation of pureed foods revealed [NAME] #166 was preparing pureed hotdogs. She added 11 hotdogs to the blender, 11 buns, and beef broth before blending. Once the items had blended approximately one minute, [NAME] #166 stated it was ready to serve. Attempted to get a spoon full to check the texture, and one third of a hotdog bun came up out of the mixture. [NAME] #166 began to pureed again without scraping the sides. After about 30 seconds, she stopped and stated the mixture was ready again. Chunks of hotdog were visible on the sides of the blender. The mixture was tasted and maintained flavor. [NAME] #166 required encouragement to scrape the sides and continue blending 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 observations, interviews, and facility policy reviews, the facility failed to ensure the kitchen was maintained in a clean manner, garbage cans were clean and the kitchen was pest free. This had the potential to affect 139 of 140 residents who received meals in the facility. The facility census was 140. Findings include: Observations were continuously made of the kitchen on 08/19/24 starting at 9:00 A.M. and ending at 9:38 A.M. Observations included a large amount of flies and gnats in the back of the pantry, one uncovered garbage can next to the back door, one dirty garbage can near walk-in refrigerator covered in splatters and grime, and another garbage covered in splatters and grime near the hand-washing sink. The walk-in refrigerator held a five pound tub of sour cream which expired on 07/26/24, there was an open bag of spaghetti noodles which was not resealed in the pantry, a partially filled 22-quart tub of sugar with a use by 03/23/24 sticker was in the pantry, the standing refrigerator did not have a thermometer inside it, shelves throughout the kitchen had grime…

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, interviews, and facility policy review, the facility failed to ensure garbage cans were clean and the kitchen was pest free. This had the potential to affect 139 of 140 residents who received meals in the facility. The facility census was 140. Findings include: Observations were continuously made of the kitchen on 08/19/24 starting at 9:00 A.M. and ending at 9:38 A.M. Observations included a large amount of flies and gnats in the back of the pantry, one uncovered garbage can next to the back door, one dirty garbage can near walk-in refrigerator covered in splatters and grime, and another garbage covered in splatters and grime near the hand-washing sink. Interview with Dietary Manager (DM) on 08/19/24 at 9:38 A.M. confirmed findings. Observation on 08/21/24 at 9:59 A.M. revealed four hot-wells with dirty water and debris floating, including two dead flies. Additionally, there were five flies flying throughout the kitchen prep area and landing on clean utensils which were being used for food preparation without being cleaned first. Interview on 08/21/24 at 10:42…

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, resident interview, and staff interview, the facility failed to ensure residents' rooms and mobility devices were properly maintained and not in a state of disrepair. This affected four (Resident #15, #68, #70, and #115's) of the 34 residents sampled. The facility census was 140. Findings include: 1. On 08/20/24 at 8:44 A.M., an observation of Resident #70's room revealed the overbed light above his bed was not working. The short chain that was on the side of the fluorescent light did not activate a light to come on when it was pulled. Resident #70 also complained of not having a string attached to the short chain that he could reach in order to be able to use the light when he desired. On 08/26/24 at 10:00 A.M., a follow up observation of Resident #70's room revealed his light over the bed still did not work and was still missing a longer string to allow the resident to use it to turn the light on and off. Findings were verified by Maintenance Director #172 on 08/26/24 at 10:18 A.M. 2. On 08/20/24 at 9:55 A.M., an observation of Resident #105's room 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure resident rooms had sufficient space. This affected one (Resident #66) of one resident reviewed for accommodations of physical needs. The facility census was 140. Findings included: Record review revealed Resident #66 admitted to the facility on [DATE] with diagnoses including type II diabetes, heart failure, dementia, and muscle weakness. Review of a care plan dated 06/27/24 revealed Resident #66 required assistance for activities of daily living (ADLs) due to cognitive impairment and immobility with interventions including but not limited to providing assistive devices to increase ADL self-care as needed. Observation and interview on 08/20/24 at 10:18 A.M. revealed Resident #66's bed and dresser near the foot of the bed were approximately two feet between them, not leaving enough space for Resident #66 to use her rollator to move through her room easily. Interview on 08/26/24 at 12:51 P.M. with Licensed Practical Nurse (LPN) #320 confirmed…

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 assist residents in locating missing items. This affected one (#4) of one resident reviewed for missing items. The facility census was 140. Findings include: 1. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including moderate intellectual disabilities, major depression, and hypertension. Review of a quarterly minimum data set completed on 07/24/24 revealed Resident #4's cognition remained intact. Interview on 08/20/24 at 9:44 A.M. with Resident #4 revealed she was missing three stuffed animals including a new teddy bear she had received recently. Interview on 08/22/24 at 9:01 A.M. with State Tested Nursing Assistants (STNAs) #182 and #257 revealed Resident #4 had a certain teddy bear with her at all times but it went missing about three weeks ago. STNA #182 stated Resident #4 had reported the missing teddy bear to a nurse on a different shift so she did not look for it or report it missing again. STNA #182 stated…

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 facility policy review, the facility failed to investigate an allegation of abuse. This affected one (Resident #4) of one resident reviewed for abuse. The facility census was 140. Findings included: Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including moderate intellectual disabilities, major depression, and hypertension. Review of a quarterly minimum data set completed on 07/24/24 revealed Resident #4's cognition remained intact. Interview on 08/20/24 at 9:38 A.M. with Resident #4 revealed an aide hit her on her left arm on night shift. Resident #4 stated it was a hard, open-handed hit. Interview on 08/21/24 at 9:35 A.M. with Licensed Practical Nurse (LPN) #239 revealed an aide had been removed from Resident #4's hallway after resident had reported the aide had tapping her arm and would not stop until Resident #4 yelled at her. LPN #239 stated Resident #4 complained her arm was hurting the following day and had been on the phone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately complete a level one Pre-admission Screening/Resident Review (PASARR) and did not list psychosis disorder on the serious mental illness section to be reviewed for a level two. This affected one resident (#86) of two reviewed for PASARR. The facility census was 140. Findings include: Review of the medical record for Resident #86, revealed an admission date of 04/08/22. Diagnoses included but were not cerebral infarction, major depressive disorder, anxiety disorder and as of 03/12/24 psychotic disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 09 out of 15 suggesting severe cognitive impairment. The resident was assessed to have a psychotic disorder. Review of a PASARR completed on 03/05/24 by the Business Office Manager (BOM) #249 revealed psychosis disorder was not indicated under the level one review for serious mental illness. Interview on 08/21/24 at 3:02 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 record review and interview, the facility failed to screen a resident for serious mental illness and intellectual disabilities on a resident review (PASRR). This affected one (Resident #66) of two residents reviewed for PASRRs. The facility census was 140. Findings included: Record review revealed Resident #66 admitted to the facility on [DATE] with diagnoses including dementia, bipolar disorder, major depression, mood disorder, and epilepsy. Review of a PASRR completed on 06/10/24 revealed the section of serious mental illness was not completed accurately and did not include the diagnoses of bipolar disorder, major depression, and mood disorder. In the section of intellectual disabilities, epilepsy was not listed. Interview on 08/21/24 at 2:31 P.M. with Business Office Manager (BOM) #249 revealed PASRRs are completed upon admission, medication changes, a new diagnosis, and admission to hospice. BOM #249 stated she completed the PASRR by using the information on the Hospital Exemption 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 record review, observation, and staff interview, the facility failed to ensure care plans were complete and comprehensive for residents with existing pressure ulcers to include appropriate interventions for offloading pressure and turning/ repositioning to promote healing of the pressure ulcers. This affected two (Resident #49 and #107) of five residents reviewed for pressure ulcers. The facility census was 140. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included paraplegia, reduced mobility, muscle weakness, need for assistance with personal care, adult onset diabetes mellitus, anemia, chronic pain, paranoid schizophrenia, severe intellectual disabilities, protein calorie malnutrition, and major depressive disorder. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired. He was not known to have displayed any behaviors, nor…

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 and resident interview, record review, and facility policy review, the facility failed to develop comprehensive care plans with the resident in attendance with an interdisciplinary team for Resident #105, and revise a nutritional care plan to include gastrostomy tube placement for Resident #115. This affected one (Resident #105) of four residents reviewed for care planning and one (Resident #115) of three residents reviewed for tube feeding. The facility census was 140. Findings include: 1. Record review of Resident #105 revealed an admission date of 12/13/22 with pertinent diagnoses of: unspecified severe protein calorie malnutrition, type two diabetes mellitus with diabetic nephropathy, osteomyelitis, diarrhea, malignant neoplasm of prostate, peripheral vascular disease, pressure ulcer of right heel, muscle weakness, hyperlipidemia, pain, chronic embolism and thrombosis of deep veins of upper extremity, allergic rhinitis, obstructive and reflux uropathy, hypertension, acute kidney failure,…

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, and staff interview, the facility failed to ensure enteral tube feeding bottles were dated and timed when they were hung during administration for a resident receiving nightly nocturnal tube feedings. This affected one (Resident #115) of three residents reviewed for tube feedings. The facility census was 140. Findings include: Review of Resident #115's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, unspecified dementia, Barrett's esophagus, severe protein- calorie malnutrition, and gastrostomy status (surgical procedure that creates an opening through the abdomen into the stomach for the placement of a feeding tube for nutritional purposes). Review of Resident #115's physician's orders revealed the resident had an order in place to receive Osmolite 1.5 cal at 60 milliliters (ml)/ hour x 12 hours for a total of 720 ml/ day via his Percutaneous Endoscopic Gastrostomy (PEG) tube via pump. The enteral feeding was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, policy review, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice when they did not have an order for oxygen for Resident #54 and did not provide oxygen at the ordered rate for Resident #78. This affected two (Resident #54, and #78) of two residents reviewed for respiratory care. The facility census was 140. Findings include: 1. Record review of Resident # 54 revealed an admission date of 07/23/19 with pertinent diagnoses of: hypotension, right bundle branch block, cardiomegaly, hypoxemia, gout, allergic rhinitis, glaucoma, muscle weakness, urinary tract infection, heart failure, peripheral vascular disease, anemia, anorexia, end stage renal disease, dependence on wheelchair, spinal stenosis, peripheral vascular disease, hypertension, major depressive disorder, chronic respiratory failure with hypoxia, anxiety disorder, and chronic obstructive pulmonary disease.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and record review the facility failed to provide or obtain laboratory services only when ordered by a physician when they did not draw a hemoglobin A1C, complete blood count, comprehensive metabolic panel, and Depakote level quarterly in June for Resident #85 and when a basic metabolic panel was not drawn as ordered for Resident #443. This affected two (Resident #85, and #443) of six Residents reviewed for laboratory values. The facility census was 140. Findings include: 1. Record review of Resident #85 revealed an admission date of 01/07/23 with pertinent diagnoses of: disorientation, delusional disorders, insomnia, anorexia, pulmonary embolism, Parkinson's disease, anxiety disorder, mood disorder, unspecified dementia with mood disturbance, fracture of first lumbar vertebrae, spondylosis, adjustment disorder with depressed mood, fracture of sacrum, cervical disc degeneration,fall, solitary pulmonary nodule, type two diabetes mellitus, intestinal malabsorption, obesity, shortness of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor and did not increase his risk for infection. This affected one (Resident #115) of one residents reviewed for indwelling urinary catheters. The facility census was 140. Findings include: Review of Resident #115's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, chronic kidney disease, history of urinary tract infections, congestive heart failure, hydronephrosis, acute kidney failure with tubular necrosis, and obstructive and reflux uropathy. Review of Resident #115's physician's orders revealed he had an order to maintain an indwelling urinary catheter every shift to straight drain due to benign prostate hypertrophy with urinary tract symptoms. The orders also included the need to change the catheter bag monthly and as needed (prn). Review of Resident #115's 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 observations, staff interviews, review of the local health department inspection reports, and facility policy review, the facility failed to ensure the kitchen was properly cleaned and sanitized prior to completing food preparation. The deficient practice had the potential to affect 127 residents who receive food from the kitchen. There was one resident (Resident #123) who was identified as having an ordered nothing by mouth (NPO) diet. Findings include: Review of the local health department (LHD) inspection report for the [NAME] Wing kitchen,completed on 06/10/24, evealed the kitchen was out of compliance with the following regulations: the person in charge demonstrated knowledge and performed duties; adequate handwashing facilities were supplied and accessible; food-contact surfaces were cleaned and sanitized; contamination was prevented during food preparation, storage, and display; non-food contact surfaces were clean; sewage and wastewater was properly disposed; and physical facilities were…

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

Based on record review, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of the facility policy, the facility failed to protect residents from resident-to-resident physical abuse. This affected one (Resident #93) of three residents reviewed for abuse. The facility census was 126 residents. Findings include: Review of the medical record for Resident #93 revealed an admission date of 11/04/22 with diagnoses including Parkinson's disease, dementia, reduced mobility, urinary tract infections, repeated falls, metabolic encephalopathy, hypertension, hyperlipidemia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #93 dated 05/10/24 revealed the resident had severe cognitive impairment. Review of the facility SRI #247741 dated 05/20/24 revealed on 5/20/24 at about 2:00 P.M. the unit manager heard a commotion and looked into the common area and witnessed two residents (Resident #60 and #18) on the ground holding onto each other. The unit manager separated the two residents, and redirected…

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 facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of the facility policy, the facility failed to conduct thorough abuse investigations and failed to protect residents from abuse during pending abuse investigations. This affected one (Resident #93) of three residents reviewed for abuse. The facility census was 126 residents. Findings include: Review of the medical record for Resident #93 revealed an admission date of 11/04/22 with diagnoses including Parkinson's disease, dementia, reduced mobility, urinary tract infections, repeated falls, metabolic encephalopathy, hypertension, hyperlipidemia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #93 dated 05/10/24 revealed the resident had severe cognitive impairment. Review of the facility SRI #247741 dated 05/20/24 revealed on 5/20/24 at about 2:00 P.M. the unit manager heard a commotion and looked into the common area and witnessed two residents (Resident #60 and #18) on the ground holding onto each other. 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, staff interview, and review of facility policy, the facility failed to ensure a plan of care and interventions were implemented for the areas of fall risk and incontinence. This affected two (Residents #104 and #120) of four residents sampled. The facility census was 126. Findings include: 1. Review of the medical record for Resident #104 revealed an admission date of 03/05/24 with diagnoses including acute respiratory failure, weakness, unsteadiness on feet, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #104 dated 03/05/24 revealed the resident had moderately impaired cognition and was always incontinent of bowel and bladder. Review of the fall risk evaluation for Resident #104 dated 03/06/24 revealed the resident was at high risk for falls. Review of the care plan for Resident #104 initiated 03/05/24 revealed no care plan or interventions had been developed for the resident for the areas of fall risk or incontinence. Interviewon 06/11/24 at 3:15 P.M with Regional Clinical Director (RCD)…

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

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents received care in accordance with the care plan in order to prevent falls. The facility also failed to investigate resident falls to determine the root cause of the fall and implement interventions to prevent recurrence. This affected two (Residents #36 and #120) of four residents reviewed for falls and accidents. The facility census was 126. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 01/23/13 with diagnoses including chronic obstructive pulmonary disorder, dementia, and reduced mobility. Review of the annual Minimum Data Set (MDS) assessment for Resident #36 dated 05/19/24 revealed the resident had severe cognitive impairment. Review of the state optional MDS assessment for Resident #36 dated 05/19/24 revealed the resident dependent upon two staff members for transfers, bed mobility, and toileting. Review of the care plan for Resident #36 dated 01/21/13 revealed the resident had an activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and family interview, and facility policy review, the facility failed to ensure concerns brought up during resident council were addressed timely. This affected 10 Residents (#30, #40, #72, #75, #81, #101, #105, #108, #111, #113) that regularly attend resident council meetings. Facility census was 130. Findings include: Review of Resident council meeting minutes dated 01/18/24 revealed complaints of resident rooms need to be cleaner. No concern forms or facility follow-up was provided upon request. Review of Resident council meeting minutes dated 02/22/24 revealed complaints of resident rooms need to be cleaned better. No concern forms or facility follow-up was provided upon request. Review of Resident council meeting minutes dated 03/21/24 revealed complaints of resident housekeeping to clean under the beds more thoroughly. Facility provided education dated 03/22/24 as their response to the concern related to cleaning under resident beds. Observations on 04/22/24 from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and family interviews, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner. This affected three Residents (#92, #94, and #121) of three reviewed for environment. Facility census was 130. Findings include: Observation on 04/22/24 at 11:10 A.M. revealed Resident #92's toilet had brown splattered substance on the toilet riser and toilet bowl. Resident was unable to respond to questions appropriately related to his room cleanliness. Observation on 04/22/24 at 11:38 A.M. revealed Resident #94's had a clear liquid dripped on the floor and a large puddle in front of his recliner. Resident was sitting in his recliner with his feet sitting in the puddle. Resident was unable to respond to questions about the spilled liquid. The splatter and puddle was visible from the hallway. At 11:40 A.M. a nurse walked into the doorway to pass medications and realized it was not the right room and walked away to provide medications to another residents.…

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 personnel files, review of tuberculosis (TB) questionnaires, review of the TB risk assessment, staff interview, and facility policy review, the facility failed to complete annual TB questionnaires or TB tests for three staff (Receptionist #401, Receptionist #405, and Receptionist #409). This affected three out of three staff reviewed for annual TB questionnaires or testing and had the potential to affect all 134 residents who resided in the facility. Findings Include: Review of the personnel file for Receptionist #401 revealed a hire date on 06/10/78. The most recent TB screening questionnaire was completed on 06/01/16. Review of the personnel file for Receptionist #405 revealed a hire date on 11/08/21. The most recent TB screening questionnaire was completed on 11/08/22. Review of the personnel file for Receptionist #409 revealed a hire date on 12/18/17. There was not any completed TB test documentation or TB screening questionnaires found in the receptionist's file. Review of the TB Risk…

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, review of personnel files, review of written staff statements, review of timecard punches, and facility policy review, the facility failed to conduct a thorough investigation of Former State Tested Nurse Aides (STNAs) #202 and #204 leaving the facility while on duty to ensure the residents that Former STNAs #202 and #204 were assigned to care for were not adversely affected or subject to any type of abuse, neglect, or misappropriation as a result of the incident. The deficient practice had the potential to affect all 23 residents who resided on [NAME] Wing, Unit 1 (Residents #131, 161, 187, 243, 246, 253, 263, 272, 275, 283, 284, 286, 291, 293, 295, 303, 305, 309, 311, 315, 317, 324, and 327). The facility census was 134. Findings Include: Review of the time punches for former State Tested Nurse Aides (STNAs) #202 and #204 for 02/29/24 revealed STNA #202 clocked in at 5:55 P.M., clocked out at 6:06 P.M., clocked back in at 9:37 P.M., and clocked out for the day at 6:11 A.M. on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, staff interviews, review of inventory lists, and facility policy review, the facility failed to protect one resident's (Resident #161) personal belongings from being lost or stolen. This affected one (Resident #161) of three residents reviewed for grievances and missing items. The facility census was 134. Findings Include: Review of the closed medical record for Resident #161 revealed an initial admission on [DATE], a readmission date on [DATE], and a discharge date due to death on [DATE]. Medical diagnoses included acute and chronic respiratory failure, Bipolar Disorder, chronic obstructive pulmonary disease (COPD), heart failure, type II Diabetes Mellitus, and dependence on supplemental oxygen. Review of the inventory lists for Resident #161 revealed the most recent inventory of personal effects was dated [DATE]. Inventory included: one coat, two sweatshirts, 30 blouses, two gloves, 19 pairs of underwear, 21 pairs of slacks, two pairs of socks, six camisoles, one set of pajamas,…

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, resident and staff interviews, the facility failed to properly treat non pressure skin issues for two residents (#721, #187) out of three reviewed for skin areas. The facility also failed to provide an incentive spirometer to treat a collapsed lung for one resident (#151) out of one resident reviewed. The facility also failed to ensure an as needed cough syrup with codeine was reordered timely and readily available as well as administering medications appropriately this affected two residents (#151 and #187) of three residents reviewed. The facility census was 134. Findings include: 1. Review of the medical record for Resident #721, revealed an admission date of 03/20/23 with a discharge to home date of 02/27/24. Diagnoses included hypertension, mood disorder and type 2 diabetes mellitus. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15 indicating cognitive impairment. The resident 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 reviews and staff interviews, the facility failed to provide proper care and services to treat pressure ulcers for three (Resident #187, #736 and # 812) of four residents reviewed for pressure ulcers. The facility census was 134. Findings include: 1. Review of the medical record for Resident #187 revealed an admission date of 11/28/23. Diagnoses included chronic respiratory failure with hypoxia, other reduced mobility, repeated falls, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 6 out of 15 which indicated severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed, toilet transfer, and toilet hygiene. Review of Resident #187's wound assessment dated [DATE] by the Wound Physician revealed the left and right heel were stage 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 observation, record review, and staff interview, the facility failed to ensure fall prevention interventions were in place for Resident #187. This affected one (Resident #187) of three residents reviewed for fall prevention interventions. The facility census was 134. Findings include: Review of the medical record for Resident #187 revealed an admission date of 11/28/23. Diagnoses included chronic respiratory failure with hypoxia, other reduced mobility, repeated falls, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 6 out of 15 indicating cognitive impairment. The resident was assessed to require substantial/maximal assistance with roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed, toilet transfer and toilet hygiene. Review of the Interdisciplinary Team note dated 03/13/24 related to a fall with injury for Resident #187 revealed an…

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 closed record review, staff interview and review of discharge instructions, the facility failed to ensure daily weights were completed as ordered and failed to ensure Resident # 121 received the appropriate diet. This affected one resident (Resident # 121) out of three residents reviewed for nutrition. The facility census was 134. Findings include: Review of the closed medical record for Resident #121 revealed an admission date of 02/21/24 with a discharge to home date of 02/27/24. Diagnoses included need for assistance with personal care, heart failure, and rheumatic mitral valve disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. Review of the progress notes for Resident #121 revealed the resident was admitted to the facility on [DATE] from The Ohio State University and was transferred back on 02/22/24 due to pain from the replacement of the rheumatic mitral valve. 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 observation, medical record review, and staff interview , the facility failed to administer medications in accordance with physicians orders producing a medication error rate greater than five percent. This resulted in four medication errors out of 25 opportunities for a medication error rate of 16 percent. This affected two (Resident #53 and Resident #122) of three residents observed for medication administration. The census was 123. Findings included: Observation on 02/08/24 of medication administration between 9:35 A.M. and 10:11 A.M. revealed the following; 1. Licensed Practical Nurse (LPN) #199 prepared medications for Resident #53 of Aricept (medication for Alzheimers disease) 10 milligrams (mg), Gualfenesin ER (allergy medication) 600 mg, Mirapex (parkinson's medication) 0.5 mg, Sertraline (antidepressant) 25 mg, probiotic acidophilus and Breo Ellipta 100-25 (inhaler for chronic obstructive pulmonary disease) micrograms (mcg) one puff. After administration of Breo Ellipta 100-25 mcg LPN #199 failed to have Resident #53 rinse her mouth out, She also informed 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 and interview, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication. This affected one (Resident #7) of three residents reviewed for antipsychotic medication use. The facility census was 120. Findings include: Review of the medical record for Resident #7 revealed an admission date of 10/11/22. Diagnoses included dementia, chronic obstructive pulmonary disease, atherosclerosis of native arteries of extremities with intermittent claudication of bilateral legs, chronic diastolic heart failure, major depressive disorder, dysphasia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The assessment indicated the resident had severely impaired cognitive skills for daily decision making. The resident did not have any hallucinations, delusions, physical, or verbal behaviors, or rejection of care. Review of the Care Plan, revision date 07/31/23,…

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, resident and staff interviews, and facility policy review, the facility failed to report to the state agency a suspected incident of sexual abuse involving Resident #13 and Resident #59. This affected two residents (Residents #13 and #59) of three residents reviewed for abuse. The facility census was 114. Findings include: Review of the medical record for Resident #13 revealed an admission date on 08/28/23. Medical diagnoses included other disorders of lung, Alzheimer's Disease, unspecified mood (affective) disorder, and disruptive mood dysregulation disorder. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #13 required extensive assistance from one to two or more staff to complete Activities of Daily Living (ADLs). Resident #13 had not displayed any behaviors. Review of the physician orders dated September 2023 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and facility policy review, the facility failed to timely and thoroughly investigate a suspected incident of sexual abuse which involved two residents (Residents #13 and #59). The deficient practice affected two residents (Residents #13 and #59) of three reviewed for abuse. The facility census was 114. Findings include: Review of the medical record for Resident #13 revealed an admission date on 08/28/23. Medical diagnoses included other disorders of lung, Alzheimer's Disease, unspecified mood (affective) disorder, and disruptive mood dysregulation disorder. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #13 required extensive assistance from one to two or more staff to complete Activities of Daily Living (ADLs). Resident #13 had not displayed any behaviors. Review of the physician orders…

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 interviews, review of hospital records, and facility policy review, the facility did not ensure adequate skin assessments were completed to identify bruising in a timely manner on Resident #115 who was later diagnosed with a hip fracture. This affected one resident (#115) of three residents reviewed for incidents/accidents. The facility census was 114. Findings Include: Review of the closed medical record for Resident #115 revealed an admission date of 03/30/17 with medical diagnoses including chronic obstructive pulmonary disorder (COPD), cerebral infarction (stroke), muscle weakness, encephalopathy (any brain disease that alters brain function or structure), and difficulty in walking. Resident #115 was discharged to the hospital on [DATE] and did not return to the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #115 had severely impaired cognition scoring a three out of 15 on the Brief Interview for Mental…

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 facility policy review, the facility failed to develop a comprehensive plan of care for four residents (#12, #15, #19, #82) in the area of respiratory care, accidents, braces, dialysis and bowel and bladder. This affected four residents (#12, #15, #19, #82) of 28 sampled residents. The facility census was 121. Findings Include: 1. Review of the medical record for Resident #12 revealed an initial admission date of 08/09/21 with the latest readmission of 03/28/23 with the admitting diagnoses of chronic obstructive pulmonary disease (COPD), sepsis, severe morbid obesity, chronic pulmonary edema, osteoarthritis, seasonal allergic rhinitis, chronic respiratory failure, congestive heart failure, atrial fibrillation, autistic disorder, severe protein-calorie malnutrition, hypertension, retention of urine, mild intellectual disabilities, sleep apnea, benign prostatic hyperplasia, penile hypospadias, anxiety disorder, major depressive disorder, insomnia, phobic anxiety…

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 interviews, the facility failed to ensure Resident #1, #12, #51, #325, who required assistance with activities of daily living (ADL) received nail care, shaving assistance and showers. This affected four residents (Resident #1, #12, #51, #325) of five residents reviewed for ADL. The facility census was 121. Findings Include: 1. Review of the medical record for Resident #12 revealed an initial admission date of 08/09/21 with the latest readmission of 03/28/23 with the admitting diagnoses of chronic obstructive pulmonary disease (COPD), sepsis, severe morbid obesity, chronic pulmonary edema, osteoarthritis, seasonal allergic rhinitis, chronic respiratory failure, congestive heart failure, atrial fibrillation, autistic disorder, severe protein-calorie malnutrition, hypertension, retention of urine, mild intellectual disabilities, sleep apnea, benign prostatic hyperplasia, penile hypospadias, anxiety disorder, major depressive disorder, insomnia, phobic anxiety disorder,…

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 facility policy review, the facility failed to provide proper justification for the use of psychotropic medications for Resident #15, #29, and #76, and failed to adequately monitor/track behaviors and side effects for Resident #80 who utilized psychotropic medications. This affected four (Residents #15, #29, #76, and #80) of five residents reviewed for unnecessary medications. The census was 121. Findings Include: 1. Resident #29 was admitted to the facility on [DATE]. Her diagnoses were other disorders of lung, pneumonia, acute respiratory failure with hypercapnia, hyperosmolality and hypernatremia, dementia, hyperlipidemia, wheezing, hypertension, anxiety disorder, edema, osteoarthritis, insomnia, vitamin D deficiency, opioid use, and other reduced mobility. Review of her Minimum Data Set (MDS) assessment, dated 05/19/23, revealed her cognitive assessment could not be completed due to her inability to adequately answer the questions. Review of Resident #29…

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, resident interview the facility failed to ensure food was served at the preferred temperature. This affected two residents (Resident #51 and Resident #72) with the potential to affect all 18 residents on the facility [NAME] 200 hall. Findings Include: On 06/05/23 at 11:34 A.M., interview with Resident #72 revealed the eggs were always cold. On 06/05/23 at 2:59 P.M., interview with Resident #51 revealed the food were always cold, especially breakfast. Observation on 06/08/23 at 7:58 A.M. of the [NAME] 200 hallway revealed the meal cart was delivered on the hallway. At 8:01 A.M. the Diet Tech #339 started to deliver the breakfast trays. At 8:02 A.M. an unknown State Tested Nursing Assistant (STNA) on the hallway started to pass the meal trays. AT 8:14 A.M. the last meal tray was delivered. The test tray was taken to the nurses station per DT #339 request. The meal consisted of scrambled egg, muffin, oatmeal, yogurt, orange juice (OJ), milk and coffee. The following…

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 honor Resident #1 and Resident #51's shower preferences. This affected two residents (Resident #1 and #51) of three residents reviewed for choices. The facility census was 121. Findings Include: 1. Review of the medical record for Resident #51 revealed an initial admission date of 09/28/20 with the latest readmission of 04/20/23 with the diagnoses including acute respiratory failure with hypoxia, diabetes mellitus, diabetes mellitus, chronic kidney disease, anemia, developmental disorder, left below the knee amputation (BKA), right above the knee amputation, glaucoma, obstructive and reflux uropathy, asthma, schizoaffective disorder, neuropathy, muscle spasms, major depressive disorder, convulsions, retention of urine, gastro-esophageal reflux disease, psychosis, pain, hypertension, benign prostatic hyperplasia, Klinefelter Syndrome, osteoarthritis and anxiety disorder. Review of the plan of care dated 09/08/20 revealed the resident had a self-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, observation and interview, the facility failed to have accurate and consistent advanced directives. This deficient practice affected one resident (Resident #8) out of two residents reviewed for advanced directives. The facility census was 121. Findings include: Review of medical record for Resident #8 revealed Resident #8 was admitted to the facility on [DATE] with admittance diagnoses which include congestive heart failure, chronic kidney disease, dementia, pain, diabetes mellitus type 2. Review of Resident #8 clinical record revealed a physician order dated [DATE] for advanced directive being Full Code requiring cardiopulmonary resuscitation (CPR). Further review of Resident #8's chart revealed an undated Ohio Do Not Resuscitate Order Form marked as Do Not Resuscitate Comfort Care (DNRCC) signed by Resident #8 without a physician's signature. Review of Resident #8 demographic information headline in the electronic medical system revealed Resident #8 had a Full Code status requiring…

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 facility policy review, the facility failed to complete a thorough and adequate investigation for misappropriation. This affected one (Resident #19) of one resident reviewed for abuse, neglect, and misappropriation. The census was 121. Findings Include: Resident #19 was admitted to the facility on [DATE]. Her diagnoses were mild intellectual disabilities, moderate intellectual disability, old myocardial infarction, adult failure to thrive, hypo-osmolality and hyponatremia, major depressive disorder, paraplegia, Down's syndrome, convulsions, insomnia, neuromuscular dysfunction of bladder, bipolar disorder, heart disease, edema, anxiety disorder, opioid use, schizophrenia, acute kidney failure, hypertension, type II diabetes, psychosis, unspecified intellectual disabilities, hypertensive heart disease, hyperlipidemia, and hemiplegia. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 03/25/23, revealed she had a severe cognitive impairment. 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 medical record review and staff interview, the facility failed to ensure Resident #103 and Resident #120's assessments were accurate. This affected two (Residents #103 and #120) of 24 residents reviewed for assessments. The census was 121. Findings Include: 1. Resident #120 was admitted to the facility on [DATE]. Her diagnoses were interstitial pulmonary disease, nausea with vomiting, osteoarthritis, drug induced hypoglycemia, type II diabetes, hypertension, major depressive disorder, anxiety disorder, hypothyroidism, dementia, insomnia, anemia, shortness of breath, and opioid use. Review of her Minimum Data Set (MDS) assessment, dated 03/14/23, revealed she was cognitively intact. Review of Resident #120 MDS assessment, section A, revealed she was discharged to an acute hospital on [DATE]. Review of Resident #120 progress notes revealed she was discharged to the community/home on [DATE]. Interview with Office Personnel #130 on 06/07/23 at 11:48 A.M. confirmed Resident #120 went home confirming the 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 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 (Resident #60 and Resident #76) of two residents reviewed for PASARR documents. The census was 121. Findings Include: 1. Resident #60 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Resident #60's diagnoses included chronic obstructive pulmonary disease, dementia, flaccid hemiplegia left dominant side, atrial fibrillation, subarachnoid hemorrhage, idiopathic neuropathy, major depressive disorder, post-traumatic stress disorder (PTSD), Epilepsy, Schizophrenia, hemiplegia and hemiparesis. Review of Resident #60's Minimum Data Set (MDS) assessment, dated 04/30/23, revealed he was cognitively intact. Review of Resident #60 PASARR document, dated 01/26/16, revealed under Section D, there were no diagnoses checked. But review of his…

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 significant mental health changes were communicated to the State mental health agency. This affected two (Resident #60 and Resident #76) of two residents reviewed for PASARR documents. The census was 121. Findings Include: 1. Resident #60 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Resident #60's diagnoses included chronic obstructive pulmonary disease, dementia, flaccid hemiplegia left dominant side, atrial fibrillation, subarachnoid hemorrhage, idiopathic neuropathy, major depressive disorder, post-traumatic stress disorder (PTSD), Epilepsy, Schizophrenia, hemiplegia and hemiparesis. Review of Resident #60's Minimum Data Set (MDS) assessment, dated 04/30/23, revealed he was cognitively intact. Review of Resident #60 PASARR document, dated 01/26/16, revealed under Section D, there were no diagnoses checked. Review of his diagnoses list, he had the following diagnoses that…

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, interview and facility policy review, the facility failed to ensure Resident #325's tracheostomy and nasogastric tube was addressed in the baseline plan of care. This affected one resident (Resident #325) of one resident received for tracheostomy and one of one resident for nasogastric (NG) tube. The facility census was 121. Findings Include: Review of the medical record for Resident #325 revealed an initial admission date of 05/31/23 with the diagnoses including malignant neoplasm of thyroid gland, secondary malignant neoplasm of intrathoracic, hypertension, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease, benign neoplasm of pituitary gland, nontoxic multinodular goiter, diaphragmatic hernia, basal cell carcinoma of skin, osteoarthritis, tracheostomy status, constipation, hypothyroidism, dry eye syndrome and pain. Review of the monthly physician orders identified orders dated 05/31/23 trach care daily, wash around tube entry site with soap and water each day, monitor for skin breakdown every shift, in case of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to appropriately revise resident care plans. This affected two (Resident #15 and #29) of 24 residents reviewed for care plans. The census was 121. Findings Include: 1. Resident #29 was admitted to the facility on [DATE]. Her diagnoses were other disorders of lung, pneumonia, acute respiratory failure with hypercapnia, hyperosmolality and hypernatremia, dementia, hyperlipidemia, wheezing, hypertension, anxiety disorder, edema, osteoarthritis, insomnia, vitamin D deficiency, opioid use, and other reduced mobility. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 05/19/23, revealed her cognitive assessment could not be completed due to her inability to adequately answer the questions. Review of Resident #29 safety assessments, dated March 2023, revealed she was assessed for the need of a chair and bed alarm due to her safety needs. The chair alarm was in place during the annual survey. Review of Resident #29…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure adequate monitoring of a change in a residents condition, failed to ensure interventions to prevent skin alterations were adequately implemented, and failed to ensure a brace was applied as ordered. This affected three residents (Resident #15, #19, and #98) of three residents reviewed for quality of care. The facility census was 121. Findings include: 1. Record review for Resident #15 revealed this resident was admitted to the facility on [DATE] and had diagnoses including reduced mobility, chronic kidney disease, type two diabetes mellitus, heart failure, altered mental status, adjustment disorder, fluid overload, history of falling, and unspecified dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 05/19/23, revealed this resident was unable to complete the interview indicated by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to be dependent upon two staff…

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 interviews, the facility failed to properly identify Resident #12's medical condition to ensure a proper catheterization treatment plan was in place. This affected one resident (Resident #12) of one resident reviewed for catheter care. Findings Include: Review of the medical record for Resident #12 revealed an initial admission date of 08/09/21 with the latest readmission of 03/28/23 with the admitting diagnoses of chronic obstructive pulmonary disease (COPD), sepsis, severe morbid obesity, chronic pulmonary edema, osteoarthritis, seasonal allergic rhinitis, chronic respiratory failure, congestive heart failure, atrial fibrillation, autistic disorder, severe protein-calorie malnutrition, hypertension, retention of urine, mild intellectual disabilities, sleep apnea, benign prostatic hyperplasia, penile hypospadias, anxiety disorder, major depressive disorder, insomnia, phobic anxiety disorder, penile hypospadias and Meniere's disease. Review of the resident's plan of care revealed no care plan addressing the resident's indwelling urinary…

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 ensure Resident #12's oxygen was humidified and respiratory equipment and supplies were stored and maintained properly. This affected one resident (Resident #12) of three residents reviewed for respiratory care. Findings include: Review of the medical record for Resident #12 revealed an initial admission date of 08/09/21 with the latest readmission of 03/28/23 with the admitting diagnoses of chronic obstructive pulmonary disease (COPD), sepsis, severe morbid obesity, chronic pulmonary edema, osteoarthritis, seasonal allergic rhinitis, chronic respiratory failure, congestive heart failure, atrial fibrillation, autistic disorder, severe protein-calorie malnutrition, hypertension, retention of urine, mild intellectual disabilities, sleep apnea, benign prostatic hyperplasia, penile hypospadias, anxiety disorder, major depressive disorder, insomnia, phobic anxiety disorder, penile hypospadias and Meniere's disease. Review of the plan of care dated 02/10/23 revealed the resident had altered respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure ongoing communication was maintained for Resident #82 between the facility and the hemodialysis center. This affected one resident (Resident #82) of one reviewed for dialysis. Findings Include: Review of the medical record for Resident #82 revealed an initial admission date of 12/02/22 with the latest readmission of 05/30/23 with the diagnoses of other disorders of lungs, protein-calorie malnutrition, sepsis due to Escherichia coli (Ecoli), toxic encephalopathy, hypertension, end stage renal disease (ESRD), urinary tract infection, diabetes mellitus, hyperlipidemia, hypothyroidism, atrial fibrillation, major depressive disorder, anemia, dysphagia, dependence on renal dialysis, anorexia, constipation, dry eye syndrome and pain. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. The resident was dependent on two staff for activities of daily living (ADL). 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 and record review, the facility failed to ensure Resident #87's medications were available for administration. This affected one resident (Resident #87) out of five residents reviewed for medication administration. Findings include: Resident #87 was admitted to the facility on [DATE]. Her diagnoses were mood disorder (05/22/23), anxiety disorder (03/21/23), dementia (03/18/23), type II diabetes, hyperlipidemia, disorder of kidney and ureter, major depressive disorder (03/18/23), psychotic disorder (03/18/23), pain, hypokalemia, opioid use, and need for assistance with personal care. Review of Resident #87's Minimum Data Set (MDS) assessment, dated 03/25/23, revealed she could not adequately answer the questions for her cognitive assessment. Review of Resident #87 Medication Administration Records (MAR), dated June 2023, revealed the following medications were not given due to not being available for administration: Buspirone 7.5 milligram (mg) twice daily on 06/05/23 (A.M. shift), Venlafaxine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of pharmacy recommendations, the facility failed to ensure pharmacy recommendations were accurately addressed. This affected one resident (#15) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 121. Findings include: Record review for Resident #15 revealed this resident was admitted to the facility on [DATE] and had diagnoses including reduced mobility, chronic kidney disease, type two diabetes mellitus, heart failure, altered mental status, adjustment disorder, fluid overload, history of falling, and unspecified dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 05/19/23, revealed this resident was unable to complete the interview indicated by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to be dependent upon two staff members for transfers, bed mobility, and toileting and to be dependent upon one staff member for eating. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident (#80) was properly monitored for side effects of anticoagulant use. This affected one of five residents reviewed for unnecessary medications. Findings Include: Review of the medical record for Resident #80 revealed an initial admission date of 10/26/19 with the most recent readmission of 05/03/21 with diagnoses including chronic obstructive pulmonary disease (COPD), restlessness and agitation, intermittent explosive disorder, functional dyspepsia, schizoaffective disorder, vitamin D deficiency, mood disorder, major depressive disorder, benign prostatic hyperplasia, altered mental status, seasonal allergic rhinitis, chronic pain syndrome, constipation, heart failure, atrial fibrillation, seizures, encephalopathy, diabetes mellitus, alcohol dependence, anemia, insomnia, peripheral autonomic neuropathy, hyperlipidemia, retention of urine and gastro-esophageal reflux disease. Review of the plan of care dated 04/07/23 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure the medication error rate was below five percent during medication administration. There were four medication errors out of 26 opportunities observed, resulting in 15.38% (percent) medication error rate. This affected two residents (#31 and #80) observed during medication administration. The facility census was 121. Findings include: 1. Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses including heart failure and hypertension. Review of Resident #31's annual Minimum Data Set (MDS) assessment, dated 04/13/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10. This resident was assessed to be independent for bed mobility, to require extensive assistance from one staff member for bed mobility, and to require limited assistance from one staff member for transfers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy review, the facility failed to ensure Resident #26 was free from significant medication error. This affected one resident (#26) out of five residents reviewed for medication administration. Findings include: Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] and had diagnoses including type two diabetes mellitus and seizures. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting and to be independent with setup help only for eating. Review of the care plan, dated 02/09/23, revealed this resident had diabetes mellitus. Interventions included to administer medications and insulin as ordered. Review of the care plan, dated 03/10/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure medications were appropriately stored. This affected two residents (#51 and #98) who were observed to have medications unattended by staff at bedside during the annual survey. The facility census was 121. Findings include: 1. Record review for Resident #98 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dysphagia, altered mental status, and dementia. Review of the active physicians orders for this resident revealed the resident was prescribed Norvasc (an antihypertensive medication) and Plavix (an antiplatelet medication). Observation and interview on 06/05/23 at 10:28 A.M. revealed Resident #98 was sitting up in bed without any staff members present in the room and had two round, white pills lying on the over-the-bed table. Resident #98 asked what the medications were. Registered Nurse (RN) #96 was called to the room and verified there were two round, white…

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.