Jag Healthcare Mansfield

Based on observation and interview, the facility failed to puree food items to a smooth texture with no chunks of food remaining. This had the potential to affect four residents, Resident #8, #20, #34, and #160, identified by the facility as receiving a pureed only diet. The facility census was 57. Findings include: Observation on 06/25/25 at 10:41 A.M. of processing pureed foods with [NAME] #247 revealed [NAME] #247 placed mixed vegetables in the food processor to puree the vegetables. When completed, [NAME] #247 placed the pureed vegetables in a metal pan and confirmed the vegetables were completed and ready to place on the steam table to serve. Observation revealed several visible small chunks throughout the pureed vegetables. Taste of the pureed vegetables revealed the chunks were the texture of several pieces of skin from the mixed vegetables that did not puree. [NAME] #247 confirmed the chunks of food in the pureed vegetables and confirmed that she was going to serve the residents the prepared pureed vegetables. Phone interview on 06/26/25 at 9:39 A.M. with Speech Therapist…

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 review of service provider quotes, the facility failed to maintain the function of the wheelchair automatic push pad door openers for the facility front entrance double doors. This affected 14 residents (#1, #6, #8, #15, #17, #19, #27, #28, #30, #37, #40, #43, #45, and #53) identified by the facility as independent with wheelchair mobility. The facility census was 57. Findings include Observations on 06/24/25 at 7:40 A.M., on 06/25/25 at 7:50 A.M., on 06/26/25 at 7:41 A.M., and on 06/30/25 at 7:45 A.M. revealed the wheelchair accessible push pads used to open the facility front entrance set of double doors were not in working order. Further observation revealed there was a doorbell outside of the facility by the outer set of exterior doors. Interview on 06/30/25 at 7:45 A.M., the Administrator verified the push pad buttons to open each set of the double doors were not working. Interview on 06/30/25 at 8:35 A.M., the Director of Maintenance (DOM) #278 revealed the openers for front door push pads were at the end of its life. DOM #278 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 review of the medical record, staff interview, and facility policy review, the facility failed to ensure resident code status was consistent throughout the medical record. This affected two (#26 and #110) of 20 residents reviewed for code status. The facility census was 57. Findings include 1. Review of the medical record for Resident #26 revealed an admission date of [DATE]. Diagnoses included paranoid schizophrenia, dementia, Parkinsonism, and Type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the electronic medical record (EMR) face sheet revealed the resident's code status was Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Further review of the EMR revealed no physician signed DNR form. Review of a physician order dated [DATE] revealed the resident's code status was DNRCC-A. Review of the care plan dated [DATE] revealed the resident/family had chosen a DNRCC-A order. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to assure missing items were investigated and followed up on for one resident, (Resident #32), of three residents reviewed for missing items. The facility census was 57. Findings include: Record review for Resident #32 revealed an admission date of 01/13/23. Diagnosis included Alzheimer's disease with late onset. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was severely cognitively impaired. Resident #32 was dependent for bed mobility, chair/bed chair transfers, and wheelchair mobility. Telephone interview on 06/24/25 at 10:07 A.M. with Resident #32's family member revealed Resident #32 was missing blankets, clothing items, and stuffed animals. Resident #32's family member revealed it had been a while, between a month or two but they did let the staff know. Resident #32's family member revealed they could not remember the staff names. Interview on 06/25/25 at 9:25 A.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy, the facility failed to complete a baseline care plan for one, (Resident #160) of eight reviewed for baseline care plans. The facility census was 57. Findings include: Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Resident #160 occasionally had pain and received scheduled and as needed (PRN) pain medications. Resident #160 had shortness of breath or trouble breathing with exertion…

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, resident interview, medical record review, review of the facility policy and review of the facility assessment, the facility failed to provide an individualized activity program designed to meet the interest and care needs of one resident (#16) of two residents reviewed for activities. The facility census was 52. Findings include: Review of Resident #16's medical record revealed an admission date of 04/02/25. Diagnoses included acquired absence of left leg below the knee, major depressive disorder, Diabetes Mellitus II with hyperglycemia and acquired absence of right foot. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #16 was cognitively intact. Resident #16 was dependent on staff for personal hygiene, lower body dressing, shower/bathing self and toileting. Review of Resident #16's care plan dated 04/07/25 revealed it did not have a care plan for activities. Interview 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 2. Review of the medical record for Resident #110 revealed an admission date of 06/13/25. Diagnoses included chronic pain, hemiplegia and hemiparesis, cerebral infarction, hypertension, atrial fibrillation, congestive heart failure, and narcissistic personality disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a wound assessment report dated 06/20/25 revealed the resident had bilateral lower extremity venous ulcers. Review of a physician order dated 06/21/25 revealed to cleanse the bilateral lower extremities with wound cleanser, pat dry, apply ammonium lactate lotion to both lower legs topically, apply non-adhering dressing then a dry dressing over wounds, cover with an elastic tubular bandage and then wrap with and outer elastic bandage daily and as needed for venous ulcer wound care. Observation on 06/23/25 at 12:30 P.M. revealed Resident #110 had elastic bandages covering his bilateral lower extremities from below the knees…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review revealed the facility failed to ensure an indwelling catheter for one resident, Resident #160 was addressed timely to include a physical assessment and reinsertion when Resident #160 removed the catheter. The facility also failed to notify the primary care physician of the catheter and failed to notify the primary care physician and Hospice provider of the results of a urinalysis timely that resulted in bacterial growth requiring treatment of an antibiotic. This affected one resident, Resident #160 and had the potential to affect an additional seven residents, Resident #5, #26, #35, #36, #40, #43, and #50 identified by the facility as having indwelling catheters. The facility census was 57. Findings include: Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, Absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy, the facility failed to ensure a resident with significant weight loss received timely follow up and the physician was notified. This affected one, (#30) of two residents reviewed for weight loss. The facility census was 57. Findings include: Record review for Resident #30 revealed an admission date of 03/11/25. Diagnoses included end stage renal disease (ESRD), unspecified protein calorie malnutrition, hypothyroidism, and Type Two Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had a weight loss of five percent (%) or more in the last month or loss of 10 % or more in the last six months. Review of the care plan for Resident #30 dated 05/07/25 revealed Resident #30 had a nutritional problem or potential nutritional problems related to ESRD, dialysis, low serum albumin levels, overweight, diabetes, chronic obstructive pulmonary disease (COPD) and diagnosis…

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 for Resident #160 revealed an admission date of 05/28/25. Diagnosis included heart failure, obesity, and diabetes mellitus with diabetic polyneuropathy. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had shortness of breath or trouble breathing with exertion and when lying flat. Review of the care plan for Resident #160 dated 06/23/25 revealed Resident #160 utilized oxygen therapy related to congestive heart failure, shortness of breath and asthma. Interventions included oxygen settings two to five liters as needed or SP02 less than 90%. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 for oxygen two to five liters as needed for shortness of breath or SPO2 less than 90 %. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure the medication error rate did not exceed five percent (%). Two errors occurred for 31 observed opportunities for an error rate of 6.45%. This affected two residents (#12 and #161) of five residents reviewed for medication administration. This had the potential to affect an additional 10 residents (#3, #8, #11, #14, #16, #27, #28, #30, #43, and #57) who received insulin via insulin pen. The facility census was 57. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 10/02/24. Diagnoses include Alzheimer's disease, altered mental status, atrial fibrillation, hypertension, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #12's physician orders revealed an order for Cosopt Ophthalmic Solution 2-0.5%. Instill one drop in both eyes two times a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #56 revealed an admission date of 04/07/25 and a discharge date of 06/02/25. Diagnoses included pneumonia, acute respiratory failure with hypoxia, heart failure, hypertension, chronic obstructive pulmonary disease, and Alzheimer's disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of the physician orders dated 04/08/25 revealed an order for Lasix 20 milligrams, one tablet by mouth every 24 hours as needed for edema or greater than three-pound weight gain in 24 hours, weigh daily in the morning, if greater than three-pound weight gain, give the as needed Lasix. Review of the Medication Administration Record (MAR) dated 05/01/25 through 06/02/25 revealed Resident #56 was not weighed per physician orders on 05/01/25, 05/12/25, 05/13/25, 05/16/25, 05/17/25, 05/18/25, 05/20/25, 05/21/25, 05/22/25, 05/26/25, 05/27/25, and 05/30/25. Further review of the MAR revealed on 05/03/25 the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure all required personal protective equipment was available and used for residents on contact precautions, failed to implement enhanced barrier precautions as required, and failed to ensure residents were screened for tuberculosis infection as required. This affected four (#10, #30, #50, and #60) of five residents reviewed for infection control practices. The census was 41. Findings Include: 1. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with the most recent readmission on [DATE]. Diagnoses include osteomyelitis of the shoulder, bacteremia, extended spectrum beta lactamase (ESBL) resistance , klebsiella pneumoniae, methicillin susceptible staphylococcus aureus infection, pseudomonas, pneumonia, chronic obstructive pulmonary disease, depression, atrial fibrillation, and fusion of spine. Review of the most recent quarterly Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were offered influenza vaccinations annually as required. This affected one (#40) of five residents reviewed for influenza vaccinations. The facility census was 41. Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, type two diabetes, dementia, anemia, delusional disorder, auditory hallucinations, and complete traumatic amputation of the left lower leg at the knee level. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact. The resident was coded to not receive the influenza vaccination as it was not offered and the pneumococcal vaccination was coded as up to date. Review of Resident #40's vaccination documentated revealed the resident's the last documented influenza vaccination was dated 10/14/22. Interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and facility staff interview, the facility failed to offer the vaccination or obtain documentation of residents' SARS-CoV2 (COVID-19) vaccination status for three (#10, #30, and #50) of five residents reviewed for vaccinations. The facility census was 41. Findings Include: 1. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with the most recent readmission on [DATE]. Diagnoses include osteomyelitis of the shoulder, bacteremia, extended spectrum beta lactamase resistance (ESBL), klebsiella pneumoniae, methicillin susceptible staphylococcus aureus infection, pseudomonas, pneumonia, chronic obstructive pulmonary disease, depression, atrial fibrillation, and fusion of the spine. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of Resident #10's vaccination documentation revealed there was no documented COVID-19 vaccinations, history of vaccinations, or declination…

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, facility policy review and interview, the facility failed to ensure resident mail was delivered to residents unopened and failed to ensure residents had access to a private working telephone. This affected 11 residents (#14, #15, #23, #24, #18, #30, #35, #39, #41, #52 and #55) and had the potential to affect all 56 residents residing in the facility. Findings include: 1. Observation on 04/01/24 at 8:10 A.M. of Business Office Manager (BOM) #831's desk revealed a stack of opened resident mail addressed and belonging to Resident #15, #18, #30, #35, #39, #41 and #55 who currently reside in the facility. Interview on 04/01/24 at 8:35 A.M. with BOM #831 revealed Chief Executive Officer (CEO) #805 had opened the resident mail. Interview on 04/01/24 at 4:50 P.M. with CEO #805 revealed he opened resident mail, but only Medicaid and Medicare mail because he thought that was allowed. He stated he would open the envelopes and place them on BOM #831's desk. He denied reading the mail addressed to residents and stated he only opened the mail. Review of the undated facility…

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

Based on record review, review of the facility assessment, policy review and interview, the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents due to a hostile work environment and insufficient funds to maintain staffing agency contracts. This had the potential to affect all 56 residents residing in the facility. Findings include: Interview on 03/26/24 at 8:36 A.M. with Scheduler #821 revealed with the use of agency staff, there was enough nursing staff as of this date but the facility was not paying the staffing agency bills and they would no longer be able to use agency staff as of 04/01/24. Scheduler #821 indicated the facility did not have enough of their own employed nurses to cover open shifts from 04/01/24 to 04/30/24. Interview on 03/26/24 at 9:45 A.M. with Chief Executive Officer (CEO) #805 revealed the facility had cash flow problems. CEO #805 revealed the facility had enough State Tested Nursing Assistants (STNAs) but relied on agency staffing for open nursing shifts. Interview on 03/26/24 at 10:39 A.M. with Former Minimum…

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

Based on record review and interview, the facility failed to ensure a registered nurse (RN) served as a full-time director of nursing (DON). This had the potential to affect all 56 residents residing in the facility. Findings include: Review of the facility Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) form from 12/01/23 to 12/31/23 revealed the previous DON worked 7.50 hours on 12/01/23 and 6.75 hours on 12/02/23. Interview on 03/26/24 at 7:38 A.M. with the Administrator confirmed the facility was without a DON from 12/03/23 to 03/18/24 when another (interim) DON was brought into the building. The Administrator confirmed the RN staff currently working in the building did not want to take on the role as a full-time DON. Interview on 03/26/24 at 1:10 P.M. with the current Interim DON confirmed her first day worked in the facility was 03/18/24. Interview on 04/03/24 at 11:40 A.M. with the Interim DON revealed her last date of work in the facility was scheduled to be 04/18/24 and she requested her staffing agency to provide her with a new assignment. 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 record review and interview, the facility failed to ensure residents were provided with rehabilitative services such as but not limited to physical therapy, speech-language pathology and occupational therapy. This affected 19 residents (#3, #4, #6, #7, #8, #12, #13, #14, #19, #20, #23, #26, #30, #37, #44, #51, #55, #106, #107 and #108) and had the potential to affect all 56 residents residing in the facility. Findings include: 1. Review of the master therapy list revealed 20 residents were currently on therapy caseload/services including Resident #3, #4, #6, #7, #8, #12, #13, #14, #19, #20, #23, #26, #30, #37, #44, #51, #55, #106, #107 and #108. Review of an email from Therapy Credit Manager #847 from the facility contracted therapy department dated 03/28/24 at 1:53 P.M. revealed this vendor had not heard from anyone (from the facility) regarding payment or a plan to get current. On 04/01/24 at 1:50 P.M. an interview with Therapy Credit Manager #847 revealed the facility was outside their contracted…

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, facility policy review, administrator agreement review, and interview, the facility failed to ensure an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 56 residents in the facility. Findings include: Interview on 03/26/24 at 7:38 A.M. with the Administrator revealed she began her employment with the facility on 03/20/23. During the interview she indicated she did not handle any financial aspects of the facility. The Administrator indicated the facility was a non-profit facility with a Board of Directors and Chief Executive Officer (CEO) #805 was responsible for the financial aspect of the facility including paying vendors. Interview on 03/26/24 at 9:45 A.M. with CEO #805 revealed the facility had cash-flow problems and the facility was on payment plans with multiple vendors. CEO #805 stated he handled the financial aspect of the facility…

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 policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all 56 facility residents. Findings include: A telephone interview on 04/01/24 at 1:41 P.M. with the Medical Director revealed he was not aware of the facility in arrears in payments. He denied concerns with residents having enough supplies, food, medications, or resident care. The Medical Director confirmed he had a quarterly Quality Assurance/Performance Improvement (QAPI) meeting the week prior and the facility did not bring up any issues with the inability to pay vendors. The Medical Director stated he was not involved in the financial side of the facility. Interview on 04/01/24 at 4:06 P.M. with Chief Executive Officer (CEO) #805 revealed the facility had a cash flow issue due to changes in management. CEO #805 indicated the…

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

Based on record review and interview, the facility failed to provide residents with quarterly statements of their resident trust fund account. This affected eighteen residents (#15, #17, #20, #28, #30, #31, #33, #35, #36, #39, #41, #43, #44, #46, #47, #51, #53, and #55) of eighteen residents with resident fund accounts. Findings include: Review of the Trust-Current Account Balance form (resident trust funds) dated 04/01/24 revealed eighteen residents including Resident #15, #17, #20, #28, #30, #31, #33, #35, #36, #39, #41, #43, #44, #46, #47, #51, #53, and #55 were not provided quarterly balance statements from their resident trust fund account. Interview on 04/0124 at 10:01 A.M. with the Administrator confirmed quarterly statements identifying the balance on resident trust fund accounts were not provided to the residents. When questioned, she could not state when the last quarterly statements were issued to the resident/resident representatives. On 04/11/24 from 9:02 A.M. to 9:05 A.M. interviews with Residents #31 and #48 denied receiving quarterly resident fund statements. 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 record review and interview, the facility failed to ensure monies in a resident fund account were finalized and dispersed within 30 days as required. This affected seven residents (#92, #93, #94, #95, #96, #97 and #98) of 12 discharged residents who the facility managed a resident fund account. Findings include: 1. Review of Resident #92's medical record revealed the resident was admitted on [DATE] and discharged on 12/15/23 with diagnoses including Alzheimer's disease, need for assistance with personal care and muscle weakness. Review of Resident #92's progress note dated 12/14/23 at 10:07 P.M. indicated the nurse called the hospital and the resident was admitted for sepsis. The resident did not return to the facility. Review of the Trust-Current Account Balance form (resident fund accounts) dated 04/01/24 revealed Resident #92 had a resident fund balance of $40.00. Interview on 04/01/24 at 12:05 P.M. with Business Office Manager (BOM) #831 confirmed Resident #92's trust fund monies were not returned…

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 residents admitted to the facility were provided a description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources as well as information concerning Medicare and Medicaid eligibility and coverage. This finding affected 41 residents (#2, #3, #5, #6, #7, #9, #10, #11, #14, #21, #27, #34, #35, #45, #48, #104, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, #131, #132 and #133) of 100 residents whose records were reviewed for admission documentation. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses including hypertension, heart failure and chronic kidney disease. Review of Resident #2's admission documentation revealed the resident and/or representative did not sign the Consent to Treatment and Other…

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 initial comprehensive assessments were completed timely and as required. This affected seven residents (#3, #5, #11, #22, #45, #130 and #133) of 24 residents reviewed for comprehensive assessments. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including non-traumatic subarachnoid hemorrhage, diabetes and hypertension. Review of Resident #3's admission Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the assessment was in progress. Interview on 04/01/24 at 8:10 A.M. with Business Office Manager (BOM) #831 confirmed Resident #3's comprehensive assessment was not completed timely. 2. Review of Resident #5's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including acute kidney failure with acute cortical necrosis, chronic obstructive pulmonary disease and hypertension. Review of Resident #5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were completed quarterly as required. This affected four residents (#13, #33, #90 and #126) of 24 residents reviewed for comprehensive assessments. Findings include: 1. Review of Resident #13's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, other lack of coordination and diabetes. Review of Resident #13's Quarterly Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the comprehensive assessment was in progress. Interview on 04/01/24 at 8:10 A.M. with Business Office Manager (BOM) #831 confirmed Resident #13's comprehensive assessment was not completed timely. 2. Review of Resident #33's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, muscle wasting and major depressive…

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, facility policy review and interview, the facility failed to ensure Resident #90's discharge summary included the reconciliation of the resident's medications upon discharge. This affected one resident (#90) of one resident record reviewed for discharge. Findings include: Review of Resident #90's medical record revealed the resident was admitted on [DATE] and discharged on 02/16/24 with diagnoses including Parkinson's disease, heart failure and anemia. Review of Resident #90's progress note dated 11/24/23 at 8:59 P.M. revealed the resident arrived at the facility alert times two with confusion. Review of Resident #90's progress note dated 02/16/24 authored by Social Service Designee (SSD) #828 revealed the resident was discharged to an assisted living by the wife and son. Hospice was updated. Review of Resident #90's Discharge Plan of Care form (Discharge Summary) dated 02/16/24 revealed the resident's medications were not reconciled to include the resident's current medications as well…

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 provide Resident #29 food items as ordered/planned. This affected one resident (#29) of three residents reviewed for dietary services. Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anemia and dysphagia oropharyngeal phase. Review of Resident #29's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #29's physician's orders revealed an order dated 10/12/23 for a regular diet, pureed texture, thin liquids with no straw. The resident also had a physician's order, dated 01/26/23 for ice cream with all meals. Review of Resident #29's Nutritional Risk Assessment 10/15/23 revealed the resident was on a mechanical soft/thin liquids diet and continued Hospice services. Ice cream was offered at every meal with three ounces of med pass four times a day to prevent…

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

Based on observations, staff and resident interviews and policy review,the facility failed to ensure a comfortable hot water temperatures were maintained throughout the facility. This affected nine (#37, #14, #18, #26, #27, #35, #36, #45 and #46) out of 15 residents sampled for the physical environment. Facility census was 46. Findings include: Observation of the shower room, across from the nursing station on Unit #1 was completed on 12/21/23 at 7:34 A.M. at which time the hot water temperatures in the sink was tested at 100 degrees Fahrenheit (F). Maintenance Director #26 went into the shower room with the surveyor at 7:40 A.M. and the hot water would not get any higher that 80 degrees F. Maintenance Director #26 confirmed the facility has been having issues off and on with the hot water temperatures. Interview with State Tested Nursing Assistant (STNA) #41 on 12/21/23 at 7:32 A.M. revealed the hot water temperatures in the shower room and residents rooms on Unit #1 are all over the place, sometimes to hot and sometimes cold. Interview with STNA #101 on 12/21/23 at 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 review of resident Personal Needs account (PNA) and staff interviews, the facility failed to ensure a residents personal funds were conveyed within 30 days upon the death of a resident. This affected one (#94) of 24 residents (Resident #94), whom have PNA accounts set up with the facility. The facility census was 43. Findings include: Review of the facility PNA accounts identified Resident #94 was admitted to the facility on [DATE]. Resident #94 expired in the facility on [DATE], with a balance of $70.00 in her account. The balance was not conveyed to Resident #94's family until the check was written for [DATE]. Interview with the Business Office Manager (BOM) #91 on [DATE] at 2:28 P.M. confirmed she thought the requirement was for 60 days and therefore the balance was late getting returned to Resident #94's estate.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews and staff interviews, the facility failed to ensure the residents Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's status. This affected one (#19) of 12 residents sampled during the survey. The facility census was 43. Findings include: Review of Resident #19's medical record identified admission to the facility on [DATE] with medical diagnosis including anxiety, chronic pain, morbid obesity and bilateral lower leg lymphedema. Resident #19 is cognitively intact and able to answer all questions and make needs known. Review of Resident #19's quarterly minimum data set (MDS) dated [DATE] identified sections C and D were not completed with the residents input. Section C of the MDS assesses for cognition and Section D assesses for resident mood and behavior. Interview with Registered Nurse (RN) #96 on 08/16/22 at 7:39 A.M. confirmed that she completes the MDS assessments for the residents. RN #96 confirmed sections C and D on Resident #19's 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.

Based on medical record review and resident and staff interviews, the facility failed to ensure residents were invited to attend care conferences and/or meetings regarding their care. This affected one (#19) of 12 sampled residents. The facility census was 43. Findings include: Review of Resident #19's medical record identified admission to the facility occurred on 12/25/21. Resident #19 had medical diagnosis including anxiety, chronic pain, morbid obesity, lymphedema and chronic foot infections. Resident #19 was identified as being cognitively intact. Review of Resident #19's medical record identified a care conference was held on 02/02/22 at which time Resident #19 and her husband attended. The record identified no additional meetings were held until 07/14/22. The care plan meeting notes identified the facility staff participated (dietary, social services and nursing manager) in the meeting; however, Resident #19 and her husband did not. The notes identified no evidence Resident #19 and her husband were invited to participate in the meeting. Interview with Resident #19 on 08/15/22…

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, observations and staff and resident interviews, the facility failed to ensure a residents wound care was completed as physician ordered. This affected one (#19) out of 12 sampled residents. The facility census was 43. Findings include: Review of Resident #19's medical record identified admission to the facility occurred on 12/25/21. Resident #19 had medical diagnosis including anxiety, chronic pain, morbid obesity, lymphedema and chronic foot infections. Resident #19 was identified as cognitively intact. Review of Resident #19's medical record identified on 06/30/22 the physician ordered clean open, seeping areas to the right lower leg, apply non-stick protective dressing and wrap with kerlix, change daily and as needed. Interview with Resident #19 on 08/15/22 at 10:25 A.M. revealed she has open, draining lymphedema to her right calf area. Resident #19 identified nursing staff are not putting a dressing on the area as the physician ordered. Resident #19 identified some nurses will do the dressing and others say it should be open to air and they do not…

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

Based on medical record review, staff interviews and policy review, the facility failed to ensure residents were free from unnecessary medications when the facility administered medications outside of the physician ordered parameters. This affected two (#1 and #42) out of five residents reviewed for unnecessary medications. The facility census was 43. Findings include: 1. Review of Resident #1's medical record identified admission to the facility occurred on 04/20/22 with medical diagnosis including; cirrhosis of the liver with ascites, low blood pressure (BP) and malnutrition. Resident #1 was receiving hospice care for end of life since 05/13/22. Review of Resident #1's medication regimen for the month of August 2022 revealed the resident was ordered Midodrine HCL five mg three times a day. Further review of orders revealed the Midodrine HCL five mg was to be held if the systolic blood pressure (BP) was above 100 and the diastolic BP was above 70 (systolic BP is identified as the top number and diastolic BP is identified as the bottom number). Review of Resident #1'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.

Based on observations, staff interview and review of maintenance report, the facility failed to provide a safe homelike environment for all residents. This affected three (#11, #31 and #42) out of 43 resident rooms observed during the survey. The facility census is 43. Finding Include: Observation on 08/15/22 at 10:34 A.M. of Resident #11's room revealed the wall behind resident's bed had two large areas of paint pealed off the wall and multiply gouged marks, revealing drywall. Observation on 08/15/22 at 10:58 A.M. of Resident #31's room revealed the air condition vents broken and missing. Observation on 08/15/22 at 11:00 A.M. of Resident #42's room revealed the air condition vents were broke and missing. Interview and observation on 08/16/22 at 2:26 P.M. with Maintenance Director #100 revealed housekeeping and nursing staff are to fill out maintenance forms, when they see areas in the facility that needs repaired. Maintenance Director #100 verified the air condition vents were broken in Resident #31 and #42's room and the wall in Resident #11's room had gouged walls and peeling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, review of a maintenance task list and policy review, the facility failed to ensure an effective pest control program was in place to ensure a resident's room did not have an infestation of flies. This affected one (#36) out of 12 sampled residents for pest control. The facility census was 43. Finding include: Review of Resident #36's medical record identified admission to the facility on [DATE] with medical diagnosis including; dementia, liver cancer with metastasis, major depression and Alzheimer's disease. Resident #36 started hospice services starting on 08/11/22 for end of life care. Observations of Resident #36 on 08/15/22 at 10:56 A.M. The observation revealed approximately five flies crawling on Resident #36's blankets and bed. Observations of Resident #36 on 08/16/22 at 6:47 A.M., 8:12 A.M. and 8:23 A.M. Resident #36 room was observed with multiple flies on or near the bed. Observation of Resident #36 on 08/16/22 at 10:21 A.M. with 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 observation, staff interview and record review, the facility failed to ensure food service equipment was maintained in a sanitary manner and resident food items were dated and labeled. This affected 66 of 67 residents who receive food from the kitchen (Resident #17 received nothing by mouth). The facility census was 67. Findings include: 1. Observation on 08/25/19 at 8:40 A.M. revealed a white substance on Cereal #1, Cereal #2, Cereal #3 and Cereal #4's cereal dispensers as well as a brownish substance with a hardened clear drip on the tip of the thickened juice dispenser. Observation on 08/25/19 at 8:46 A.M. revealed a white substance around the outside of the hot water dispenser as well as a brownish substance around the outside of the coffee dispenser. Interview with Dietary Manager #149 on 08/25/19 at 9:02 A.M. verified the above findings. 2. Observation of the station one refrigerator on 08/27/19 at 12:58 P.M. revealed resident food items which included mashed potatoes, meatloaf, vegetable stew and ranch dressing. All of these items were neither labeled nor dated.…

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

Based on medical record review, observation, staff interview and review of facility policy and procedure, the facility failed to notify the physician timely when Resident #58's had new onset of swelling/edema. This affected one (#58) of one resident reviewed for edema. The facility census was 67. Findings include: Review of Resident #58's medical record revealed an admission date of 07/05/19. Diagnoses included muscle weakness, difficulty walking, right femur stress fracture, Atrial Fibrillation (A-Fib) and high blood pressure (HTN). Review of the Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had impaired cognition, required total dependence on one staff for transfers and extensive assistance of one staff for personal hygiene. Review of Resident #58's hospital documentation from 06/30/19 through 07/02/19 revealed no documented evidence of edema or swelling to the residents lower extremities prior to admission at the facility. Review of the resident's physician orders, dated 07/05/19, revealed orders for Lasix (a diuretic medication) 20 milligrams (mg)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain a wheelchair cushion clean and in good repair for one (Resident #13) of 20 residents reviewed for maintenance and cleanliness of resident equipment and supplies. The facility census was 67. Findings include: Review of Resident #13's medical record revealed she admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, anxiety, major depressive disorder and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/09/19, revealed Resident #13 had a severe cognitive impairment. Observations on 08/26/19 at 8:14 A.M., 08/26/19 at 11:31 A.M. and 08/26/19 at 2:17 P.M. revealed Resident #13's wheelchair cushion was dirty with apparent stains and had an eight inch rip along the seam and exposing the cushion. Interview on 08/26/19 at 2:25 P.M. with State-Tested Nursing Assistant (STNA) #98 confirmed Resident #13's wheelchair cushion was dirty with apparent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of facility's Self-Reported Incident, medical record review and review of facility policy, the facility failed to prevent physical abuse for one (Resident #22) of two residents reviewed for abuse. The facility census was 67. Findings include: Review of Resident #22's medical record revealed she admitted to the facility on [DATE] with diagnoses including: major depressive disorder and a history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/02/19, revealed Resident #22 was moderately cognitively impaired. Resident #22 was receiving hospice services and required extensive assistance with activities of daily living. Review of the facility's Self-Reported Incident (SRI), dated 08/17/19, revealed it was an allegation of physical abuse. Resident #34 informed State-Tested Nursing Aid (STNA) #215 around 6:30 A.M. on 08/17/19 that she had smacked Resident #22's hand and had spilled her water at dinner the previous night. Licensed Practical Nurse (LPN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of facility's Self-Reported Incident, review of medical records and review of facility policy, the facility failed to thoroughly investigate an allegation of physical abuse for one (Resident #22) of two residents reviewed for abuse. The facility census was 67. Findings include: Review of Resident #22's medical record revealed she admitted to the facility on [DATE] with diagnoses including: major depressive disorder and a history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/02/19, revealed Resident #22 was moderately cognitively impaired. Resident #22 was receiving hospice services and required extensive assistance with activities of daily living. Review of the facility's Self-Reported Incident (SRI), dated 08/17/19, revealed it was an allegation of physical abuse. Resident #34 informed State-Tested Nursing Aid (STNA) #215 around 6:30 A.M. on 08/17/19 that she had smacked Resident #22's hand and had spilled her water at dinner the previous…

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, resident and staff interview, review of the Resident Assessment Instrument (RAI) and review of the medical record, the facility failed to complete accurate Minimum Data Set (MDS) assessments for two (Resident #11 and #20) of 20 residents reviewed for accurate MDS assessments. The census was 67. Findings include: 1. Record review for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphagia and dementia. Review of Resident #11's care plan, dated 07/10/18, revealed he had broken teeth related to poor oral hygiene. Review of the MDS assessment, dated 07/06/19, revealed he was cognitively intact. The MDS also stated that Resident #11 had no broken natural teeth. Interview and observation on 08/25/19 at 9:46 A.M. revealed Resident #11 stated he has had a broken tooth for a couple years. Observation of the resident's mouth revealed Resident #11's top left tooth was broken. Interview on 08/26/19 at 3:15 P.M. with MDS Coordinator #196 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 medical record review, observation, family interview, staff interview and review of facility policy and procedure, the facility failed to assess and monitor Resident's #40's ongoing scab to his nose. This affected one (#40) of one resident reviewed for skin conditions. The facility census was 67. Findings include: Record review for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included anemia, dementia with behavioral disturbance, major depressive disorder, anxiety, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 06/06/19, revealed he was severely cognitively impaired. Review of Resident #40's skin assessments from 04/18/19 through 08/25/19 revealed no evidence of Resident #40's scab or picking at his scab. Observations on 08/25/19 at 1:28 P.M., 08/26/19 at 8:12 A.M., 08/26/19 at 10:09 A.M., 08/26/19 at 11:37 A.M., 08/26/19 at 2:30 P.M., and 08/27/19 at 11:09 A.M. revealed a pea-sized brown scab on the tip of Resident…

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

Based on medical record review, resident interview, staff interview, and review of facility policy and procedure, the facility failed to re-assess Resident #36's pain after the discontinuation of a pain relieving medicated patch. This affected one resident (#36) of one resident reviewed for pain management. The facility identified 30 residents on a pain management program. The facility census was 67. Findings include: Review of Resident #36's medical record revealed a admission date of 09/18/18. Diagnoses included osteoporosis, difficulty walking, altered mental status, testicular pain and kidney stones. Review of the care plan, dated 06/05/19, revealed the resident had chronic neck pain with interventions to monitor, record and report complaints of pain and notify the physician if interventions were unsuccessful or if there was a significant change from the residents past experience of pain. Review of the Minimum Data Set (MDS) assessment, dated 06/25/19, revealed the resident had intact cognition and he had frequent pain. The MDS assessment, dated 08/19/19, revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of facility policy and procedure, the facility failed to maintain infection control after personal care for three residents. This affected three (#40, #52 and #120) of three residents reviewed for urinary tract infections. The facility identified three residents with indwelling urinary catheters. The census was 67. Findings include: 1. Review of Resident #40's medical record revealed an admission date of 10/08/09 and the diagnoses of obstructive and reflux uropathy. Review of the physician orders revealed an order for indwelling urinary catheter care every shift. Review of the Minimum Data Set (MDS) assessment, dated 06/06/19, revealed the resident had an indwelling catheter. The resident's care revealed the indwelling catheter was in place due to diagnoses of obstructive uropathy with interventions for catheter care every shift per orders. An observation on 08/26/19 from 1:15 P.M. through 1:30 P.M. of perineal care and catheter care 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.