Marietta Heights Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident/representative interview, staff interview, policy review, record review, and review of binding arbitration agreements, the facility failed to ensure binding arbitration agreements were explained to residents/representatives in a manner that they understood and included an explanation that they were giving up the right to litigation in a court proceeding and could withdraw/terminate the agreement within 30 days after signing. This affected five residents (#2, #7, #10, #17, and #19) of six residents reviewed for arbitration agreements. The facility census was 38.Findings Include:The facility Administrator identified, with a list, that all 38 residents in the facility had signed a binding arbitration agreement. 1. Review of the record for Resident #7 revealed a readmission date of 11/25/25. A Minimum Data Set (MDS) assessment on 12/19/25 indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of a Binding Arbitration Agreement revealed it indicated…

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, policy review, and interview, the facility failed to ensure a resident was provided a dignified dining experience. This affected one resident (#6) of five residents observed for dining. The facility census was 38.Findings include: Review of Resident #6's medical record revealed a 01/28/25 admission with diagnoses including atrial fibrillation, hypertension, vascular dementia with behavioral disturbance, hypothyroidism, anemia, Vitamin D deficiency, vascular dementia, mood disturbance, depression, history of falling, insomnia, dysphagia, abnormalities of gait and mobility, long term use of anticoagulants, hypokalemia, muscle weakness and cognitive communication deficit. Review of the resident's Activity of Daily Living/Mobility plan of care included the resident required assistance related to weakness, and impaired mobility. Interventions included the resident will have needs anticipated and met by staff. Eating: Up to supervision/verbal cues with assist of one for task initiation and follow through initiated: 02/03/25 revision on: 12/17/25. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, policy review, and facility CQI/QA Assessment Tool review, the facility failed to ensure an allegation of neglect/mistreatment was reported to the State Survey Agency as required. This affected one resident (#15) of three residents reviewed for abuse/neglect/mistreatment. The facility census was 38.Findings include: Interview with Resident #15's husband on 02/23/26 at 2:12 P.M. revealed that a few weeks ago, one staff person assisted the resident to the bathroom when there should have been two staff assisting with the use of a lift. He stated the resident fell in the bathroom with resulting bruising to her waist area.Review of the medical record for Resident #15 revealed an admission date of 12/31/24 and diagnoses including chronic obstructive pulmonary disease, diabetes, cirrhosis of the liver, Crohn's disease, and vascular dementia.The resident had a physician's order dated 10/14/25 that stated the resident was to be a two person assist with the use of a sit to stand lift…

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 Minimum Data Set (MDS) assessments were accurately coded related to dental and vision. This affected two residents (#6 and #38) of 13 residents reviewed for accuracy of assessments.Findings include:1. Review of Resident #6's medical record revealed a 01/28/25 admission with diagnoses including atrial fibrillation, hypertension, vascular dementia with behavioral disturbance, hypothyroidism, anemia, Vitamin D deficiency, vascular dementia, mood disturbance, depression, history of falling, insomnia, dysphagia, abnormalities of gait and mobility, long term use of anticoagulants, hypokalemia, muscle weakness and cognitive communication deficit. Review of the 01/25/26 impaired visual function plan of care included the resident wears prescription glasses. Interventions included to keep glasses within reach of resident. Resident has impaired visual function. Resident wears prescription glasses, with history of conjunctivitis, and allergies. Review of the 01/25/25 dental plan of care included resident has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and policy review the facility failed to ensure care plans were revised to reflect current activities and discharge planning. This affected two (Resident #18 and #22) of 13 records reviewed. The facility census was 38. Findings include: 1.Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure with hypercapnia, obstructive sleep apnea, dependence of supplemental oxygen, congestive heart failure, morbid obesity due to excess calories, essential hypertension, iron deficiency anemia secondary to blood loss, nonalcoholic steatohepatitis, personal history of disease of the digestive system, anxiety, unsteadiness on feet, need for assistance with personal care, edema, muscle weakness, pain in unspecified knee, insomnia, unilateral primary osteoarthrosis, left knee, long term use of non-steroidal anti-inflammatory, gastro-esophageal reflux disease without esophagitis, and depression. Review of Resident…

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

Based on observation, record review and interview, the facility failed to ensure a dependent resident was provided adequate and appropriate denture care. This affected one (Resident #6) of five residents reviewed for dental care. The facility census was 38. Findings include: Review of Resident #6's medical record revealed an admission date of 01/28/25 with diagnoses including atrial fibrillation, vascular dementia with behavioral disturbance, mood disturbance, depression, history of falling, insomnia, dysphagia (difficulty swallowing), abnormalities of gait and mobility, muscle weakness and cognitive communication deficit. Review of the 01/25/25 dental plan of care included the resident had oral/dental health problems. Resident is edentulous with upper and lower dentures. No complaint of pain or discomfort related to dentures. Monitor/document/report to physician as needed oral/dental problems needing attention. Review of the 01/25/25 Activity of Daily Living (ADL)/Mobiity plan of care revealed the resident was at risk for ADL/mobility decline and required assistance 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 medical record review, observation, and interview the facility failed to provide a comprehensive, resident centered activity program to meet resident needs. This affected one (Resident #22) of two residents reviewed for activities. The facility census was 38. Findings include: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnosis including obstructive sleep apnea, dependence of supplemental oxygen, congestive heart failure, morbid obesity due to excess calories, anxiety, unsteadiness on feet, need for assistance with personal care, muscle weakness, pain in unspecified knee, insomnia, unilateral primary osteoarthrosis, left knee, and depression. Review of consulting behavioral health note from the former consulting Licensed Social Worker #577 dated 08/01/25 revealed the resident was seen for anxiety, depression, mental health history, and substance use/recovery support. The resident was alert and oriented times four and open and cooperative. The resident was seen today…

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 ophthalmology services as ordered and assist the resident with the application of their glasses. This affected one (Resident #38) of four residents reviewed for vision. The facility census was 38. Findings include:Review of Resident #38's medical record revealed an admission date of 11/15/23 with diagnoses including sensorineural hearing loss bilaterally, visual hallucinations, abnormalities of gait and mobility, diabetes mellitus, need for assistance with personal care, age related nuclear cataracts bilaterally, dry eye syndrome, dementia, long term use of insulin, psychotic disturbance, anxiety, hypothyroidism, Alzheimer's disease, cognitive communication deficit and muscle weakness.Review of a 01/25/24 Impaired Visual Function plan of care related to impaired peripheral vision, cataracts bilateral, dry eyes bilateral, wears glasses, and wants surgery for cataracts was revised 10/09/25. Interventions included to keep glasses within reach of the resident. Resident has impaired visual function. Patient wears…

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 pressure relieving devices (Prevalon boots) in place as ordered. This affected one resident (#38) of three residents reviewed for pressure ulcers. Findings Include: Review of Resident #38's record revealed an admission date of 11/15/23 with diagnoses including sensorineural hearing loss bilaterally, visual hallucinations, acute pyelonephritis, abnormalities of gait and mobility, diabetes mellitus, altered mental status, neuromuscular disfunction, need for assistance with personal care, chronic pain, presence of artificial hip joint, osteoarthritis, neuropathy, dementia, mood disturbance, anxiety, hypothyroidism, Alzheimer's disease, cognitive communication deficit and muscle weakness. Review of the Resident #38's care plan dated 03/31/24 revealed the resident had the potential for an alteration in skin integrity/pressure ulcers related to history of skin breakdown, immobility, incontinence, use of neck pillow while in bed, 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 medical record review, interviews, employee file review, review of a facility investigation report and policy review the facility failed to provide adequate assistance and interventions to prevent injury during a transfer. The facility also failed to ensure fall prevention interventions were in place for a resident at risk for falls. This affected two residents (#15 and #31) of five residents reviewed for accidents. The facility census was 38.Findings included: 1. Review of the medical record for Resident #15 revealed an admission date of 12/31/24 with diagnoses including chronic obstructive pulmonary disease, diabetes, cirrhosis of the liver, Crohn's disease, and vascular dementia. Review of the plan of care initiated 01/02/25 and revised 12/05/25 (after a fall) revealed Resident #15 was at risk for falls with or without injury related to anemia, impaired mobility, chronic pain syndrome, chronic disease progression, weakness, incontinence, decreased endurance related to chronic obstructive pulmonary…

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, observation, and policy review, the facility failed to ensure oxygen use was documented and humidification was provided per the resident's plan of care. This affected two (Resident #3 and #37) of two reviewed of respiratory care. Findings Include: 1. Review of Resident #37's medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including abnormal findings of lung fields, nicotine dependence, edema, chronic obstructive pulmonary disease, anxiety, chronic respiratory failure, and palliative care. Review of Resident #37's oxygen plan of care dated 10/15/25 revealed to administer oxygen per order and change humidification and oxygen tubing as indicated. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] reflected oxygen use. Review of Resident #37's Medication and Treatment administration record dated 02/02/26 revealed an order for oxygen four liters via nasal cannula every four hours as needed for 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.

Based on record review, observation, and interview, the facility failed to ensure dialysis residents fluid restrictions were accurate and implemented timely. This affected two (Resident #2 and #11) of two reviewed for dialysis. Findings Include: 1. Medical record review revealed Resident #2 was admitted to the facility 04/28/25 with diagnoses including dependence of renal dialysis, end stage renal disease, and heart disease. Review of Resident #2's nutritional recommendation dated 02/26/26 revealed a 1500 milliliter (ml) fluid restriction with instructions for nursing to administer 780 ml and dietary to administer 720 ml (240 ml with breakfast, lunch, and dinner). Review of Resident #2's nutritional plan of care dated 04/30/25 and revised on 03/02/26, and dehydration plan of care dated 04/29/25 and revised on 03/02/26, revealed a 1500 ml fluid restriction with instructions for dietary to serve 1080 ml (breakfast: 480 ml, lunch: 240 ml, and dinner: 360 ml) and nursing to administer 420 ml (7-3 shift: 200 ml, 3-11 shift: 120 ml, and 11-7 shift: 100 ml). Review of Resident #2'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 medical record review, observation, facility assessment review and interview the facility failed to ensure a comprehensive, trauma-informed approach to care was implemented for a resident with post-traumatic stress disorder (PTSD). This affected one resident (Resident #22) of three residents reviewed for behaviors.Findings include:|Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnosis including anxiety, need for assistance with personal care, insomnia, and depression. There was no diagnosis of PTSD listed on the resident diagnoses list. Review of the resident's hospital Discharge summary, dated [DATE] and authored by Medical Doctor (MD) #900, revealed Resident #22 did have some mention of depression due to his current situation, and he was seen in consultation by neuropsychology with impression and recommendation as follows: patient describes longstanding history of recurrent depression which has been only recently addressed. He also reports increased anxiety. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure residents were reviewed monthly by the pharmacist. This affected three (Resident #2, #3, and #22) of five reviewed for unnecessary medication review. Findings include: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnosis including anxiety, need for assistance with personal care, insomnia, and depression. Review of Resident #22's medical record revealed no documented evidence the pharmacist completed a monthly medication regimen review for the month of October 2025. Interview on 03/02/26 at 9:26 AM with the Director of Nursing (DON) and Regional Director of Clinical Service #578 confirmed there was no documented evidence the pharmacist reviewed Resident #22 in October 2025. 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnosis including osteomyelitis, cellulitis, diabetes, depression, hypotension, renal dialysis, chronic ulcers, longer term use 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, interviews and policy review, the facility failed to ensure residents were provided with dental services to meet their needs. This affected two of five residents reviewed for dental (Residents #2 and #16). The facility census was 38.Findings include: 1. Medical record review for Resident #2 revealed the resident was admitted to the facility 04/28/25 on with diagnosis of diabetes, gastric-esophageal reflux disease, moderate protein calorie malnutrition, anemia, aphasia, and heart disease. Review of Resident #2's dental care plan related to loose fitting dentures dated 10/03/25 revealed to inform dentist of problems. Review of Resident #2's dental note date 10/17/25 revealed dental impression was obtained for new dentures. Further review of Resident #2's medical record revealed no evidence the resident had received new dentures or seen the dentist after 10/17/25. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had broken or loose…

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 medical records were available for inspection. This affected two residents (#4 and #22) of 15 resident records reviewed. The facility census was 38.Findings Include: 1. Review of the record for Resident #4 revealed an admission date of 11/05/25 with diagnoses including malignant neoplasm of the lung, adult failure to thrive, acute kidney failure, and esophageal obstruction. The resident had a physician's order dated 11/10/25 for hospice services with diagnosis of malignant neoplasm of the lung. A notebook containing the hospice plan of care was noted at the nursing station. Review of the notebook indicated the resident would have visits from hospice staff including nurse, chaplain, and nursing assistant. However, there were no visit notes in the notebook since December 2025. Interview with Licensed Practical Nurse (LPN) #532 on 02/25/26 at 2:00 P.M. confirmed there were no hospice visit notes by nurses, aides, or chaplains since December…

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 policy review, the facility failed to ensure all residents were provided with a dignified dining experience. This affected one (#50) of five residents reviewed for meals. The facility census was 53. Findings include:Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including type II diabetes, muscle weakness, and cognitive communication deficit. Review of the care plan last reviewed on 09/14/25 revealed no concerns with Resident #50's behaviors related to use of urinals. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #50's cognition remained intact, he declined care one to three days of the review period, he required supervision/touching assistance with toileting transfers, and required set-up/clean up help with personal hygiene. Review of a late entry note dated11/24/25 entered for 9:00 A.M. by Staffing Coordinator (SC) #142 stated attempted to enter residents' room and resident expressed agitation and did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and facility policy review, the facility failed to notify the resident and the resident's primary care physician of a medication error. This affected one resident (#50) of three residents reviewed for medication errors. The facility census was 53.Findings Include:Review of the medical record for Resident #50 revealed an initial admission date of 08/27/25 with the diagnoses including but not limited to diabetes mellitus (DM), chronic obstructive pulmonary disease, asthma, hypertension, chronic kidney disease, polyneuropathy, intervertebral disc degeneration, lumbar region, severe morbid obesity, osteoarthritis and obstructive sleep apnea. Review of the plan of care dated 08/27/25 revealed the resident experienced acute and chronic pain or discomfort due to osteoarthritis, neuropathies, wounds, left below the knee amputation, DM, morbid obesity and degenerative disc disease. Interventions included administer medications as ordered, assess for non-verbal indicators of pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of staff schedules, review of the facility assessment, and policy review, the facility failed to maintain safe staffing levels to prevent harm to residents. This affected one (#22) of three residents reviewed and had the potential to affect 19 additional residents residing on the 400 unit. The facility census was 53. Findings include:Review of Resident #22's closed medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including type I diabetes with diabetic neuropathy, muscle weakness, and difficulty in walking. Review of a care plan dated 09/10/25 revealed Resident #22 required hyperglycemic medication related to diabetes. Goals included Resident #22 would exhibit a therapeutic effect related to the use of medication, would not have signs or symptoms of hyperglycemia, and would not have side effects related to the medication. Interventions included to administer medications per orders, vital signs as indicated, pharmacy review as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility incident report review, interview and facility policy review, the facility failed to ensure residents were free from unnecessary medication. This affected two residents (#54 and #87) of five residents reviewed for medication administration errors. The facility census was 53. Findings include:1. Review of the medical record for Resident #54 revealed an initial admission date of 10/18/25 with the diagnoses including but not limited to cerebral infarction, encounter for palliative care, aphasia, contusion of scalp, chronic obstructive pulmonary disease, protein calorie malnutrition, age related physical debility, hydronephrosis, dysphagia, pressure induced deep tissue damage to right heel, disorders of lungs and anxiety disorder. Review of the plan of care dated 10/20/25 revealed the resident required the use of anti-anxiety medication (Lorazepam) related to diagnosis of anxiety disorder. Interventions included administer antianxiety medications as ordered by the physician.…

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 schedule review, facility assessment review, resident council meeting minute review, resident interview and staff interview, the facility failed to provide sufficient staffing to meet the needs of residents in a timely manner. This had the potential to affect all 48 residents residing within the facility. The facility census was 48.Findings Include: Review of the Facility assessment dated [DATE] revealed the assessment will inform the facility's staffing decisions to ensure there are a sufficient number of staff with appropriate competencies necessary to care for residents' needs as identified through resident assessments and plans of care. The facility will consider staffing needs for each resident unit in the facility for each shift and adjust a necessary based on resident population. The facility's contingency plan includes processed to ensure that staffing needs are addressed as they arise. In an unplanned staffing need, the facility uses on-call nurse management to either fill the shift or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to maintain the kitchen in a sanitary manner. This affected 47 of 48 residents who receive meals from the kitchen The facility identified one resident who did not receive nutrition from the kitchen. The facility census was 48. Findings include:Observation of the kitchen on [DATE] starting at 8:29 A.M. revealed splatters on the backsplash and walls behind the over and stove area, grime on the toaster oven controls, debris on the shelves containing hot-well pans, splatters on the wall behind the juice machine, and a half-full 19-ounce container of sesame seeds which expired on [DATE]. Interview on [DATE] with [NAME] #149 confirmed the splatters on backsplashes and walls, grime on toaster oven controls, debris on shelves containing clean hot-well dishes, and the expired container of sesame seeds. Review of a policy titled Sanitation dated 04/2006 revealed all kitchens, kitchen areas, and dining areas shall be kept clean, free from litter 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, record review, policy review and interview, the facility failed to develop and implement a comprehensive and effective infection control program to prevent the spread of infection. The facility failed to ensure hand hygiene was performed during care, failed to ensure the infection control log was complete and accurate and failed to follow the water management plan for Legionella per facility policy. This affected two (#1 and #3) residents reviewed for wound care, six residents (#19, #17, #4, #11, #21 and #36) reviewed on the facility infection control log and had the potential to affect all 48 residents residing in the facility. Findings include: 1.Review of the infection control log for April 2025 revealed Resident #19 had a wound infection. The signs and symptoms were not listed; Resident #17 was listed for an unknown infection with no signs or symptoms listed; Resident #4 was listed with an unknown infection with no signs or symptoms listed; and Resident #11, #21, and #36 had not been…

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 policy review, the facility failed to ensure residents or representatives were notified of bed hold days remaining and transfer to hospital as well as notification to the ombudsman. Additionally, the facility failed to ensure residents had a completed recapitulation of stay upon discharge. This affected six residents (#2, #3, #4, #19, #29, and #51) of six residents reviewed for transfer and discharge. The facility census was 48.Findings include:1.Record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including type II diabetes, mild intellectual disabilities, and anxiety disorder. Review of a nursing note dated [DATE] at 2:37 P.M. by Registered Nurse (RN) #144 revealed Resident #2's roommate approached the nurse stating she was concerned about how long Resident #2 had slept. RN #144 spoke with Resident #2 who stated she was just tired. Resident #2 was repositioned in bed and noted to be very sweaty, and her blood glucose was 198. Resident #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure residents received nutritional interventions after weight loss was identified and failed to ensure residents were weighed as ordered. This affected four residents (#2, #6, #9 and #29) of four residents reviewed for nutrition. The census was 48.Findings Include:1. Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including dysphagia (oropharyngeal phase), schizophrenia, diabetes mellitus and bipolar disorder. Review of the Individual Nutrition Recommendations/Response dated 05/15/25 revealed the physician agreed with a dietitian recommendation to add weekly weights for four weeks. Review of the record revealed no evidence weekly weights were obtained as ordered. Review of the Nutritional Narrative Note dated 06/13/25 revealed Resident #9 recently went to hospital with slurred speech and low blood pressure. Symptoms were likely secondary to not wearing oxygen and a buildup 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, interview, and policy review, the facility failed to ensure residents were aware of the risks versus benefits of the use of psychotropic medications. This affected one resident (#2) of five residents reviewed for unnecessary medication. Findings Include:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including type II diabetes, mild intellectual disabilities, and anxiety disorder. Review of a care plan dated 06/26/25 and revised on 05/07/25 revealed Resident #2 required the used of psychotropic medications with potential for adverse reactions related to anxiety. Review of a minimum data set (MDS) dated [DATE] revealed Resident #2 had moderately impaired cognition and no behaviors. A physician order dated 05/19/25 revealed Resident #2 was receiving anti-anxiety medications and should be monitored for drowsiness, slurred speech, dizziness, nausea, and aggressive/impulsive behaviors every shift. Review of a physician order dated 05/23/25 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 observation, medical record review and interview, the facility failed to maintain a safe and comfortable living environment. This affected one resident (#12) of 16 sampled residents. The census was 48. Findings include:Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, heart failure, anxiety disorder and osteoporosis. Review of the annual Minimum Data Set assessment dated [DATE] revealed the resident was moderately impaired for daily decision-making, utilized a wheelchair and walker for mobility, required supervision/touch assistance with toilet transfers, and was frequently incontinent of bowel/bladder. On 09/02/25 at 9:52 A.M., observation revealed Resident #12's bathroom toilet was positioned across from the bathroom door. Observation of the floor at the base of the toilet revealed the caulking was positioned away from the front and left sides of the toilet. On 09/02/25 at 10:55 A.M., interview with Resident #12 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, preadmission screening and resident review (PASRR) review and interview, the facility failed to ensure PASRR level II screenings were completed as determined by resident needs and determinations by the state level II program were available for review. This affected one resident (#9) reviewed for PASSR. The census was 48. Findings Include:Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including bipolar disorder, schizophrenia and depression. Review of the significant change in condition PASRR dated 07/28/23 revealed Resident #9 had a decline. Diagnoses included paranoid schizophrenia, bipolar disorder, insomnia and other psychotic disorder. The resident had no functional limitations due to the mental disorder and had not been prescribed psychotropic medications in the previous six months. The facility was unable to provide screening results as to the determination by the state level II PASRR. Review of the electronic Physician Orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive care plans were developed as required. This affected three residents (Residents #2, #4 and #7) of 15 residents reviewed for care plans. The census was 48. Findings Include:1.Medical record review revealed Resident #4 was admitted on [DATE] with diagnoses including metabolic encephalopathy, hypertension, gastroesophageal reflux, benign prostatic hyperplasia, insomnia, osteoarthritis, history of fractures and constipation. Review of the electronic Physician Orders dated August and September 2025 revealed Resident #4 received the following medications: baclofen (muscle spasms) 10 milligrams (mg) as needed for hiccups, cholecalciferol (Vitamin D supplement) 50,000 units weekly, cyanocobalamin (Vitamin B-12 supplement) 1000 mcg/mL injection monthly, losartan potassium (hypertension) 50 (mg) daily, magnesium hydroxide 30 milliliters (ml) daily as needed for constipation, mirtazapine (antidepressant) 15 (mg) at bedtime for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a resident, who was dependent on staff for personal care, was provided the assistance needed to complete bathing activities of her choice when scheduled, and nail care was provided when needed. This affected one (Resident #7) of four residents reviewed for activities of daily living (ADL's). The facility census was 48. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included rheumatoid arthritis, osteoarthritis, difficulty walking, and adult-onset diabetes mellitus. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. Her cognition was moderately impaired. She was not known to have displayed any behaviors or reject care during the seven day assessment period (06/20/25- 06/26/25). She required partial/ moderate assistance with showers/ bathing and required set up or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure care planned interventions for turning and repositioning were completed to promote timely and adequate healing of a pressure ulcer for Resident #1 and failed to ensure newly identified skin breakdown was timely identified and treated. This affected one resident (#1) of two residents reviewed for wound care. The facility census was 48.Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including type II diabetes, muscle weakness, and acute kidney failure.Review of a care plan initiated on 03/20/24 (and last updated on 06/11/25) revealed Resident #1 had an alteration in skin integrity related to pressure, a Stage III (defined as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) to the sacrum, and a boil to left hip. A goal included demonstrating gradual healing as evidenced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure smoking aprons were worn during smoking time. This affected one resident (#49) of five residents observed during their smoking time. The census was 48.Findings include:Record review revealed Resident #49 was admitted [DATE] with diagnoses including cerebral infraction, aphasia, hemiplegia, lupus, stage three chronic kidney disease, hypertension, hyperlipidemia, gastro-esophageal reflux disease, muscle weakness, obesity, depression, apraxia, and anxiety.Review of quarterly minimum data set (MDS) completed 06/11/25 revealed a brief interview for mental status (BIMS) score of 13. Resident #49 had upper extremity impairment.Review of Resident #49's most recent quarterly smoking observation/ assessment completed 07/02/25 revealed the resident is a smoker, smokes cigarettes, the resident has dexterity impairment, the resident needed adaptive equipment of a smoking apron with supervision. Resident was observed to drop ashes and cigarette…

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, policy review and interview, the facility failed to ensure systems were in place to restore normal bladder function for Resident #9 and to prevent additional decline in urinary continence. This affected one resident (#9) of one sampled resident for bladder incontinence. The facility identified 22 residents with bladder incontinence. The census was 48. Findings Include: Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including bipolar disorder, schizophrenia and depression. Review of the quarterly Minimum Data Set 3.0 (MDS) assessments dated 01/04/25 and 04/05/25 revealed Resident #9 was moderately impaired for daily decision-making. The resident was independent in both toileting hygiene and toilet transfers during both assessments and was occasionally incontinent of urine without a retraining/toileting program. The resident was continent of bowel. The resident was receiving antipsychotic medications on a routine basis only. 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 record review, interview and policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner and contained a rationale for decision. This affected two (#2 and #49) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: 1.Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including type II diabetes, mild intellectual disabilities, and anxiety disorder. Review of a document titled Gradual Dose Reduction (GDR) Recommendation dated 04/25/25 revealed a recommendation to reduce buspirone (anti-anxiety) and duloxetine (antidepressant). The physician declined the recommendation and stated see psych notes. Review of a care plan initiated on 06/26/24 and revised on 05/07/25 revealed Resident #2 required the use of psychotropic medications with potential for adverse reactions related to anxiety. Interventions included but were not limited to evaluate the effectiveness and side effects 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, policy review and interview, the facility failed to ensure opioid pain medications had adequate monitoring including indications of when to administer. This affected one resident (#4) of five residents reviewed for unnecessary medications. The census was 48. Findings Include: Medical record review revealed Resident #411/14/22 was admitted on [DATE] with diagnoses including metabolic encephalopathy, hypertension, gastroesophageal reflux, benign prostatic hyperplasia, insomnia, osteoarthritis, history of fractures and constipation. The resident was admitted to hospice services on 07/19/25. Review of the care plan: Risk for Pain/Discomfort related to arthritis, depression, hip fracture and neuralgia initiated 04/03/24 and revised on 03/10/25 included the following interventions: administer pain medications as ordered by the physician. Assess for pain and if experiencing pain, rate the pain per [NAME]-BAKER faces pain scale. Document, report complaints and non-verbal signs of pain.…

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, policy review and interview, the facility failed to prevent a significant medication error involving Resident #4 when the resident was not administered an antibiotic as ordered to treat aspiration pneumonia. This affected one resident (#4) of five residents sampled for unnecessary medications. The census was 48. Findings Include:Medical record review revealed Resident #4 was admitted on [DATE] with diagnoses including metabolic encephalopathy, dysphagia, pharyngeal phase, Barrett's esophagus without dysplasia and diaphragmatic hernia without obstruction or gangrene. Review of the Significant Change in Status assessment/5-day MDS assessment dated [DATE] revealed Resident #4 was severely impaired for daily decision-making and was receiving an antibiotic. Review of the electronic Physician Orders dated July 2025 revealed to administer cefpodoxime (antibiotic) 200 milligrams every 12 hours via PEG tube for aspiration pneumonia. Review of the electronic Medication Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review the facility failed to ensure medications were stored and labeled properly. This had the potential to affect two residents (#2, #23) of three residents observed for medication pass and four medication carts with one medication room observed for medication storage and labeling.Findings include:. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, type II diabetes, Chronic Obstructive Pulmonary Disease (COPD), rheumatoid arthritis, cognitive communication deficit, resp failure with hypoxia, muscle weakness, ulcerative colitis, transient ischemic attack (TIA), moderate protein-calorie malnutrition, atrial fibrillation, mild intellectual disabilities, dysphagia, syncope and collapse, cerebral infarction, hypertension, bell's palsy, dementia, anemia, gout, hyperlipidemia, hypokalemia, atherosclerotic heart disease without angina, hypertensive heart disease with heart 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 and staff interview, the facility failed to ensure laboratory tests were obtained as ordered by the physician. This affected one (Resident #29) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #29's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included mixed hyperlipidemia (a condition characterized by elevated levels of multiple types of lipids (fats) in the blood). Review of Resident #29's physician's orders revealed the resident had an order in place to obtain a lipid profile every six months to be obtained in the months of June and December. The order originated on 06/03/25. Further review of Resident #29's electronic medical record (EMR) revealed it was absent for any documented evidence of a lipid profile being obtained as ordered every six months beginning on 06/03/25. Laboratory tests were scanned and uploaded under the documents tab of the EMR. Laboratory tests had been obtained from 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, dietary card review, policy review and interview, the facility failed to serve food to meet the resident needs. This affected one resident (#9) of four residents sampled for nutrition. The census was 48. Findings Include: Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including dysphagia, oropharyngeal phase. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #9 was moderately impaired for daily decision-making, received a therapeutic and mechanically altered diet, and was edentulous.Review of the care plan: At Potential Risk of Nutritional Decline related to the resident's need for a mechanically altered diet revised 07/17/25 revealed interventions included to provide her diet and supplement per dietitian recommendation and physician order. Review of the electronic Clinical Physician Orders dated September 2025 revealed Resident #9 was ordered a regular diet, soft and bite-sized textures and thin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's cycle and special diet menus, observation, and interview, the facility failed to ensure a resident received the appropriate therapeutic diet as ordered by the physician for management of end stage renal disease with dependence on hemodialysis. This affected one (Resident #6) of one resident reviewed for dialysis and nutrition. Findings include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic kidney disease- stage IV (severe). Review of Resident #6's physician's orders revealed the resident had an order in place to receive a renal diet. The diet order originated on 07/24/25. Her physician's orders also indicated the resident received hemodialysis at a dialysis center. Review of Resident #6's 5-day Medicare (MCR) Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She did not display any behaviors and was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's medical record was complete to include completion dates of consents for immunizations. This affected one resident (#3) of five residents reviewed for infection control. The facility census was 48. Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including polyneuropathy, end stage renal disease, and atrial fibrillation. Review of a Minimum Data Set, dated [DATE] revealed Resident #3's cognition remained intact. Review of an Influenza Vaccine Consent Form revealed Resident #3 declined the vaccine and the document was not dated. Review of a Pneumococcal Vaccine Consent Form revealed Resident #3 declined the vaccine and the document was not dated. Review of a COVID Vaccine Consent Form revealed Resident #3 declined the vaccine and the document was not dated. Interview on 09/09/25 at 1:27 P.M. with Director of Nursing confirmed the consent forms for flu, pneumonia, and COVID…

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 medical record review and interview, the facility failed to complete an accurate comprehensive assessment. This affected one resident (#3) of three residents sampled. The census was 49.Closed medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including Alzheimer's disease, schizoaffective disorder and intermittent explosive disorder.Review of the Physician Progress Note dated 04/15/25 revealed Resident #3 was being evaluated for his dementia. The facility gave the patient and family a 30-day notice that the secured unit was closing. The resident was not suitable for the main floor and was at high-risk for elopement, had a history of aggressive behaviors and agitation. He had a brief time out on the main floor and things did not go well. He was at high risk for elopement, aggression and needs close supervision and a secure unit to protect him and others. Family provided facility she would like referred to. Staff to make the referral.Review of the Notice of Transfer or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure Resident #13 was free verbal and emotional abuse. This affected one resident (#13) of one resident reviewed for abuse. The facility census was 51. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, bipolar disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13's cognition was intact and she had no behaviors. Review of a social service note dated 06/03/25 at 9:40 A.M. by the Social Services Director revealed Resident #13, Activities Director (AD) #101, and Ombudsman #66 met and came up with a resolution everyone was agreeable with regarding puzzles in the activity room. Interview on 06/04/25 at 1:48 P.M. with Ombudsman #66 revealed Resident #13 had kept puzzles in the activity room for ten years since she admitted to the facility. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, and interview, and policy the facility failed to ensure an allegation of resident sexual abuse was reported to the state survey agency and the facility administrator within the required timeframes. This affected one resident (#43) of three residents reviewed for abuse. Findings included: Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia, thrombocytopenia, contractures, depression, and insomnia. Review of Resident #43's medical record revealed a psych note dated 05/14/25 that identified the resident was oriented times three and the resident's memory was intact times three. The resident had appropriate judgment concerning daily activities and social judgement, normal range of thought, and no abnormal psychotic thoughts, aware of current events, past history, and vocabulary. Resident #43 reported she had difficulty dressing due to arthritis, was toileting on her own 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, interviews, and policy review the facility failed to ensure resident representatives received complete discharge notices timely and failed to notify the state health department of resident discharge. This affected five residents (#58, #59, #60, #61, and #62) of five residents reviewed for discharge from the facility's secured unit. Findings included: 1. Review of Resident #58's closed medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, Alzheimer's, intermittent explosive disorder, conduct disorder, unspecified dementia, noncompliance with medication regimen, behavior pattern, wandering disease, age-related cognitive decline, and need for assistance with personal care. Review of Resident #58's physician orders dated 04/21/25 revealed ok to discharge to long-term care facility. Review of Resident #58's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident was discharged to 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.

Based on personnel file review, interview and policy review, the facility failed ensure staff hired to work at the facility did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This had the potential to affect all residents. The census was 57. Findings include: 1. Review of the personnel file for Medical Records #272 revealed a hire date of 10/14/24. There was no evidence MR #272 was checked against the Nurse Aid Registry (NAR) prior to hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. 2. Review of the personnel file for Social Worker #254 revealed a hire date of 10/21/24. There was no evidence SW #254 was checked against the NAR prior to hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation 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 observation, policy review and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 57 residents who were served meals from the kitchen. Findings include: On 03/03/25 between 8:13 A.M. through 8:35 A.M., observation of the kitchen revealed [NAME] #300 and [NAME] #490 were cleaning up from breakfast. The following observations were made: 1. Observation of the walk-in freezer revealed large icicles from the back coils and laying on the shelf against the back of the freezer. There was no thermometer observed in the walk-in freezer. [NAME] #300 verified the freezer did not have a thermometer in it. [NAME] #300 verified items in the walk-in freezer included an open box of 25 frozen biscuits, a 13.5 pound box of mild pork sausage patties, a 3/4-full 13.5 pound box of french toast, a sealed 10 pound box of Salisbury steak, one 48 pack box of vanilla ice cream, one 48 pack box of chocolate ice cream and nine individual magic cup desserts. The ice cream cups were soft when held and when squeezed, the plastic ice cream cup left…

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 personnel files, interview and policy review, the facility failed to ensure Certified Nursing Assistants (CNAs) received the required 12 hours of in-services annually. This had the potential to affect all 57 residents residing in the facility. Findings include: Review of the personnel files for CNA #257, CNA #269, CNA #274, and Activity Director (AD) #204, who occasionally worked the floor as a CNA, revealed no evidence of 12 hours of annual inservices in 2024 or 2025. Interview on 03/22/25 at 3:15 P.M. with Human Resources (HR) #241 confirmed CNAs #257, #269, #274, and AD #204 did not have evidence of 12 hours of annual in-services. Review of a policy titled In-Service Training, All Staff dated 2001 revealed all staff are required to participate in regular in-service education. The objective of this training is to ensure staff are able to interact in a manner that enhances the resident's quality of life and care and can demonstrate competency in the topic of the training areas. Required trainings include effective communication with residents and family (for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus, unspecified dementia, age related cognitive decline, muscle weakness, and need for assistance with personal care. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. His cognition was severely impaired. He was not known to display any behaviors or reject care during the seven days of the assessment period. He was dependent on staff for bathing/ showers and a substantial/ maximum assist was needed with personal hygiene. Review of Resident #27's active care plans revealed the resident had a care plan in place for an activities of daily living (ADL) performance deficit related to dementia, impaired balance, and the use of psychotropic medications. The care plan did not address personal hygiene or the need to provide the resident with nail care. Review of Resident #27's bathing…

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, dietary meal card review, medical record review, policy review and interview, the facility failed to serve double portions when indicated. This affected one resident (#50) who required double portions during observation of trayline. The facility identified two residents that required double portions. The census was 57. Findings include: Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including unspecified dementia, aphasia and depression. Review of the diet order dated 10/21/24 revealed the resident receives a regular diet with large portions. Review of the quarterly Nutritional Risk Review dated 01/24/25 revealed continues on regular diet, large portion. Weight on 01/08/25 was 154 pounds, likely meeting estimated nutrient needs with meal and snack intakes as evidence by gradual beneficial/desirable weight gain. Goal for weight maintenance. Review of Resident #50's Meal Card dated 03/05/25 revealed a regular diet with double portions. The resident was 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 observation, diet guide sheet review, medical record review, policy review and interview, the facility failed to ensure pureed food was the correct consistency. This affected two residents (#35 and #45) of six residents receiving pureed diets. The census was 57. Findings include: 1. Medical record review revealed Resident #35 was admitted on [DATE] with diagnoses including Alzheimer's disease. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #35 was severely impaired for daily decision-making and received a mechanically altered diet. Review of the Physician Orders dated March 2025 revealed Resident #35 was ordered to receive a pureed diet. Review of the Diet Guide Sheet (Day 4) revealed the lunch meal consisted of an open faced roast pork sandwich, brown gravy, mashed potatoes, glazed carrot, mashed potatoes, a dinner roll and lemon cake with lemon icing. Marinated chicken breast with poultry gravy, parsley cauliflower and buttered noodles were also on the menu 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, observation, staff interview, and policy review, the facility failed to develop and implement a comprehensive and effective infection control program to decrease the risk of infection. The facility failed to ensure staff applied (donned) appropriate personal protective equipment (PPE) when entering the room of a resident in transmission based precautions (TBP's), failed to ensure staff performed proper hand hygiene during wound care and during meal delivery processes, and failed to ensure nephrostomy bags were maintained off the floor to help prevent infection. This affected one resident (#27) of three residents reviewed for TBP's, one resident (#7) of one resident reviewed for pressure ulcers, one resident (#256) of four residents reviewed for urinary catheters, three residents (#22, #39, and #156), who received their lunch meals in their rooms on the 300 hall on 03/03/25, and nine residents (#1, #2, #6, #7, #15, #16, #28, #45, and #46) who received their lunch meal in the dining room 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 medical record review, infection control log review, policy review and interview, the facility failed to monitor the use of antibiotics and ensure infection criteria was met. This affected three residents (#7, #19 and #46) of three residents reviewed for antibiotic use. Findings include: 1. Medical record review revealed Resident #7 was admitted on [DATE] with diagnoses including diabetes mellitus, acute kidney failure, urinary retention unspecified, pyelonephritis, bacteremia and neurogenic bladder. Review of Laboratory Bloodwork dated 11/24/24 revealed Resident #7 had a white blood cell count of 15.3 uL/mL (normal was 3.5 to 11.0). The nurse practitioner was notified and ordered rocephin (antibiotic) one (1) gram intramuscular daily for three days. There was no evidence or a urinalysis or urine culture obtained. Review of the electronic Physician Orders dated November 2024 revealed Resident #7 had an indwelling urinary catheter and was ordered Ceftriaxone Sodium 1 gram (g) intramuscularly (IM) daily…

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, review of email correspondence between the facility and an outside heating, cooling, plumbing, and refrigeration company, review of resident council meeting minutes, resident interview, and staff staff interview, the facility failed to ensure the building was free of any offensive odors. This had the potential to affect all 19 residents (#1, #5, #9, #11, #12, #13, #14, #17, #19, #21, #23, #27, #28, #34, #35, #38, #51, #206, and #260) that resided on the 400 hall. Findings include: On 03/03/25 through 03/06/25 and again on 03/10/25, observations of the 400 hall noted there to be an offensive sewage type of odor present that was very noticeable when walking onto the hall. The odor was noted from the front of the hall and extended all the way to the back of the hall. The odor was consistent and not transient in nature and could not be pinpointed to any particular residents' rooms. Observation revealed there were 19 residents, Resident #1, #5, #9, #11, #12, #13, #14, #17, #19, #21, #23, #27, #28, #34, #35, #38, #51, #206, and #260 who resided on the 400 hall.…

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, review of camera footage, medical record review, interview and policy review, the facility failed to ensure residents were treated with respect and dignity. This affected two residents (#18 and #42) of 31 sampled residents. The census was 57. Findings include: 1. Medical record review revealed Resident #18 revealed the resident was admitted on [DATE] with diagnoses including major depressive disorder. On 03/04/25 at 8:09 A.M., observation revealed Certified Nurse Aide (CNA) #201 and CNA #202 both entered the main dining room and knocked on the Kitchen door. CNA #201 asked for dry cereal for Resident #18 as it had not been on her breakfast tray. CNA #202 was heard calling Resident #18 a hateful old lady while talking to CNA #201 and dietary staff. CNA #202 continued talking about Resident #18, in a not respectful way. When CNA #202 saw the surveyor sitting at one of the dining room tables, she acknowledged the above, stated the resident was moody and said I probably should not have said…

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 ensure a resident's desired code status was consistent between what was identified in the electronic medical record (EMR) and what was identified in the hard chart of the medical record. This affected one (Resident #51) of one residents reviewed for advanced directives. Findings include: Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus, sleep apnea, chronic kidney disease, and asthma. Review of Resident #51's advanced directives in the hard chart of her medical record revealed the resident was a Do Not Resuscitate Comfort Care- Arrest (DNRCC-A). The DNR order form was signed by a physician on [DATE] (prior to her initial admission into the facility). The DNR form indicated the provider would treat the resident as any other, without a DNR order, until the point of cardiac or respiratory arrest at which point all 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 observation, medical record review and interview, the facility failed to maintain resident privacy during the administration of insulin. This affected one resident (#7) of nine residents seated in the dining room during a meal observation. The census was 57. Findings include: Medical record review revealed Resident #7 was admitted on [DATE] with diagnoses including diabetes mellitus and depression. Review of the electronic Physician Order Sheet dated March 2025 revealed Resident #7 was to receive glucose monitoring before meals and NovoLOG Solution 100 units per milliliter (Insulin Aspart) administer five (5) units subcutaneously before meals and at bedtime. On 03/04/25 at 11:25 A.M., observation of the lunch meal in the main dining room revealed Resident #1, #2, #6, #7, #15, #16, #28, #45 and #46 were seated at dining tables and were being served their lunch. On 03/04/25 at 11:40 A.M., observation revealed Licensed Practical Nurse (LPN) #203 approached Resident #7 while she was eating lunch and told…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected two residents (#7 and #16) of 31 residents reviewed. The census was 57. Findings include: 1. Medical record review revealed Resident #16 was admitted on [DATE] with diagnoses including vascular dementia, hypothyroidism, anemia, hypertension, insomnia, falls, depression and cognitive communication deficit. Review of the admission Dental Record - V 1.0 dated 01/23/25 revealed the resident had full upper and lower dentures. Comments indicated the resident's upper dentures were not in her mouth and the resident stated she had misplaced them. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16's dental section was marked 'no' for no natural teeth or tooth fragments (edentulous). On 03/05/25 at 5:55 P.M. interview with the Director of Nursing (DON) verified Resident #16's admission MDS dental section was inaccurately coded. 2. Medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to complete baseline care plans within 48 hours of admission to the facility. This affected two residents (#16 and #256) of 31 residents reviewed for care plans. The census was 57. Findings include: 1. Medical record review revealed Resident #16 was admitted on [DATE] with diagnoses including vascular dementia, hypothyroidism, anemia, hypertension, insomnia, falls, depression and cognitive communication deficit. Review of the Baseline Care Plan Person-Centered Care Planning - V 3.1 dated 01/24/25 and one dated 01/27/25 revealed the assessments were not completed and were marked as pending. There was no evidence the Baseline Care plan was finished or provided to the resident/responsible party as required. On 03/05/25 at 5:55 P.M., interview with the Director of Nursing (DON) verified Resident #16's Baseline Care plan was not completed as required. 2. Record review revealed Resident #256 was admitted to the facility on [DATE] with diagnoses…

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 ensure Residents #42 and #45 and/or their representatives provided input during review and revision of care plans by participating in care conferences. The facility also failed to ensure care plans for Resident #7 were accurate. This affected three residents (#7, #42 and #45) of 31 residents reviewed for care planning. The facility census was 57. Findings include: 1. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia with behavioral disturbances, chronic obstructive pulmonary disease (COPD), difficulty walking, pressure ulcer of the right buttock, cognitive communication deficit, need for assistance with personal care, and persistent mood disorder. Review of the Minimum Data Set (MDS) section C, completed 02/06/25, revealed a brief interview for mental status (BIMS) score of 06, indicating severe cognitive impairment. Further review of the medical record 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 record review, observation, interview, and policy review, the facility failed to ensure (non-pressure ulcer related) dressings were changed per physician orders and the bowel protocol was followed. This affected one (#46) of three residents reviewed for bowel and bladder continence and two residents (#7 and #8) of four residents reviewed for general skin conditions. The facility census was 57. Findings include: 1. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy, type II diabetes, acute kidney failure, and altered mental status. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had mild cognitive impairment, no behaviors, and had no venous ulcers. Review of a provider note dated 03/05/25 at 12:00 A.M. by Nurse Practitioner (NP) #505 revealed Resident #7 was receiving wound care to her sacrum and left trochanter (hip). There was no evidence of treatment or assessment of a venous wound to the right lower…

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, observation, and policy review the facility failed to ensure a pressure ulcer dressing was in place per physician order. This affected one resident (#22) of three residents reviewed for skin alteration. Findings included: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy, type II diabetes, pressure ulcer right buttock, skin ulcer, anemia, and needs assistance with personal care. Review of Resident #22's wound assessment note dated 05/07/25 revealed the resident had a stage III pressure ulcer (full-thickness skin loss) on sacrum that measured 2.2 centimeter (cm) in length by 0.5 cm width, 0.3 cm depth with light serosanguineous drainage noted. Review of Resident #22's wound assessment note completed by the Wound Nurse Practitioner dated 05/07/25 revealed the resident had a stage III pressure ulcer on the sacrococcygeal that measured 2.2 cm by 0.5 cm by 0.3 cm with moderate serosanguineous with light…

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 with contractures had orthotics applied daily for contracture management, as per their plan of care. This affected one (Resident #35) of four residents reviewed for limited range of motion (ROM). Findings include: Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia, contracture of an unspecified hand, contracture of the left elbow, muscle weakness, and need for assistance with personal care. Review of Resident #35's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech. She was rarely/ never understood and was rarely/ never able to understand others. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was not known to have any behaviors and was not known to reject care during the seven…

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, review of a facility investigation, review of an employee personnel file, staff interview, and policy review, the facility failed to ensure a resident's fall prevention interventions were implemented as per plan of care. They also failed to ensure another resident's medication that was mixed and attempted to be administered in a snack was taken by the resident it was intended for and not left unattended, which resulted in the medication being partially ingested by the resident's visiting family member. This affected two (Resident #23 and #42) of seven residents reviewed for accidents. Findings include: 1. Review of Resident#23's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included weakness, need for assistance with personal care, and a history of falls. Review of Resident #23's progress notes revealed a nurse's note dated 12/09/24 at 6:50 A.M. that indicated the nurse was called to the resident's room due to the resident sliding…

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, national institute of health review and interview, the facility failed to provide ordered care and services for an indwelling urinary catheter. This affected one resident (#7) of four reviewed for Urinary Catheter or UTI (Urinary Tract Infection). The facility identified seven residents with the use of an urinary catheter. The census was 57. Findings include: Medical record review revealed Resident #7 was admitted on [DATE] with diagnoses including diabetes mellitus, neuromuscular disorder of bladder, acute kidney failure, urinary retention unspecified, history of UTI, pyelonephritis (kidney infection), bacteremia and neurogenic bladder. Review of the Urology Note dated 04/22/24 revealed Resident #7 was seen related to a UTI with an indwelling catheter. The resident had recurrent UTI's and the urologist's plan was to continue methenamine (antibiotic long term use to prevent infection) and vaginal estrogen per infectious disease recommendations, and change 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, staff interview, observation, and policy review the facility failed to provide care and services to maintain acceptable parameters of nutritional status by monitoring resident meal intakes and failed to ensure residents who experienced weight loss were properly monitored and changes were reported to the physician. This affected two (Resident #45 and Residents #25) of five residents reviewed for nutritional status. The census was 57. Findings include: 1. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia with behavioral disturbances, chronic obstructive pulmonary disease (COPD), difficulty walking, pressure ulcer of the right buttock, need for assistance with personal care, and persistent mood disorder. Review of the Minimum Data Set (MDS) section C completed 02/06/25 revealed a brief interview for mental status (BIMS) score of 06 indicating cognitive impairment. Review of the MDS section D: the resident had 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 interview, observation, policy review, and record review the facility failed to timely identify, treat, monitor, and manage Resident #6 pain, and provide appropriate pain interventions during care to Resident #7. This affected two (Resident #6 and Resident #7) of four residents reviewed for pain management. The census was 57. Findings include: 1. Medical record review revealed Resident #7 was admitted on [DATE] with diagnoses including diabetes mellitus, stage III pressure ulcer (full thickness tissue loss without bone, tendon or muscle exposed) and chronic pain. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #7 was moderately impaired for daily decision-making, had one Stage III pressure ulcer, received scheduled pain medications and complained of occasional pain rated a four out of 10. Observation of Resident #7 revealed the following: On 03/03/25 at 2:17 P.M., interview with Resident #7 revealed leg pain rated an eight out of 10 from where a cup of coffee…

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, diet guide review, education/in-service review and interview, the facility failed to ensure certified nurse aides (CNAs) had the knowledge to identify mechanically altered food. This affected one resident (#45) of three reviewed for accidents. The census was 57. Findings include: Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including atrial fibrillation, dementia with behavioral disturbances, hypertension cognitive communication deficit and chronic kidney disease. Review of the electronic Physician Orders dated 03/03/25 revealed Resident #35 was ordered to receive a pureed diet. Review of the Diet Guide Sheet (Day 5) Breakfast for 03/06/25 revealed pureed breakfast meal included pureed buttermilk pancakes, pureed sausage patty, two ounces of brown gravy and oatmeal cereal, four ounces of orange juice, six ounces of coffee or hot tea and eight ounces of milk. On 03/06/25 between 7:52 A.M. and 8:10 A.M., observation revealed 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 record review and interview the facility failed ensure assess/monitor Resident #40 for side effects and behaviors to prevent unnecessary use of psychotropic medications. The facility also failed to ensure Resident #48 did not receive psychotropic medications without an appropriate diagnosis and documentation of necessity. This affected two residents (#40 and #48) of six sampled for unnecessary psychotropic medications. The facility census was 57. Findings include: 1. Review of Resident #40's medical record revealed an admission date of 11/08/24, a re-entry date of 01/08/25 and diagnoses including unspecified psychosis, dementia, delusional disorders, visual hallucinations, panic disorder, essential tremor, anxiety disorder, hypertension and Major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 had Brief Interview for Mental Status (BIMS) score of 10 indicating mildly impaired cognition. Further review of the MDS revealed Resident #40 was independent…

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, menu review and interview, the facility failed to provide meals that were palatable and attractive. This affected one resident (#7) of three residents reviewed for food. The census was 57. Findings include: Medical record review revealed Resident #7 was admitted on [DATE] with diagnoses including diabetes mellitus, pressure ulcer, and depression. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderately impaired for daily decision-making. Review of the Diet Guide Sheet (Day 3) for 03/04/25 revealed lunch meal consisted of three Sweet & Sour Meatballs, Sweet & Sour sauce, garlic green beans, steamed rice, mandarin oranges, dinner roll and margarine. On 03/03/25 at 2:08 P.M., interview with Resident #7 stated the food did not taste good especially the meat. On 03/04/25 at 11:45 A.M., observation of Resident #7's lunch meal revealed two of three meatballs were black and burnt on half of the meatball. The burnt portion 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 observation, dietary snack summary review, medical record review and interview, the facility failed to ensure residents received evening snacks. This affected two residents (#3 and #28) of 13 residents ordered an evening/bedtime snack from the dietary department. The census was 57. Findings include: Medical record review revealed Resident #3 was readmitted on [DATE] with diagnoses including diabetes mellitus, mild intellectual disabilities and cerebral infarction. Medical record review revealed Resident #28 was admitted on [DATE] with diagnoses including non-Alzheimer's dementia and anxiety disorder. Review of the dietary department Snack Summary for the week of 03/04/25 revealed Resident #3 was to receive vanilla ice cream at bedtime and Resident #28 was to receive nectar thickened cranberry juice. On 03/05/25 between 6:50 P.M. and 7:07 P.M., observation revealed a cafeteria-style tray was delivered and was sitting on the ledge at the nurses' station. Maintenance Director #243, Activity Director #204,…

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, meal ticket review and interview, the facility failed to provide assistive eating equipment as needed. This affected one resident (#2) of eight residents who ate meals in the dining room. The census was 57. Findings include: Record review revealed Resident #2 was admitted on [DATE] with diagnoses including unspecified dementia, dysphagia, and traumatic brain injury. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact for daily decision making. Review of the electronic Physician Orders dated March 2025 revealed Resident #2 received a regular diet, thin liquids consistency, and a divided plate to increase independence. Review of the Meal Ticket for Resident #2 revealed divided plate and scoop plate was to be used. On 03/05/25 at 11:20 A.M., observation of the lunch tray line revealed [NAME] #300 placed a slice of bread in a scooper bowl and placed a pork patty with gravy and mashed potatoes and carrots all in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to maintain comprehensive and accurate medical record. This affected one resident (#26) of 31 residents sampled. The census was 57. Findings include: Medical record revealed Resident #26 was admitted on [DATE] with diagnoses including end stage renal disease requiring hemodialysis, hypertension and constipation. A. Review of the electronic Physician Orders dated 11/24/24 revealed to administer amlodipine desylate 10 milligrams daily for hypertension. The medication was to be held if systolic blood pressure (SBP) was less than 90 mmHg and/or heart rate was less than 90 (beats per minute) and notify the physician. The medication was to also be held on dialysis days (Monday-Wednesday-Friday). Review of the electronic Medication Administration Record (eMAR) dated February and March 2025 revealed the following regarding the administration of amlodipine: a. On 02/01/25 through 02/10/25, the medication was not held per physician instructions when 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 review of facility billing/financial ledger and interviews, the facility administration failed to operate in a manner to ensure bills were being paid in a timely manner to prevent potential interruption in service and failed to ensure adequate transfer of services following a change in ownership to provide continuity of care. This had the potential to affect all 53 residents residing in the building. Findings included: Review of the Administrator's personnel file revealed the Administrator was hired on 07/15/24. Review of the undated Administrator's job description revealed the primary purpose of the position was to direct day to day functions in the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long term care facilities to assure that the highest degree of quality of care could be provided to the residents at all times. Duties and responsibilities included: prepare an annual operating budget for approval by the governing board and allocate the resources to carry out programs and activities 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of a sheriff report, and interview the facility failed to ensure effective measures/interventions were in place to prevent Resident #1 from exiting the facility unsupervised. This affected one (#1) of three residents reviewed for elopement. Findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including psychosis, dementia, delusional disorder, visual hallucination, panic disorder, major depression, disorientation, macular degeneration, insomnia, the need assistance with personal care, and muscle weakness. Review of Resident #1's admission fall and elopement assessment dated [DATE], and completed 11/09/24, revealed the resident was at risk for falls and elopement due to cognitive impairment, diagnoses, the ability to ambulate independently, visual and auditory deficits, verbally expressing a desire to go home and history of elopement. The assessment noted the resident wandered aimlessly, had…

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

Based on observation and staff interviews, the facility failed to maintain a clean and safe environment for the residents residing in the facility. This affected 25 of 53 residents (#1, #2, #3, #4, #5, #6, #7, #8 #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52 and #53) residing in the facility and two of three shower rooms (100 and 400 hall). The census in the facility was 53. Findings include: An observation on 11/20/24 at 3:07 P.M. revealed a black substance on the grout of the shower floor and between the floor and the wall of the shower in the 100-hall shower room. Further observation of the 100-hall shower room revealed a musty, stale, earthy odor similar to the odor associated with mold or mildew. An observation on 11/20/24 at 3:10 P.M. revealed a musty, rotten egg-like odor similar to sewage in the shower room on the 400-hall. Interview on 11/20/24 at 3:45 P.M. with the Director of Nursing (DON) verified the black substance on the grout of the shower floor and between floor and wall of shower and the musty, stale, earthy odor similar to the odor…

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

Based on observation, staff interviews and medical record review, the facility failed to implement interventions to prevent falls as per the plan of care. This affected two of three residents (#29 and #35) reviewed for falls. The facility census was 53. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 08/09/24 and diagnoses including atrial fibrillation, anemia, chronic obstructive pulmonary disease, and hypertension. Review of Resident #35's fall assessments for the previous month revealed the resident had fallen on 10/25/24,10/26/24 and 11/11/24. Review of Resident #35's care plan revealed the following fall prevention interventions were to be in place for the resident: On 08/26/24 encourage the resident to wear non-skid socks at all times, 09/11/24 a perimeter (concave) mattress to the resident's bed to allow the resident to define the edges of the bed, 09/18/24 a fall mat to the floor on the right side of bed, 09/18/24 a low bed, 09/18/24 the resident to be up in his wheelchair when restless, 09/30/24 dycem (a thin non-slip, rubber-like…

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 facility billing/financial information, review of the Facility Assessment, facility policy review and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services. This had the potential to affect all 61 residents residing in the facility. Findings Include: Although there was no evidence of any current shut-off notices for services at the time of the investigation, the risk for notice or interruption of services was identified. The facility failed to provide evidence of fund availability and systems in place to ensure bills/invoices were paid timely and as due. On 06/05/24 at 3:50 P.M., an interview with the facility Administrator revealed that currently all bills were paid by the accounts payable department at the corporate level. The Administrator stated he had no direct knowledge of whether the bills were being paid. The Administrator stated that he does receive invoices and would review them 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, podiatry list review, contract review and interview, the facility failed to provide routine foot/podiatry care to maintain good foot health for residents. This affected two residents (#57 and #101) of 36 residents identified as needing podiatry services and had the potential to affect all 26 residents with diagnosis of diabetes who were at risk for foot complications related to their condition (#9, #11, #19, #21, #24, #25, #27, #31, #33, #35, #39, #41, #43, #49, #69, #73, #77, #85, #87, #97, #101, #111, #113, #115, #117 and #127) residing in the facility. The census was 61. Findings include: 1. Medical record review revealed Resident #101 was admitted [DATE] with diagnoses including dementia, diabetes mellitus, pressure ulcers and hypertension. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was moderately impaired for daily decision-making, was dependent on staff for personal hygiene, had a diagnosis of diabetes and received insulin daily.…

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 fund review and interview, the facility failed to provide medically related social services to ensure cognitively impaired residents were assisted in financial matters when needed. This affected one resident (#123) of three sampled residents. The census was 61. Findings include: 1. Medical record review revealed Resident #123 was admitted on [DATE] with diagnoses including dementia with psychotic disturbances and metabolic encephalopathy. Resident #123 expired on [DATE]. Review of the hospital Discharge summary dated [DATE] revealed prior to Resident #123's hospitalization she was living alone and determined to have severe cognitive deficits. The resident's neighbor was her medical power of attorney (POA), and there was no financial POA or guardian identified. Review of the electronic medical record Resident Profile revealed Resident #123 had a medical POA and the resident was her own A/R Guarantor. Review of the IDT (interdisciplinary team)/Care Conference Notes-V 3…

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 develop policies and procedures regarding advance directives and failed to ensure a procedure was in place to effectively implement a resident's advance directives. This affected one (Resident #80) of 50 residents records reviewed but had the potential to affect all 65 residents. Findings include: Review of the closed medical record for Resident #80 revealed an admission date of [DATE] with diagnoses including diabetes mellitus, acute kidney failure, acute respiratory failure, pulmonary embolism, and cellulitis. Review of an acute care hospital Discharge summary dated [DATE] revealed the resident had been admitted to the hospital on [DATE]. She presented to the emergency department with complaints of generalized weakness and a fall on [DATE]. During her stay she had low blood pressure which improved with intravenous fluids and holding of all antihypertensive therapy. It stated her blood pressure was then stable 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 observation, review of facility billing/financial information, review of the Facility Assessment, facility policy review and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services. This had the potential to affect all 65 residents residing in the facility. Findings Include: On 03/27/24 at 1:57 PM an interview with Medical Records #157 revealed she was also responsible for paying vendors. During the interview, Medical Records #157 revealed the facility was behind on bills, however historically when they would receive a shut off notice the company would pay the bill to avoid disruption of services. No bills were paid in January 2024 due to two upper management staff having quit leaving no one to approve the bills. Currently the septic company who does the grease traps would not return due to non-payment and TCL transportation company would not provide service as the facility owed them money. 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, medical record review, staff interview, resident interview, review of the facility assessment, and review of resident council meeting minutes, the facility failed to have sufficient nursing staff to meet the needs of residents in areas including bathing, incontinence care, toileting, interventions to prevent pressure ulcers such as turning/repositioning, answering call lights, dining service, and medication administration. This had the potential to affect all 65 residents in the facility. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 06/06/23. Review of a Minimum Data Set (MDS) assessment completed 03/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment further stated the resident was incontinent of bowel and bladder, required substantial/maximal assistance with toileting,and partial/moderate assistance with rolling left to right on the bed. The resident was not identified to…

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

Based on review of quality assurance/performance improvement (QAPI) minutes, review of the facility governing body information, review of list of previous and current Administrators and Director of Nursing, interviews, and policy review the facility failed to have an effective governing body to oversee the functions of the facility. This had the potential to affect all 65 residents residing in the facility. Finding included: Review of the facility governing body form (undated) revealed the facility was governed by a management service agreement that consists of a President, [NAME] President, Secretary, and a Treasurer. Review of QAPI minutes dated 11/2023, 12/29/23, 01/25/24, 02/22/24 and 03/29/24 revealed the November 2023 meeting minutes had no exact date the meeting was conducted, or concerns except a mock survey was conducted in the dietary department. There was no list of who attended the meeting. The December 2023 meeting minutes included the facility needed for better communication with the lab and audits were done on code status and would be repeated in December. There was…

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

Based on review of the facility record of Administrators and Directors of Nursing (DON) and interview the facility failed to notify the state agency of changes in administration. This had the potential to affect all 65 residents residing in the facility. Findings included: Review of an email from Administrator #200 dated 03/28/24 at 12:00 P.M. revealed there had been five changes in Administrator at the facility since 01/01/23: 01/01/23 to 03/06/23 Administrator #300 03/01/23 to 12/04/23 Administrator #301 12/04/23 to 03/19/24 Administrator #302 03/20/24 to 03/27/24 Administrator #101 03/27/24 to present Administrator #200. The email further revealed there had been five changes in Director of Nursing since 01/01/23: 01/02/23 to 05/24/23 Director of Nursing #303 05/22/23 to 12/04/23 Director of Nursing #304 12/04/23 to 01/25/24 Director of Nursing #305 01/25/24 to 02/07/24 Director of Nursing #306 02/05/24 to present Director of Nursing #147. Interview on 03/28/24 at 11:30 A.M., with Administrator #200 confirmed the facility did not update the state agency on changes in…

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 quality assurance/performance improvement (QAPI) minutes, interviews, and policy review the facility failed to have an effective QAPI program. This had the potential to affect all 65 residents residing in the facility. Finding included: Review of QAPI minutes dated 11/2023, 12/29/23, 01/25/24, 02/22/24 and 03/29/24 revealed the November 2023 meeting minutes had no exact date the meeting was conducted, or concerns except a mock survey was conducted in the dietary department. There was no list of who attended the meeting. The December 2023 meeting minutes included the facility needed for better communication with the lab and audits were done on code status and would be repeated in December. There was no evidence the audits were completed. The January 2024 meeting minutes didn't identify any new concerns and indicated a mock survey was conducted in October 2023 of the kitchen and recommendations were made to clean the kitchen walls and walk in coolers. The February 2024 meeting minutes revealed no concerns were identified. The March 2024 meeting minutes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of infection control log, interview, and policy review the facility failed to ensure the infection control log was comprehensive. This affected one resident (#34) of 36 reviewed for quality of control, with the potential to affect all 65 residents residing in the building. Findings included. 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including sepsis due to Escherichia coli (E. coli), urinary tract infections (UTI), diabetes, congestive heart failure, nonrheumatic aortic stenosis, presence of prosthetic heart valve, presences of cardiac pacemaker, history of transient ischemic attack, hypertensive heart disease with heart failure, sick sinus syndrome, acute respiratory failure, and anxiety. a. Review of Resident #34's orders and medication administration records dated 03/04/24 to 03/11/24 revealed the resident was ordered and received Nystatin cream to the tip of penis three times a day for yeast infection for seven days. 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.

Based on review the facility's timeline for who was the infection preventionist (IP), interview, and policy review the facility failed to ensure the IP was qualified. This had the potential to affect all 65 residents residing in the building. Findings included: Review of the facility's timeline for IP staff (undated) revealed from 07/28/23 to 10/27/23 was IP #202 and from 10/27/23 to 03/14/24 was IP #203. Interview on 03/27/24 at 1:39 P.M., with Unit Manager (UM) #164 reported she just started three days ago as the UM and IP nurse. The UM reported she just started her IP training course yesterday and has not completed it at this time. Interview on 03/28/24 at 10:14 A.M., with the Assistant Administrator (AA) #137 confirmed the facility was unable to provide evidence IP #202 and IP #203 had completed an IP training course. Review of the facility policy and procedure titled Infection Prevention and Control Program (dated 11/30/23) revealed no evidence of the IP qualifications or training requirements. Review of the facility policy and procedure titled Antibiotic Stewardship Program…

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 policy review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This affected 65 of 65 residents in the facility. Findings include: Interview with Director of Nursing (DON) #147 on 03/27/24 at 12:55 P.M. revealed when an unspecified resident was admitted to the facility on [DATE] to room [ROOM NUMBER], he had bites on him. She stated the family was bringing his personal items in and they had bites on them also so the facility stopped them from bringing in anything further. She said the facility was concerned about bed bugs so they moved the resident to another room (room [ROOM NUMBER]). She stated they shut room [ROOM NUMBER] down until it could be cleaned and they dried all of the resident's clothes in the heat of the dryer. She stated that staff said they saw one bed bug but administration did not see any. DON #147 further stated on 03/27/24 at 12:55 P.M. that on 03/16/24 two unspecified residents were moved out of room…

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 resident interview, staff interview, and policy review, the facility failed to ensure residents were treated with respect and dignity. This affected four of 50 records reviewed (Residents #13, #25, #37, and #54). The facility census was 65. Findings include: 1. Interview with Resident #13 on 03/27/24 at 9:40 A.M. revealed she hears staff arguing in the hallway. She heard a nursing assistant say you need to get your ass back there and do your job. She stated staff use the F word in the hall and staff are always on their cell phones. She stated she hears staff being reprimanded in the halls and stated residents should not have to hear these kinds of things. 2. Interview with Resident #54 on 03/27/24 at 10:50 A.M. revealed he hears nursing assistants arguing in the halls. He stated it has happened at different times and was disturbing to him. 3. Interview with Resident #37 on 03/27/24 at 11:00 A.M. revealed she has heard staff yelling in the hall things like that's your job. She stated she does not like hearing that. 4. Interview with Resident #25 on 03/27/24 at 10:33 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 medical record review, interview, and policy review the facility failed to ensure resident/responsibility parties were notified timely of changes in resident treatment and changes in condition. This affected four residents (Resident #4, #24, #31, and #44) of 36 records reviewed for quality of care. Findings included: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, heart disease, malignant neoplasm of part of the lung, acquired absence of the lung, age-related physical disability, and neuropathy. Review of Resident #44's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed the resident BIMS was 15 out of 15 (cognition intact). Review of Resident #44 paper orders dated 03/25/24 revealed new orders for discharge planning for this Friday, hemoglobin, and hematocrit (H/H) daily for four days, Carafate (prevent/treat ulcers) 1 gram twice daily for 14 days, and Gabapentin 100 milligram (mg) three times a day…

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, resident interview, staff interview, and review of resident council meeting minutes, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene in the areas of bathing and incontinence care. This affected five residents (#13, #41, #50, #54, and #79) of 36 residents reviewed for quality of care . The facility census was 65. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 06/06/23. Review of a Minimum Data Set (MDS) assessment completed 03/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment further stated the resident was incontinent of bowel and bladder, required substantial/maximal assistance with toileting,and partial/moderate assistance with rolling left to right on the bed. The resident was not identified to have any pressure areas. The plan of 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, medical record review, staff interview, policy review, and resident interview, the facility failed to provide pharmaceutical services to meet the needs of each resident. This affected 11 residents (#4, #9, #15, #16, #24, #25, #26 #35, #41, #44, and #60) of 50 residents reviewed. The facility census was 65. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 04/08/23 and diagnoses including gastroesophageal reflux (GERD), pain, dementia, and Parkinson's disease. The resident had physician's orders 01/18/24 for a nerve pain medication (Gabapentin) 100 milligrams (mg) two times daily in the morning and evening for pain, and an antacid (Pepcid) 20 mg two times daily in the morning and evening for GERD. Review of the medication administration record (MAR) for March 2024 revealed the Gabapentin and Pepcid were documented as not available and not given on the morning of 03/26/24. The facility had a Cubex/Medbank system that stored extra medications 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure residents were free of significant medication errors. This affected five residents (#16, #34, #60, #66 and #73) of 36 residents reviewed for quality of care. Findings included: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including dissection of unspecified site of aorta, hypertensive emergency, substance abuse, cerebral infarction due to embolism, acute kidney failure with tubular necrosis, and presence of coronary angioplasty implant and graft. Review of Resident #16's medication administration record (MAR) dated 03/2024 revealed the Brilinta (antiplatelet) 90 milligrams(mg) was ordered one tablet twice daily on 03/20/24, however it was never administered due to the drug was not available, and then discontinued on 03/24/24. Plavix (antiplatelet) 75 milligram (mg) once a day was started on 03/25/24. Interview on 04/02/24 at 8:46 A.M., with Certified Nurse Practitioner (CNP)…

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 reviews, interviews, and policy review the facility failed to ensure admission assessment were completed timely, skilled charting was documented daily, and appointments, wounds, and adverse reactions were documented accurately. This affected ten residents (#1, #18, #35, #41, #44, #66, #72, #77, #78, and #81) of 50 residents records reviewed. Findings included: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including lymphedema, candida esophagitis, and need for assistance with personal care. Review of Resident #1's paper and electronic medical record revealed no evidence of a consult note from an outside dental office or a dental appointment. Review of a social service note dated 11/22/22 revealed the resident had an appointment at an outside dental office on 01/30/23 and would be placed on a cancellation list. Review of a fax from a dental office dated 04/10/24 revealed the resident was only seen once on 10/25/23 and the doctor had to…

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

Based on observation, resident interview, staff interview, policy review, and record review, the facility failed to ensure residents had the right to choose bathing schedules consistent with their interests. This affected two of 50 records reviewed (Residents #1 and #41). The facility census was 65. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 03/24/22. Review of a Minimum Data Set (MDS) assessment completed 01/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the plan of care dated 01/30/24 revealed the resident preferred staff help with set up for bathing and then help with certain parts. The resident preferred a shower on Wednesday and Saturday. Interview with Certified Nurse Practitioner (CNP) #104 on 04/01/24 at 8:15 A.M. revealed Resident #1 had voiced concerns to her about not getting timely showers. She stated he was ready at 6:30 A.M. and still had not gotten a shower at 11:00 A.M. a week or so ago. Interview with Resident #1 on 04/03/24 at 7:15 A.M. revealed he…

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, resident interview, staff interview, and policy review, the facility failed to ensure a resident was provided with personal privacy. This affected one resident (#13) of 65 residents in the facility. Findings include: Observations on 03/27/24 at 9:40 A.M. revealed the surveyor was in Resident #13's room conducting an interview with the door shut. During the interview, Housekeeper #138 entered Resident #13's room without knocking. Resident #13 stated, at that time, that staff only knock on her closed door about half the time. She stated it bothered her as she could be sitting there with no clothes on. Interview with Housekeeping/Laundry Supervisor #162 on 03/27/24 at 10:20 A.M. confirmed staff should knock before entering a resident's room with the door closed. Interview with Housekeeper #138 on 03/27/24 at 10:22 A.M. revealed she sometimes forgets to knock before entering a resident's room where the door is closed. Review of the facility policy titled Resident Rights (dated 11/30/23) revealed the facility will take measures to ensure that each resident has 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 family interview, staff interview, review of grievance forms, record review, and policy review, the facility failed to make prompt efforts to resolve resident grievances. This affected two residents (Residents #44 and #50) of 50 records reviewed. The facility census was 65. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 06/06/23. Review of a Minimum Data Set assessment completed 03/15/24 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The assessment further stated the resident was incontinent of bowel and bladder, required substantial/maximal assistance with toileting,and partial/moderate assistance with rolling left to right on the bed. The resident was not identified to have any pressure areas. The plan of care dated 12/28/23 stated the resident was incontinent of bowel and bladder. Interventions included check for wetness before and after meals, at bed time, and on rounds during the night. If continent, offer 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 medical record review, interview, and policy review the facility failed to ensure resident medications were not misappropriated. This affected two residents (#42, #44) of four reviewed for pain management. Findings included: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, heart disease, malignant neoplasm of part of the lung, acquired absence of the lung, age-related physical disability, and neuropathy. Review of Resident #44's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed the resident BIMS was 15 out of 15 (cognition intact). Review of Resident #44's paper orders dated 03/25/24 revealed Gabapentin 100 milligrams (mg) three times daily for neuropathy. The order was signed off on 03/26/24 at 12:45 A.M Interview on 03/27/24 at 4:14 P.M., with Resident #44 revealed he just finally received the first dose of Gabapentin today, and his neuropathy pain was a 12 out 10. Interview on 03/27/24 from 4:18 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 medical record review, interview, and policy review the facility failed to ensure the resident received a copy of the baseline care plan. This affected one resident (#44) of 50 records reviewed. Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, heart disease, malignant neoplasm of part of the lung, acquired absence of the lung, age-related physical disability, and neuropathy. Review of Resident #44's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed the resident BIMS was 15 out of 15 (cognition intact). Review of the baseline plan of care (dated 03/11/24) revealed the resident and/or interested party was unavailable to review care plan and medication list. Printed copy left at bedside. Interview on 03/28/24 at 8:15 A.M., with Resident #44's wife confirmed they never received a copy of the baseline care plan, and it was not left in her husband's room. The resident's wife reported she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff interview, the facility failed to develop comprehensive care plans related to the prevention of and care for pressure ulcers. This affected three residents (#29, #30, and #41) of three residents reviewed for pressure ulcers. The facility census was 65. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 01/19/24 with diagnoses including Parkinsons disease and chronic pain syndrome. A Minimum Data Set (MDS) assessment completed 01/25/24 documented a brief interview for mental status (BIMS) score of 13, indicating intact cognition. It further stated the resident was dependent upon staff for toileting, showering, dressing, hygiene, rolling in bed, and transfers. The MDS indicated the resident had one Stage 3 pressure ulcer on admission. (A stage 3 pressure ulcer is a full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often…

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 interview, staff interview, and policy review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of the resident to effectively transition the resident to post-discharge care, and the reduction of factors leading to preventable readmissions. This affected one resident (#54) of 50 resident records reviewed. The facility census was 65. Findings include: Review of the medical record for Resident #54 revealed an admission date of 03/13/24 and diagnoses including morbid obesity, diabetes mellitus, hypertension, and schizophrenia. Review of an admission Minimum Data Set assessment 03/19/24 revealed the resident had a brief interview for mental status score of 15, indicating intact cognition. It stated the resident was occasionally incontinent of bowel and bladder and was not on a toileting program. Review of bladder tracking revealed the resident had been incontinent of bladder 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 medical record review, interview, and policy review the facility failed to ensure intravenous (IV) fluids were administered per orders. This affected one resident (#34) of 36 reviewed for quality of care. Findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, heart failure, sepsis, urinary tract infection, paralytic ileus, nausea with vomiting, diabetes mellitus, anemia, hyponatremia, and liver disease. Review of Resident #34's nurses note dated 03/19/24 at 2:17 P.M., revealed the resident was lying in bed saying he's not feeling well. He had eaten less than 50% of his meals. New orders received for one liter of Sodium Chloride Solution 0.9% at 100 milliliter (ml) per hour (hr.) intravenous for acute kidney injury, stool cultures for diarrhea, hold Lasix and Spironolactone for three days for acute kidney injury, stop metformin for diarrhea and acute kidney disease, completed blood count (CBC)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure aerosol treatments and antibiotics were started timely for resident with a diagnosed respiratory infection. This affected one resident (#32) of 36 residents reviewed for quality of care. Findings included: Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including pneumonia, pelvis fracture, and heart disease. Review of Resident #32's Certified Nurse Practitioner (CNP) #104's note dated 03/18/24 revealed nursing staff reported the resident had wheezing and coughing. New orders for chest-Xray and four plex-respiratory panel. Review of Resident #32's chest x-ray results dated 03/19/24 revealed the resident had right sided pneumonia. Review of Resident #32's nursing note dated 03/19/24 revealed the resident chest x-ray came back positive for pneumonia. He started having labored breathing. Oxygen two liters applied via nasal cannula. Nurse Practitioner (NP) notified and new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of grievance log, interview, and policy review the facility failed to provide medically related social services to ensure social services ensured a safe discharge and grievances/concerns were followed up with timely. This affected three residents (#50, #54, and #67) of 50 sampled residents. The facility census was 65. Findings included: Review of the grievance/concern log dated 01/2024 to 03/2024 revealed no evidence of a grievance/concern log for 02/2024. Interview on 04/01/24 at 10:49 AM with Social Service (SS) #159 revealed he can not find the grievance/concern log for February 2024. He tried reaching out to the previous SS and was not able to reach her. She was still employed by the facility as needed. 1. Record review revealed Resident #67 was admitted to the facility on [DATE] and was discharged on 03/16/24. The resident's diagnoses included orthopedic aftercare, fracture of lower end of right femur, presence of right artificial joint, asthma, pneumonia, acute kidney…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure laboratory results were obtained per orders. This affected two residents (#32 and #73) of 50 records reviewed. Findings included: 1. Closed record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, heart failure, ischemic cardiomyopathy, and presence of a pacemaker and defibrillator. The resident was discharged on 10/28/24. Review of Resident #73's orders dated 10/17/23 revealed check prothrombin/international normalized ratio (PT/INR) every Monday, Tuesday, Wednesday, Thursday, and Friday due to the resident being on an anticoagulant. Review of Resident #73's MAR dated 10/2023 revealed the resident was on Warfarin (anticoagulant) 5 milligrams (mg) daily and Plavix (antiplatelet)75 mg daily. Review of Resident #73's laboratory results dated [DATE] to 10/28/23 revealed no evidence a PT/INR was collected on 10/17/23, 10/18/23, 10/19/23, 10/20/23, 10/23/23,…

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 record review, review of infection control log, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected one resident (#34) of 36 residents reviewed for quality of care. Findings included. 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including sepsis due to Escherichia coli (E. coli), urinary tract infections (UTI), diabetes, congestive heart failure, nonrheumatic aortic stenosis, presence of prosthetic heart valve, presences of cardiac pacemaker, history of transient ischemic attack, hypertensive heart disease with heart failure, sick sinus syndrome, acute respiratory failure, and anxiety. Review of Resident #34's urinalysis results, which were not in the medical record and faxed to the facility on [DATE], dated 03/05/24 revealed the resident tested positive for Enterobacterales and Klebsiella pneumoniae (ESBL) 03/07/24 and contact isolation protocols should be used with this resident. There…

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