Saint Luke Lutheran Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, review of in-room videos, review of the facility self-reported incident, and review of facility policy, the facility failed to ensure Resident #117 was free from physical abuse. This affected one (#117) of four residents reviewed for abuse. The facility census was 121.Findings include:Review of the medical record for Resident #117 revealed and admission date of 12/29/25. Diagnoses included but were not limited to neurocognitive disorder with Lewy Bodies dementia, generalized anxiety disorder and Alzheimer's disease with late onset. Resident #117 was also noted to receive hospice services.Review of Resident #117's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required maximum assistance for toileting hygiene. Review of Resident #117's care plan last reviewed on 01/14/26 revealed Resident #117 was receiving hospice services, was noted to have self-care deficits and required staff assistance 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 observation, record review, resident interview, staff interview, and policy review, the facility failed to implement their abuse policy when Resident #6's allegation of abuse and staff concerns regarding the neglect of care for Resident #10 were not reported to the Administrator. Additionally the facility failed to ensure Resident #47's injury of unknown origin were reported to the State Agency. This affected three (#6, #47 and #10) of four residents reviewed for abuse. The facility census was 121. Findings include: 1.Review of the medical record for Resident #6 revealed an admission date of 11/28/2025. Diagnoses included ischemic cardiomyopathy, acute respiratory failure with hypoxia, chronic atrial fibrillation, chronic obstructive pulmonary disease with acute exacerbation, diabetes mellitus, anxiety disorder, and depression. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. Review of Resident #6's March 2026 physicians orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of facility Self-Reported Incidents (SRIs) and policy review the facility failed to complete an investigation for Resident #47 and also failed to complete a thorough investigation for Resident #117 as required. This affected two (#47 and #117) of three residents reviewed for abuse. The facility census was 121. Findings include:1.Review of the medical record for Resident #117 revealed an admission date of 12/29/25. Diagnoses included but were not limited to neurocognitive disorder with Lewy Bodies, generalized anxiety disorder, chronic pain syndrome and Alzheimer's dementia. Review of the physician's orders revealed an order dated 12/30/25 for Resident #117 for hospice services. Review of the 01/02/26 admission Minimum Data Set (MDS) 3.0 for Resident #117 revealed a Brief Interview of Mental Status (BIMs) of four which indicated severe cognitive impairment. Resident #117 was noted to require maximum staff assistance with toileting. Review of the facility Self-Reported…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and policy review, the facility failed to ensure adequate monitoring, assessments, and wound treatments were completed as ordered. This affected one (#31) of one resident reviewed for wounds. The facility census was 121. Findings include: Review of Resident #31's medical record revealed the resident was admitted on [DATE] and expired in the facility on [DATE]. Diagnoses included Alzheimer's disease, and peripheral vascular disease. Resident #31 was discharged to the hospital on [DATE] and returned to the facility on [DATE] status post (s/p) right great toe amputation on [DATE]. Review of Resident #31's Discharge Return Anticipated MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #31's admission Assessment form (readmission) dated [DATE] revealed the resident was unable to understand and had surgical incisions of the right hip and right great toes. Review of Resident #31's history and physical dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and policy review, the facility failed to implement pressure ulcer prevention interventions and treatments. This affected one (#10) of three residents reviewed for pressure ulcers. The facility census was 121. Findings include:Review of the medical record for Resident #10 revealed an admission date of 01/30/26 with diagnoses including heart failure, diabetes mellitus and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was dependent for toileting, showers and transfers. Resident #10 was occasionally incontinent of bowel. He had no skin impairment noted on this assessment. Review of the care plan dated 02/10/26 for Resident #10 revealed he was at risk for skin breakdown related to incontinence of bowel, having an indwelling device, impaired mobility, weakness and age-related changes. Interventions included to notify the physician of skin problems and treatments would be initiated per orders.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident #117 received a thorough fall investigation and failed to ensure fall interventions were in place for Resident #8. This affected two (#117 and #8) of four residents reviewed for falls. The facility census was 121. Findings include:1.Review of the medical record for Resident #117 revealed the resident was admitted on [DATE] with diagnoses including Lewy Bodies Dementia, chronic pain syndrome and Alzheimer's disease. Review of Resident #117's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #117's care plan dated 01/01/26 revealed a risk for falls characterized by history of falls/injury and multiple risk factors. Interventions included analyzing previous resident falls to determine whether pattern/trend can be addressed, call light accessible, and if a fall occurs, assess factors leading to fall and notify the doctor and family of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure Resident #10's foley catheter output was monitored as ordered. This affected one (Resident #10) of three reviewed for catheters. The facility census was 121. Findings include:Review of the medical record for Resident #10 revealed an admission date of 01/30/26 with diagnoses including heart failure, diabetes mellitus and muscle weakness.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was dependent for toileting, showers and transfers. Resident #10 was occasionally incontinent of bowel and had an indwelling catheter.Review of the care plan dated 02/10/26 for Resident #10 revealed he had an indwelling catheter. Interventions included for staff to record input and output.Review of the physician's orders for Resident #10 revealed he had an order for staff to record foley output every shift (day, evening and night shift) dated 02/03/26 and discontinued 02/26/26. His physician's orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, staff interview, and the facility policy review the facility failed to ensure Resident #01's percutaneous endoscopic gastrostomy (PEG) tube dressing was in place. This affected one of one residents reviewed for PEG tube care. The facility census was 121. Findings include:Review of Resident #01's medical record revealed a facility admission date of 01/31/26 with a diagnosis of pneumonitis due to inhalation of food and vomit.Review of Resident #01's Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 had a feeding tube.Review of Resident #01's physician orders revealed an order for PEG tube site care to cleanse around the PEG tube site with normal saline daily and apply a split dry dressing every night shift.Review of Resident #01's enteral nutrition care plan, dated 02/18/26, revealed no PEG tube dressing care listed as an intervention in the care plan.Review of Resident #01's treatment administration record revealed the PEG tube dressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered. This affected three (#1, #4 and #47) of seven residents reviewed for medications administration. The facility census was 121.Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 04/20/23 with diagnoses including chronic respiratory failure, diabetes mellitus, chronic kidney disease and depression.Review of the current physician's orders revealed Resident #1 had orders dated 01/31/26 for Albuterol Sulfate Inhalation 2.5 milligrams (mg) per 3 milliliters (mL), inhale orally three times a day for shortness of breath, Clonidine 0.1 mg every eight hours for hypertension, Gabapentin 400 mg three times a day for pain, and Hydralazine 100 mg three times a day for hypertension. Review of the Medication Administration Record (MAR) for February 2026 for Resident #1 revealed Albuterol Sulfate was not administered on 02/05/26, 02/08/26 and 02/22/26 at 6:00 A.M. and on 02/22/26 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to ensure monthly pharmacy recommendations were completed timely and further failed to ensure the physician order for pharmacy recommendations were followed. This affected two (#4 and #6) of five residents reviewed for unnecessary medications. The facility census was 121. Findings include:1. Review of the medical record for Resident #4 revealed an admission date of 05/31/24 with diagnoses including chronic kidney disease, depression and anxiety. Review of the pharmacy recommendation dated 03/20/25 revealed the pharmacist reviewed Resident #4's medication and inquired if a gradual dose reduction of either Fluoxetine 20 milligrams (mg) (antidepressant) or Hydroxyzine 10 mg (antihistamine with sedative properties used to treat anxiety and itching) would be appropriate at that time. The physician had responded on 06/09/25, stating to discontinue the Hydroxyzine. Review of the physician orders revealed no order to discontinue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were free of significant medication errors. This finding affected two (Residents #85 and #141) of seven residents reviewed for medication administration. The facility census was 121.Findings include:1. Review of Resident #141's medical record revealed the resident was admitted on [DATE] and discharged back to the assisted living facility on 02/06/26. Diagnoses included cellulitis, anemia and depression. Review of Resident #141's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #141's care plan dated 01/23/26 revealed the resident was on an antibiotic and an intervention was to administer medications as ordered. Review of Resident #141's physician orders revealed an order dated 01/10/26 for meropenem (broad-spectrum intravenous (IV) antibiotic used to treat severe bacterial infections), one gram intravenously every eight hours for cellulitis to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, review of storage information, and facility policy review, the facility failed to ensure insulin pen injectors were disposed of when expired and the facility failed to ensure medications were not left at bedside. This affected one (#85) of one resident reviewed for medications at bedside and two (#104 and #01) of two residents receiving insulin. The facility census was 121. Findings Include:1. Review of Resident #104's medical record revealed a facility admission date of 04/19/23 with the diagnosis of type II diabetes mellitus. Review of Resident #104's physician orders revealed an order for Humalog subcutaneous solution pen injector 100 units per milliliter and to give two units with meals. Observation on 03/05/2026 at 8:24 A.M. of the Ridgeview medication cart with Licensed Practical Nurse (LPN) #897 revealed two expired Humalog pens dated 01/28/26 and 01/29/26 for Resident #104. LPN #897 verified the medication cart contained two Humalog insulin pens for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) were used for Residents #01, #69, and #10. This affected three (#01, #69 and #10) of three residents reviewed for EBP. The facility census was 121. Findings include:1. Review of Resident #01's medical record revealed an admission date of 01/31/26 with diagnoses including pneumonitis due to inhalation of food and vomit. Review of Resident #01's Minimum Data Set (MDS) assessment, dated 02/02/26, revealed Resident #01 had a feeding tube. Review of Resident #01's physician's orders revealed an order for enhanced barrier precautions (EBP) due to a percutaneous endoscopic gastrostomy (PEG) tube each shift. Review of Resident #01's care plan, dated 02/18/26, revealed there were no enhanced barrier precautions listed as an intervention for the PEG tube administration. Observation on 03/05/2026 at 11:50 A.M. of Resident #01's medication administration with Agency Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, review of room temperature logs, and interview, the facility failed to ensure room temperatures and temperatures in common areas were maintained within the required range and for the comfort of residents. Room temperature monitoring revealed inappropriate room temperatures in four (rooms 147, 171, 270 and 275) of 11 resident rooms and three of seven common areas affecting seven residents (Residents #29, #40, #46, #52, #68, #72 and #73) and two unidentified residents. The census was 118.Findings Include: On 01/28/26 between 9:20 A.M. and 9:52 A.M., random room temperatures were monitored by Maintenance Technician #200, using the facility ambient thermometer. The following rooms/areas were identified to be outside the regulatory temperature ranges: (temperatures were measured in Fahrenheit)a. Review of Resident #52's medical record revealed diagnoses including type two diabetes mellitus and hypertension. A Brief Interview for Mental Status (BIMS) assessment dated…

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

Based on observation, policy review, and interview, the facility failed to ensure medications remained in their original labeled packaging and failed to ensure insulin pens and vials were appropriately labeled and not used past the expiration date. Improper medication storage was identified in two of four medication carts observed. This affected three residents (Residents#22, #86 and #113). The facility census was 118.Findings Include: 1. On 01/28/26 at 12:30 P.M., the Ridgeview medication cart was observed with Licensed Practical Nurse (LPN) #230. There was an unlabeled vial of open Lantus insulin. The vial was not designated as belonging to a specific resident. On 01/28/26 at 12:30 P.M., LPN #230 stated the vial of Lantus insulin had to belong to Resident #86 because he was the only resident whose medications were stored on the cart that received Lantus insulin. LPN #230 verified the vial was unlabeled with no specific residents, instructions for use, or documentation of when the vial was opened. LPN #230 stated she would have to discard the vial.2. On 01/28/26 at 12:51 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 observation, review of the medical record, interview, and review of the facility policy, the facility failed to ensure the privacy of Resident #118's medical record was maintained and failed to ensure privacy was maintained during care for Resident #54. This affected two residents (Resident #54 and #118) of five observed for privacy. Findings Include:1. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included diabetes mild cognitive impairment, hypothyroidism, hypertension, generalized anxiety disorder, dementia, personality disorder, peripheral vascular disease, and bipolar disorder.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 had intact cognition.Observations on 12/31/25 from 9:30 A.M. to 9:35 A.M. revealed Resident #118's medical information was visible on the computer at the unattended medication cart in the hallway. The medical information listed was the residents' medications list, and identifier…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of shower schedules, interview, and review of the facility policy, the facility failed to ensure personal bathing preferences were accommodated and showers were documented/completed for Resident #27. This affected one resident (#27) out of three residents reviewed for bathing.Findings Include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included volvulus, urinary tract infection osteoarthritis, peripheral neuropathy, breast cancer, skin cancer, acute embolism of right lower extremity, and osteoporosis.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition and did not refuse care. She required moderate assistance with bathing.Review of the nurse's note dated 10/06/25 at 2:57 P.M. revealed Resident #27 refused to shower this shift, stating she would not take a shower after 7:30 A.M. Review of the nurse's note dated 12/15/25 at 2:10 P.M. revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, observation, and facility policy review, the facility failed to ensure systems were in place to provide appropriately sized incontinence products to residents, subsequently leading to Resident #79's development of moisture-associated skin damage (MASD). Additionally, the facility failed to ensure Resident #79 was comprehensively assessed after developing MASD. This affected one resident (#79) of three residents reviewed for adequate supplies. Findings Include:Review of the medical record revealed Resident #79 admitted to the facility on [DATE]. Diagnoses included displaced bimalleolar fracture of the right lower leg, chronic obstructive pulmonary disease, rheumatoid arthritis, glaucoma, congestive heart failure, atrial flutter, vertigo, tachycardia, spinal stenosis, and insomnia.Review of the admission assessment dated [DATE] revealed Resident #79 had no skin issues. Review of the admission Braden Scale dated 11/26/25 revealed Resident #79 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 observation, interview, policy review and review of material safety data sheet (MSDS), the facility failed to ensure possible hazardous areas and materials were properly secure on the memory care unit. This had the potential to affect 25 residents (#2, #8, #10, #12, #16, #30, #38, #39, #40, #45, #54, #60, #64, #65, #71, #79, #87, #89, #92, #94, #100, #115, #118, #121, and #129) that were able to ambulate and propel in wheelchairs on the memory care unit. Facility census was 129.Findings include:An observation of the memory care unit on 11/17/25 at 12:06 P.M. revealed the door to the soiled utility room located on Somerset Hall was unlocked. The soiled utility room had barrels for soiled linens and trash. Several wheelchairs and other equipment were located in the soiled utility room. An observation of the memory care unit on 11/18/25 at 2:31 P.M. revealed the door to the clean utility room located on Greenbriar Hall was unlocked. There were two containers with 160 wipes in each of Microkill Germicidal Wipes The shelving unit would be accessible to residents standing 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 policy review the facility failed to ensure resident representatives received room change notification. This affected one resident (#121) of three residents reviewed for family notifications. The census was 129.Findings include: Review of the medical record for Resident #121 revealed an admission date of 06/07/23. Diagnoses included but not limited to acute kidney failure, dementia, and unspecified psychosis. Resident #121 resided on the secured, locked, memory care unit.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 14 out of 15 on the Brief Interview Mental Status (BIMS) indicating intact cognition.Review of Resident #121's medical record revealed a progress note dated 10/10/25 at 11:13 A.M., late entry, the patient was moved from (current room) to (current room) and was showered and changed.There was no indication in the medical record Resident #121's representative received notification of the room change.Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident #81 was administered intravenous antibiotics as ordered resulting in a significant medication error. This affected one (Resident #81) out of three residents reviewed for medication administration. Facility census was 129.Findings include: A review of the medical record revealed Resident #81 was admitted on [DATE] with diagnoses that included sepsis due to pseudomonas, osteomyelitis of right ankle and foot, and type 2 diabetes. Resident #81 was ordered to receive intravenous antibiotics.Review of Printable Hospital Discharge Form in the medical record revealed on 10/21/25 at 10:58 A.M. Hospital Case Manager #497 wrote the only other option if Avycaz (intravenous antibiotic to treat serious Gram-negative bacterial infections, a combination antibiotic of ceftazidime and avibactam) was too expensive, would be Fetroja (an antibiotic to treat serious bacterial infections). Hospital Case Manager #497 asked to be notified if one or the other…

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

Based on medical record review and interview the facility failed to timely assess and obtain necessary treatment for Resident #207 for a urinary tract infection. This affected one resident (#207) of three residents reviewed for urinary tract infection. The facility census was 127. Findings include: Review of Resident #207's medical record revealed an admission date of 02/22/25 with diagnoses including chronic atrial fibrillation, hypothyroidism and congestive heart failure. Review of the Resident #207's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 08/29/25 revealed the resident had moderate cognitive impairment and was dependent upon staff for assistance with toileting and always incontinent of urine. Review of the nursing progress notes, dated 09/28/25 at 1:12 P.M. revealed Resident #207 complained of burning during urination and a new order was obtained to straight cath (inserting catheter into the bladder to obtain urine) for urine sample and the family was notified. Review of the nursing notes revealed no evidence of any documentation of family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility temperature log review, policy review and interview, the facility failed to ensure the boiler systems were functional and operational for resident/staff access to adequate hot water. This had the potential to affect all 124 residents residing in the facility. Findings Include: Review of facility concern logs for [DATE] revealed there was a concern with hot water running and resolution of repairs being made. In [DATE] there was a concern of water temperatures being Lukewarm. Interview on [DATE] at 6:39 A.M. with Certified Nursing Assistant (CNA) #378 revealed there had been no hot water on the memory care unit for the past couple weeks. CNA #378 reported this had affected the staff ability to assist with showers. Observation on [DATE] from 6:52 A.M. to 7:03 A.M. on the Memory Care Unit with CNA #378 of resident rooms of the water from the hot water spigot revealed the following: Resident #27's hot water spigot was turned on and the surveyor placed a hand in the…

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

Based on observation, record review, facility temperature log review, policy review and interview, the facility failed to ensure a clean, comfortable and homelike environment. The facility failed to ensure water temperatures were maintained at a comfortable level for resident bathing/showers, failed to maintain an adequate supply of clean bath linens for resident use and failed to ensure garbage bags were available and provided in resident rooms to contain trash. This affected 11 residents (#3, #20, #27, #30, #32, #44, #96, #100, #111, #113 and #124) reviewed for water temperatures, one resident (#40) reviewed for linen availability with the potential to affected an additional undetermined number of residents based on staff interview and four residents (#32, #40, #44, and #48) reviewed for garbage disposal. The facility census was 124. Findings include: During the onsite investigation, the following environmental concerns were identified: 1. Review of facility concern logs for June 2025 revealed there was a concern with hot water running and resolution of repairs being made. 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 record review, interview, and facility policy review, the facility failed to ensure care plans were comprehensive. This affected three residents (Resident #62, #93, and #125) of 10 residents reviewed for care plans. Facility census was 124. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 08/02/25 and diagnoses included pneumonia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 had impaired cognition. Review of the physician order dated August 2025 revealed Resident #62 received Eliquis (anticoagulant) 5 milligram (mg) one (1) tablet in the morning and 1 tablet in the evening (HS).Review of the care plan dated 08/02/25 revealed there was no care plan for anticoagulant therapy.Interview on 08/28/25 at 10:27 A.M. with Minimum Data Set (MDS) Registered Nurse (RN) #260 confirmed there was no anticoagulant therapy care plan for Resident #62 and there should have been. Review of facility policy, Care Plans, Comprehensive,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, care conference postcard and letter invitation review, interviews and policy review the facility failed to ensure care plan meetings were offered timely, per preference, and in person. This affected one (Resident #40) of three residents reviewed for care plan meetings. The facility census was 124.Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/16/22. Diagnoses included but not limited to encephalopathy, bipolar disorder, schizophrenia, psychosis and dementia. with behavioral disturbance.Review of the quarterly minimum data set (MDS) dated [DATE], revealed Resident #40 scored a zero on the brief interview mental status (BIMS) out of 15, resulting in severely impaired cognition. Resident #40 was dependent on staff for all her care needs to include toileting, showering, and eating.Interview on 09/10/25 at 9:45 A.M. with Resident #40's family member revealed she was not offered any care conferences in over five (5) months with the last 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.

Based on interviews and closed medical record review, the facility failed to ensure physician orders were followed and the physician was contacted with elevated blood pressure findings. This affected one resident (125). The facility census was 124.Findings included: Review of the closed medical record for Resident #125 revealed an admission date of 07/16/25 and a discharge date home of 07/21/25. Diagnosis included but not limited to fracture of sacrum pubis, and wedge compression fracture of T11-T12 Vertebra, malignant neoplasm of glottis, and chronic venous hypertension with ulcer of left lower extremity.Review of the physician orders dated 07/16/25 for Resident #125 revealed an order for orthostatic blood pressure (BP) times (x) three (3) shifts every shift for lying BP, sitting BP, and standing BP.Review of the physician orders dated 07/17/25 for Resident #125 revealed an order for transfers: two person physical assist every shift.Review of the blood pressure readings for Resident #125 revealed on 07/17/25 at 1:07 A.M. lying blood pressure (BP) was 186/99 and sitting BP 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 observation, interviews and policy review, the facility failed to ensure meals were served timely on the Memory Care Unit. This affected all 33 residents residing on the Memory Care Units (Resident #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, and #51). The facility Census was 124. Findings include: Interview on 09/10/25 at 9:45 A.M. with Resident #40's family reported the food trays are always late to the dining room by almost an hour.Observation on 09/11/25 at 12:00 P.M of the dining room in Memory Care Unit revealed 17 residents were seated and awaiting their lunch meals.Interview on 09/11/25 at 12:13 P.M. with Certified Nursing Assistant (CNA) #353 confirmed meals are late.Interview on 09/11/25 at 12:13 P.M. with CNA #408 confirmed meals are late.Observation on 09/11/25 at 12:37 P.M. revealed the first meal cart arrived to the unit. Seven (7) staff (two unidentified staff and CNA #345, CNA #353, CNA #375, CNA #408, and Licensed Practical Nurse (LPN) #331)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement infection control procedures during medication administration. This affected one resident (#100) of five residents observed for medication administration. The facility census was 124.Findings include: Review of record for Resident #100 revealed an admission date of 08/20/22. Diagnosis included but not limited to volvulus, history of malignant neoplasm of the breast and skin, and absence of parts of the digestive tract and of both cervix and uterus.Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #100 had intact cognition.Review of the physician orders for August 2025 revealed Resident #100 was ordered Vitamin D3 50 microgram (mcg) give two capsules by mouth (PO) in the morning.Observation of medication administration on 08/28/25 at 8:15 A.M. revealed with Registered Nurse (RN) #316 administered Vitamin D3 50 mcg one capsule to Resident #100. RN #316 then realized the order was for Vitamin D3 50 mcg 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 interviews, record reviews, policy review, and staffing schedules, the facility failed to ensure they were adequately staffed to ensure Residents ( #7, #9, #14, #17, #20, #22, #23, #24, #25, #26, #28, #29, #32, #33, #37, #38, #41, #44, #50, #51, #52, #59, #62, #66, #73, #74, #75, #77, #89, #92, #95, #96, #100, #110, #115, #122, #125, #126, #127, #135, #139, and #145) were adequately supervised, provided incontinence care, had medications administered as ordered, had treatments completed as ordered, and received meal trays. This affected 42 Residents( #7, #9, #14, #17, #20, #22, #23, #24, #25, #26, #28, #29, #32, #33, #37, #38, #41, #44, #50, #51, #52, #59, #62, #66, #73, #74, #75, #77, #89, #92, #95, #96, #100, #110, #115, #122, #125, #126, #127, #135, #139, and #145) out of 141 residents. However, this had the potential to affect all residents. The facility census was 141. Findings include:1. Review of the call light times for 07/05/25 revealed at 7:24 A.M. Resident #110's call light was on for two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and test tray results, the facility failed to maintain palatable and appetizing food temperatures. This had the potential to affect all but two residents ( Resident #68 and Resident #66) who did not receive a meal tray from the kitchen. The census was 144. Findings include: 1.Review of Resident #39's medical record revealed an admission date of 03/27/23. Medical diagnosis included nontraumatic intracranial hemorrhage, pneumonia, depression, anxiety, bipolar and dementia. Review of Minimum Data Set ( MDS) 3.0 quarterly assessment dated [DATE] revealed cognition was moderately impaired. No rejection of care was noted. Resident #39 needed supervision to eat. Review of Nutrition assessment dated [DATE] revealed Resident #39 was on a regular diet consistency, regular liquid consistency with a no added salt restriction. Interview on 07/02/25 at 1:02 P.M. with Resident #39 who stated the chicken was too hard to chew and cut, ,therefore, she did not eat the chicken 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, review of facility billing/financial information, review of the facility assessment, review of the Administrator's job description, and interviews the facility failed to ensure effective and efficient administration to meet the total care needs of all residents in the facility. The facility census was 141. Findings include: Review of survey history revealed the facility was cited neglect for financial solvency and this had not been resolved or corrected as of the 08/04/25 survey resulting in a recite for neglect and substandard quality of care.On 07/08/25 at 10:10 A.M. an interview with Human Resources #509 revealed the Administrator started his position August 26, 2024. 2. On 06/27/25 at 11:04 A.M. an interview with FMD #727 revealed the facility terminated his position on 04/30/25 as the medical director and had not paid for his services for the past thirteen months.Review of document titled Medical Director Invoice Number 03022025, billed to 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 Record review, facility policy review, facility assessment, and interviews , the facility failed to ensure an effective governing body, legally responsible for establishing and implementing policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 141 residents in the facility. Findings include:Review of the facility survey history revealed on 05/12/25 a complaint survey was completed which resulted in concerns related to financial solvency under neglect at substandard quality of care However, at the time of the complaint survey completed 08/04/25, the facility failed to ensure their governing body was effective in establishing and implementing policies in regard to the management and operation of the facility, which included ongoing compliance with all financial obligations for the delivery of care as detailed below.1. On 06/27/25 at 11:04 A.M. an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interviews and facility policy review, the facility failed to maintain a sanitary and homelike environment. This affected three residents (Resident #11, #53 and #65) but had the potential to affect all 141 residents. Findings include:1.Resident #11 was admitted to the facility on [DATE]. Medical diagnosis included fracture of femur, cerebral infarction, major depression , hypertension and hemiplegia.Review of Minimum Data Set (MDS) 3.0 annual assessment revealed Resident #11's cognition was not intact and did not reject care. Observation on 06/26/25 at 7:57 A.M. of Resident #11's room revealed old spoons, cracker wrappers, old mild and cereal from 06/25/25. Licensed Practical Nurse (LPN) #500 verified the findings and stated she was unsure if housekeeping cleaned Resident 11's room. 2.Observation on 06/30/25 from 9:30 A.M. to 11:19 A.M. with Maintenance worker #607 revealed the shower room on the Twin Hills unit had a black ring inside the toilet bowel above the water…

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

Based on observation, interview, and policy review, the facility failed to ensure medications were secure on the memory care unit. This had the potential to affect all 35 residents on the memory care unit. The facility census was 141. Findings include:An observation on 07/09/25 at 9:54 A.M. revealed nine residents were in the dining room on the memory care unit. A medication cart was sitting against the wall in the dining room. The medication cart lock was not pushed in to lock the cart. A large bottle of acetaminophen (for fever or pain) 500 milligrams was sitting on the top of the medication cart. The lid was off the acetaminophen and lying on the cart. There were approximately 15 to 20 tablets in the open bottle of acetaminophen. A Certified Nursing Assistant (CNA) was assisting residents out of the dining room. On 07/09/25 at 9:55 A.M. Licensed Practical Nurse (LPN) #639 came quickly down the hallway and stated she had just stepped away for a moment. LPN #639 verified the medication cart was unlocked and there was an open bottle of acetaminophen sitting on top of the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #37 was provided with a diet texture as ordered. This had the potential to affect eight residents ( Resident #34, #81, #95, #97, #98, #101, #134, and #135) who received puree diets. The facility census was 141. Findings include: Resident #37 was admitted to the facility on [DATE]. Medical diagnosis included Alzheimer's disease, osteoarthritis, hypertension, major depressive disorder, type two diabetes, dementia and encephalopathy. Review of physician orders dated 02/23/24 revealed Resident #37 was ordered a puree diet with thin liquid consistency. Review of Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE], revealed Resident #37 had short and long term memory problems. Resident #37 needed moderate assistance to eat and had no loss of liquids from mouth or was holding food in mouth or choking during meals during the review period. Resident #37 was on a mechanically altered and therapeutic diet. Review of Nutritoin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, facility email, medical record review, and policy review, the facility failed to ensure Resident #26 was treated with dignity and respect. This affected one (Resident #26) out of three residents reviewed for dignity and respect. The facility census was 141. Findings include: Review of the medical record revealed Resident #26 was admitted on [DATE] with diagnoses that included hypertension, chronic kidney disease stage four, dehydration, hyponatremia, polyarthritis, depressive disorder, diabetes mellitus, moderate calorie malnutrition, and anxiety disorder. Review of the Preferences for Routines and Activities dated 02/12/25 revealed it was very important to Resident #26 to choose her own bedtime. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 required partial to moderate assistance for transfer from chair to bed. Review of an email from Director of Nursing (DON) to Ombudsman dated 07/16/25 at 6:00 P.M. revealed Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure residents had access to funds in a reasonable amount of time. This affected four residents ( Resident #139, #38, #22, and #85) of four residents reviewed for resident funds. The facility managed 40 resident fund accounts. The facility census was 141. Findings include : 1. 1. Resident #139 was admitted to the facility on [DATE]. Medical diagnosis included type two diabetes, gastroesophageal reflux disease, hypothyroidism, hypertension, anxiety, osteoporosis, dementia, major depressive disorder, personality disorder, bipolar disorder.Review of Minimum Data Set ( MDS) 3.0 quarterly assessment dated [DATE] revealed cognition was intact and did not exhibit hallucinations or delusions. Resident #139 was her own financial responsible party and Primary Payer source was Care Source Medicaid.Interview on 07/14/25 at 10:16 A.M. with Resident #139 revealed she could not receive fifty dollars from petty cash on 07/13/25. Resident #139 stated she needed her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor Resident #145's power-of-attorney (POA) request for Depakote (mood stabilizer) to be held. This affected one (Resident #145) out of three residents reviewed for choices. The facility census was 141.Findings include:Review of the medical record revealed Resident #145 was admitted on [DATE] with diagnoses that included ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. A progress note dated 07/02/25 at 9:20 A.M. revealed Resident #145's POA visited and had multiple questions. Resident #145's POA re-iterated she did not want Resident #145 on any medications containing a black box warning. The POA's conversation and concerns were reported in a binder for the provider to address. A psychiatric evaluation note dated 07/10/25 revealed Resident #145 was a [AGE] year-old male presented for initial psychiatric evaluation. The assessment note revealed Resident #145 was to continue Zoloft…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify Resident #145's family and physician in a timely manner of changes in behavior and medications. This affected one (Resident #145) out of three reviewed for notifications. Facility census was 141.Findings include:Review of the medical record revealed Resident #145 was admitted on [DATE] with diagnoses that included ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive.A care plan dated 06/25/25 revealed Resident #145 had inappropriate behavior and was resistive to care. Interventions included allowing flexibility in activities of daily living routine to accommodate mood, elicit family input for best approaches to resident, and if Resident #145 refused care, and leave Resident #145 and return in 5-10 minutes. a. A progress note dated 06/29/25 at 2:39 A.M. revealed Resident #145 had a skin tear to the left elbow that measured one centimeter (cm) long and three cm wide. An additional progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility investigation, self-reported incident (SRI), and policy review, the facility failed to complete a thorough and adequate investigation in a timely manner. This affected one (Resident #145) out of two reviewed for abuse. The facility census was 141.Findings include: Review of the medical record revealed Resident #145 was admitted on [DATE] with diagnoses that included ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive.A care plan dated 06/25/25 revealed Resident #145 had inappropriate behavior and was resistive to care. Interventions to allow flexibility in the activities of daily living routine to accommodate mood, elicit family input for best approaches to Resident #145, and leave and return in five to ten minutes if Resident #145 refuses care. Review of video footage of the hall and common area outside Resident #145's room revealed on 07/06/25 at 5:46 A.M. Resident #145 walked out into 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 and interview, the facility failed to ensure an assessment was completed before Resident #145 was placed on the secure/memory care unit. This affected one (Resident #145) out of three reviewed for placement on the secure unit. The facility census was 141. Findings include:Review of the medical record revealed Resident #145 was admitted on [DATE] with diagnoses that included ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive.A care plan dated 06/25/25 revealed Resident #145 wanted to go home and was an elopement risk related to behaviors of pacing the halls and wandering into resident rooms. Interventions included to check function of secure tech bracelet weekly, reinforce reasons for placement, and encourage family involvement/support.Review of the medical record revealed no evidence of an assessment being completed to ensure Resident #145 was appropriate for placement on a secure unit.An interview on 07/14/25 at 8:46 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 interview and record review, the facility failed to ensure Resident #145 had an individualized care plan in place to address behaviors. This affected one (Resident #145) out of three residents reviewed for care plans. The facility census was 141.Findings include:Review of the medical record revealed Resident #145 was admitted on [DATE] with diagnoses that included ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive.A care plan dated 06/25/25 revealed Resident #145 had inappropriate behavior and was resistive to care. Interventions included to allow flexibility in activities of daily living routine to accommodate mood, elicit family input for best approaches to resident, and if resident refuses care, leave and return in five to ten minutes. The Kardex report printed 07/14/24 for the Certified Nursing Assistants (CNA) revealed no indication of Resident #145 having behaviors or interventions for behaviors. The CNA report sheet (no date) 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 record review, interview, and policy review, the facility failed to provide residents who were dependent with bathing, two showers a week. This affected one (Resident #77) out of three reviewed for activities of daily living (ADL). The facility census was 141.Findings include:Review of the medical record revealed Resident #77 was admitted on [DATE] with diagnoses that included multiple sclerosis, recurrent depressive disorders, and chronic kidney disease.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact. The MDS also revealed Resident #77 was dependent on staff for bathing. Review of the bathing documentation revealed Resident #77 received a shower on 07/03/25, 07/10/25, and 07/17/25. Resident #77 received a bed bath on 07/24/25. An interview on 07/28/25 at 1:55 P.M. Director of Nursing (DON) verified Resident #77 did not receive a shower twice a week as scheduled. An interview on 07/28/25 at 2:41 P.M. Resident #77 verified she only received one shower a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on obervation, review of video and photographic images, review of the facility assessment, review of the facility admission agreement, review of utility bills, review of vendor/supplier invoices, interview with staff, residents, facility vendors and medical supply companies and utility company representatives, the facility failed to effectively manage financial obligations required to secure the necessary resources required to ensure the ongoing appropriate delivery of care to meet the needs of the residents resulting in potential situations of resident neglect. This had the potential to affect all 132 residents residing in the facility. Findings include: On 05/01/25 at 2:11 P.M. confidential information provided to the State agency revealed concerns related to the facility not paying their bills for trash removal, thereby causing garbage to be piled up in the facility's basement and a maintenance truck full of expired foods that were unable to be removed from the property due to the lack of trash removal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plans were comprehensive for Residents #102 and #122. This affected two residents (#102 and #122) of six residents whose care plans were reviewed. The facility census was 132. Findings include: 1. Review of the medical record for Resident #122 revealed an admission date of 09/01/23. Diagnoses included heart disease, kidney disease, hearing loss, anxiety and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #122 was severely cognitively impaired. She required set up help for eating and oral hygiene, supervision for toileting, substantial assistance for showering and dressing and was dependent on staff for personal hygiene. She displayed physical behavioral symptoms such as hitting, kicking, pushing and scratching, verbal behaviors such as threatening and screaming at others and often rejected care. Review of the care plan dated 02/09/25 revealed no evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records, interviews, review of the shower schedule, and review of facility policy, the facility failed to provide assistance with bathing services as scheduled to Residents #67 and #102. This affected two residents (#67 and #102) of three residents who were reviewed for assistance with activities of daily living (ADL). The facility census was 132. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 06/11/19. Diagnoses included encounter for orthopedic aftercare following surgical amputation, dysphagia, anorexia, urinary incontinence, adult failure to thrive, gastrostomy status, atrial fibrillation, unspecified dementia, difficulty walking, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment completed on 02/03/25 revealed Resident #67 had severely impaired cognition and was dependent on staff for all ADL, including bathing. Review of the care plan dated 01/24/19 through 07/29/25 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.

Based on observation, record review, interview and facility policy review, the facility failed to maintain a clean and sanitary environment. This affected 33 residents (#2, #5, #6, #15, #20, #28, #34, #37, #38, #39, #41, #47, #51, #52, #53, #56, #68, #73, #74, #78, #79, #80, #86, #92, #95, #98, #116, #118, #119, #120, #122, #124 and #125) on the memory care unit and had the potential to affect all 132 residents in the facility. Findings include: Observation on 05/05/25 at 9:26 A.M. of the memory care unit revealed two ceiling tiles in the common area living room removed and a red bucket on the floor underneath. Interview with Certified Nurse Aide (CNA) #309 at the time of the observation confirmed the ceiling tiles had been removed when she came into work, and she believed the bucket was to catch any liquids that may have been dripping. Observations on 05/05/25 at 12:45 P.M. of the laundry area revealed a brown substance on two of the ceiling tiles covering approximately 40 percent of each tile. Three other tiles were bulging from the frame. A pipe was coming from a ceiling tile…

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

Based on medical record review and staff interview the facility failed to transfer residents appropriately using a mechanical lift resulting in a fall. This affected one (Resident #19) of three residents reviewed for falls. The facility census was 145. Findings include: Review of Resident #19's medical record revealed an admission date of 02/28/25 with admission diagnoses that included cerebrovascular accident with ataxia, chronic obstructive pulmonary disease, hypertension and history of falls. Upon admission a fall risk assessment indicated the resident was at risk for falls and required extensive assist with mobility. An admission fall risk care plan identified the resident as a high risk for falls characterized by history of falls/injury. Review of the physician's orders revealed on 03/01/25 the resident was to be transferred by two persons and utilize and hoyer (mechanical) lift. Review of the progress notes revealed on 03/04/25 the resident sustained a fall without injury when transferring in the bathroom with staff when not using a hoyer lift. Review of the facility fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record, and interviews the facility failed to ensure fingernails were cleaned and trimmed for dependent Residents #13, #54, and #63 and failed to ensure showers were completed as scheduled for dependent Residents #41 and #45. This affected five residents ( Resident #13, #41, #45, #54, and #63) of seven reviewed for activities of daily living (ADLs). Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, restless leg syndrome, osteoarthritis, atrial fibrillation, and contractures. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had severely impaired cognition and required extensive assistance with personal hygiene. Review of the progress notes from 19/25/22 to 01/24/23 revealed no documentation Resident #13 refused to have her fingernails trimmed. Observations on 01/23/23 at 8:13 A.M., 10:33 A.M., and 1:35 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.

Based on medical record review and staff interview the facility failed to ensure resident representatives were notified of a resident with significant weight loss. This affected one (Resident #70) of three residents reviewed for weight loss. The facility census was 108. Findings include: Review of Resident #70's medical record revealed an admission date of 08/26/20 with admission diagnoses that included Alzheimer's disease with dementia and chronic kidney disease. Further review of the medical record including monthly weights revealed on 07/06/22 Resident #70's weight was recorded as 123.8 pounds. Weight on 08/05/22 indicated Resident #70 was 109.6 pounds, a weight loss of 14.2 pounds or 11.5 percent weight loss. Further review of the monthly weights revealed on 01/04/23 a weight of 107.8 pounds, which indicated a 16 pound weight loss or 12.9 percent over six months. Review of nutritional progress notes revealed a 30 day significant weight loss was identified and documented on 08/08/22 which indicated Resident #70 had lost significant weight from the month previous. Additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, and interview, the facility failed to ensure fall risk assessments were completed for two (Resident #29 and Resident #34) of five residents reviewed for falls. The facility census was 108. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 10/11/22. Diagnoses included diabetes mellitus, cardiac pacemaker, hypertension, severe protein-calorie malnutrition, and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #29, dated 10/31/22, revealed the resident had intact cognition. The assessment indicated the resident required extensive, one-person assistance for bed mobility, transfers, dressing, walking in the room, and toileting. The resident's mobility devices were a walker and a wheelchair. Review of the plan of care for Resident #29 revealed the resident had a potential for falls due to balance problems. Interventions included to assess for factors leading to a fall. Review of Incident/Event Summary Investigation, dated 11/14/22, revealed on 11/14/22 at 5:25…

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

Based on medical record review, staff interview and policy review the facility failed to ensure antibiotic assessments were completed prior to initiation of antibiotic medication to determine appropriate use and indication of antibiotic medication. This affected one (Resident #56) of six residents reviewed for antibiotic medication use. The facility census was 108. Findings include: Review of Resident #56's medical record revealed an admission date of 02/28/18 with admission diagnoses that included Alzheimer's disease, peripheral vascular disease, chronic non-pressure ulcer to the left ankle. Further review of the medical record including physician's medication orders revealed on 03/24/22 Bactrim DS (antibiotic) was prescribed for infection to the left ankle wound, 03/10/22 Keflex (antibiotic) was prescribed for infection to the left ankle wound and 01/27/22 doxycycline (antibiotic) was prescribed for infection to the left ankle wound. Further review of the medical recording including antibiotic use assessments found no evidence an assessment was completed prior to initiation 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 review of the medical record, resident interviews and staff interviews the facility failed to ensure Resident #44 and Resident #51 received COVID-19 vaccine education. This affected two residents (Resident #44 and #51) of five reviewed for COVID-19 vaccinations. Findings include: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, depressive disorders, hyperlipidemia, vitamin D deficiency, atherosclerotic heart disease, delirium, malaise, alcohol dependence, and protein-calorie malnutrition. Further review of the medical record revealed no evidence COVID-19 vaccination education was given to Resident #51 or a declination form signed refusing the vaccine. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #51 had intact cognition. On 01/25/23 at 10:15 A.M. Resident #51 indicated she was never given COVID-19 vaccine education or asked to sign a declination form. On 01/25/23 at 4:10 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.

Based on personnel record review and staff interview, the facility failed to complete annual State Tested Nurse Assistant (STNA) performance evaluations as required. This affected three STNA's (STNA #247, STNA #259, and STNA #263) of three STNA's reviewed for annual performance evaluations and had the potential to affect all residents receiving care in the facility. Findings include: 1. Review of the personnel file revealed STNA #247's date of hire was 10/10/13. Her last annual performance evaluation was completed on 07/03/18. There was no evidence an annual performance evaluation had been completed prior to the start of the facility's annual inspection on 02/03/20. An interview on 02/06/20 at 9:50 A.M. with Human Resource Manager #320 confirmed the above performance evaluation was not completed annually as required. 2. Review of the personnel file revealed STNA #259's date of hire was 10/01/18. There was no evidence an annual performance evaluation had been completed prior to the start of the facility's annual inspection on 02/03/20. An interview on 02/06/20 at 9:50 A.M. with Human…

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

Based on observation, interview and facility policy and procedure, the facility failed to properly store medications in the Greenbrier medication cart (serving Residents #8, #10, #18, #33, #36, #39, #44, #55, #67, #100, #101, #110, #112, #113, #144, #390, and #391) cart and the Ridgeview medication cart (serving Residents #7, #15, #20, #43, #48, #49, #53, #58, #60, #61, #62, #71, #72, #74, #76, #90, #93, #120, #122, and #439) and the facility failed to properly dispose of medications on the dementia unit. These concerns had the potential to affect all 37 residents receiving medications from the two medication carts and had the potential to affect 10 residents (#11, #18, 44, #45, #67, #84, #109, #111, #241, #391) who were mobile in the dementia unit dining room out of 37 residents on the dementia unit. The census was 136. Findings include: 1. An observation and interview on 02/04/20 at 4:45 P.M. of the Greenbrier medication cart with Licensed Practical Nurse (LPN) #139 revealed half of an unidentifiable round orange pill and a whole light brown pill with Z on it, identified as…

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

Based on observation, interview and record review the facility failed to ensure servings were appropriate, food was palatable, and food was served at appropriate holding temperatures. This had the potential to affect 37 residents (Resident #4, #13, #15, #20, #21, #25,#28, #29, #40, #49, #53, #56, #58, #60, #64, #73, #74, #82, #86, #87, #88, #89, #91, #93, #98, #99, #118, #121, #123, #125, #126, #127, #130, #132, #136, #339, and #439) of 84 residents who reside on the second floor and eat meals served from the kitchenettes and affected Resident #15, #20, #28, #60, #93 and #118 and had the potential to affect the other 42 residents (Residents #5, #7, #8, #9, #10, #11, #12, #18, #24, #30, #33, #35, #38, #41, #44, #49, #51, #53, #57, #63, #67, #79, #81, #84, #85, #91, #98, #99, #102, #104, #108, #112, #113, #114, #120, #123, #127, #129, #135, #136, #391, and #439) who received a regular texture diet of chicken breast. The facility's census was 136. Findings include: 1. Observation on 02/05/20 at 7:48 A.M. until 8:28 A.M. revealed Dietary Aid #265 plating food for the residents in 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 and interview the facility failed to ensure Advanced Directives, directions for desired care in the event of cardiac or respiratory arrest, were clear and accurate for Resident #32. This affected one of one resident reviewed for Advanced Directives. The facilities census was 136. Findings include: Review of Resident #32's medical record revealed an admission date of [DATE], with diagnoses that included dysphasia (difficulty swallowing), end stage renal (kidney) disease, and high blood pressure. Review of Resident #32's physician's orders revealed an order dated [DATE] for a code status of, Do Not Resuscitate-Comfort Care (DNR-CC). DNRCC means a person will receive any care that eases pain and suffering, but no resuscitative measures to save or sustain life will be provided. Review of the medical chart revealed a signed Advanced Directive indicating Resident #32 had a Do Not Resuscitate -Comfort Care Arrest (DNRCCA). A DNR-CCA indicates a person wishes to have all medical care to sustain…

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

Based on observation, medical record review and staff interview, the facility failed to ensure residents using a Broda chair were assessed to determine if the chair was being used as a possible restraint prior to implementation. This affected one (Resident #59) of one residents reviewed for restraint use. Findings include: Review of Resident #59's medical record revealed an admission date of 03/03/13 with an admission diagnosis that included Alzheimer's disease with dementia. Observations of Resident #59 on 02/02/20 at 10:28 A.M. revealed the use of a Broda chair (specialized wheelchair with reclining a seatback and cushioned side panels). Additional observation on 02/05/20 at 9:21 A.M. and 02/05/20 at 8:38 A.M. revealed Resident #59 in a reclined position in the Broda chair. Review of the monthly physician's orders indicated the use of a Broda chair for comfort and positioning on 11/30/2017. Further review of the medical record found no evidence of a restraint assessment for the use of a reclining Broda chair to determine if the chair restricted Resident #59's freedom of movement.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately screen Resident #46 via the pre-admission screening and resident review (PASARR) to determine necessary care and services. This affected one resident of one resident reviewed for PASARR. The facility's census was 136. Findings include: Review of Resident #46's medical chart revealed an admission date of 05/25/18 with diagnosis that included anxiety disorder, unspecified psychosis not due to substance or known physiological condition, and vascular dementia with behavioral disturbance. Review of Resident #46's PASSAR revealed that it was completed on 06/08/18, and did not indicate that the resident had vascular dementia or psychosis. Interview on 02/04/20 at 10:57 A.M. with Social Worker #31 confirmed the initial PASSAR was not completed correctly therefore the determination stating that the resident did not need services may not be accurate.

Based on medical record review, observation and interview the facility failed to ensure Resident #32 had her geri- sleeves applied per physician order. This affected one resident out of one reviewed for adaptive equipment. The facility census was 136. Findings include: Review of Resident #32's medical record revealed an admission date of 11/18/13 with diagnoses that included, adjustment disorder with depressed mood, end stage renal disease, and muscle wasting and atrophy. Review of Resident #32's physician's orders revealed a 12/03/19 physician's order for geriatric or geri-sleeves (protective sleeves) to the resident's arms. The geri-sleeves were to be applied in the morning and removed at night. Review of Resident #32's current care plan revealed she was at risk for skin breakdown and would scratch open areas causes scabbing. The care plan indicates an intervention for geri-sleeves to be applied to both arms in the morning and to be removed at night. Interview on 02/03/20 at 2:28 P.M. with Resident #32 revealed staff sometimes but on her geri-sleeves but not always. She did 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 observation, record review, and interview the facility failed to conduct a safe Hoyer (mechanical) lift transfer for Resident #48. This affected one of five residents reviewed for accidents. The census was 136. Findings include: Review of Resident #48's medical record revealed an admission date of [DATE] and the diagnoses of multiple sclerosis (MS), quadriplegia (paralysis of the torso, the arms and legs), anxiety, urinary incontinence, and muscle wasting atrophy. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14, scores of 13 to 15 indicate the person is alert, oriented and cognitively intact. This assessment indicated he was totally dependence on two staff for bed mobility and transfers. Review of the monthly summary, dated [DATE], revealed Resident #48 required total assistance and devices for transfers. A care plan dated [DATE] revealed Resident #48 required assistance from staff related to impaired mobility and MS with interventions 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 medical record review and staff interview, the facility failed to ensure Resident #137 had orders in place for staff to provide routine care and cleaning for his indwelling urinary catheter. This affected one of one resident reviewed for urinary catheters. Findings include: Review of Resident #137's medical record revealed an admission date of 06/21/19 with diagnoses that included urinary retention and nodular prostate. Review of the physician's orders revealed the use of a suprapubic catheter (indwelling catheter inserted through the lower abdomen wall and into the bladder) on 12/06/19. Further review of the physician's orders found no evidence of orders in place for routine cleaning and care of the suprapubic catheter to maintain cleanliness and prevent contamination/infection. Review of the current Treatment Administration Record (TAR) also found no evidence of staff providing routine cleaning or care for Resident #137's suprapubic catheter. Review of an Advanced Practice Nurse note dated 01/17/20 advised staff to clean Resident #137's catheter and insertion site every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two residents were free from unnecessary medications. This affected two (Resident #24 and Resident #82) out of six residents reviewed for unnecessary medications. The census was 136. Findings include: 1. A review of Resident #24's medical record revealed an admitting date of 01/08/19 and the diagnoses of Parkinson's disease, anxiety, pain, depression, Alzheimer's disease, and depression without behavioral disturbances. A Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 04 indicating severely impaired cognition and she required the extensive two staff assistance for transfers and bed mobility, and she had no hallucinations or behaviors. Review of her current physician orders revealed she was receiving Risperdal, an antipsychotic medication, 0.25 milligrams (mg) twice daily for agitation. A care plan dated 01/22/19 revealed the resident had potential for 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 observation, record review, and interview, the facility failed to follow proper infection control measures during incontinence care for Resident #37 and with a dressing care for Resident #95. This affected two (Resident #37 and Resident #95) out of two residents during random infection control observations. The census was 136. Findings include: 1. A medical record review revealed Resident #95 had an admission date of 02/21/11 and the diagnoses of cellulitis to right lower limb and left lower limb. A Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 15, indicating intact cognition, and he required limited assistance of one staff member for bed mobility, transfers and personal hygiene. It further revealed the resident had venous ulcers. Review of the resident's current physician orders reveled orders to apply Santyl, an ointment for wounds to removed dead/dying tissue, to the right foot twice daily and as needed and to clean the right…

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