St Clare Commons

Based on observation, resident interview, staff interview, medical record review, review of Resident Council meeting minutes, and review of facility policy, the facility failed to ensure residents who were dependent for care received showers as scheduled. This affected three (#1, #25, and #31) of three residents reviewed for showers. The facility census was 54.Findings include:1. Review of Resident #1's medical record revealed an admission date of 07/23/25. Diagnoses included atrial fibrillation, weakness, and parkinsonism (causes movement problems such as tremors, stiffness and slow movements and balance issues).Review of the Minimum Data Set (MDS) assessment, dated 10/28/25, revealed Resident #1 was cognitively intact and required maximal (staff) assistance with activities of daily living (ADLs).Review of the care plan, revised on 08/12/25, revealed Resident #1 had and ADL self-care performance deficit related to parkinsonism. Interventions included providing a sponge bath when a full bath or shower could not be tolerated, and the resident required maximum (staff) assistance for…

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

Based on observation, resident interview, staff interview, review of the medical record, and review of facility policy, the facility failed to provide timely incontinence care. This affected one (#1) of three residents reviewed for incontinence care. The facility census was 54.Findings include:Review of Resident #1's medical record revealed an admission date of 07/23/25. Diagnoses included atrial fibrillation, weakness, and parkinsonism (causes movement problems such as tremors, stiffness and slow movements and balance issues).Review of the Minimum Data Set (MDS) assessment, dated 10/28/25, revealed Resident #1 was cognitively intact and required maximal (staff) assistance with activities of daily living (ADLs).Review of the care plan, dated 07/23/25, revealed Resident #1 had bowel incontinence related to mobility. Interventions included to assist with toileting as needed.Review of a wound care progress note dated 11/20/25 revealed Resident #1 was seen for an area on his buttocks, with a new diagnosis of irritant dermatitis due to body fluid.Interview on 11/25/25 at 8:30 A.M. with…

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

Based on family, provider, and staff interview, medical record review, and policy review, the facility failed to ensure transportation to medical appointments. This affected one (#31) of three residents reviewed for outside medical appointments. The facility census was 54. Findings include:Review of the medical record for Resident #31 revealed an admission date of 01/13/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, retention of urine, and anxiety.Review of the quarterly Minimum Date Set (MDS) assessment, dated 11/21/25, revealed Resident #31 had intact cognition. Resident #31 was (staff) dependent for activities of daily living (ADLs). Review of the Nurse Practitioner (NP) progress note date 05/05/25 revealed Resident #31 was seen for a follow-up evaluation of diabetes with neuropathy (damage to nerves outside the brain that causes pain, tingling and numbness in hands and feet), and left hemiparesis. Further review revealed Resident #31 had left shoulder pain likely due to osteoarthritis and stiffness. The NP referred Resident #31 to Physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of the dietary spreadsheets (DS), medical record review, and staff interview, the facility failed to ensure correct portion sizes for meals. This affected one (#3) of three residents reviewed for portion sizes. The facility census was 54.Findings include:Review of the medical record for Resident #3 revealed an admission date of 09/17/25. Diagnoses included Alzheimer's disease, chronic kidney disease, and epilepsy.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/25, revealed Resident #3 had severe cognitive impairment.Review of the care plan dated 09/18/24 revealed Resident #3 had nutritional problems or a potential nutritional problem related to Alzheimer's and received a mechanically altered diet related to dysphagia. Interventions included providing diet as ordered, and monitoring intakes.Review of the DS for 11/25/25 revealed the lunch meal for a pureed diet was six ounces of pureed baked potato soup, six ounces of pureed [NAME] Marzetti (pasta dish), four ounces of pureed home fried potatoes, four ounces of pureed seasoned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the medical record revealed Resident #42 was admitted on [DATE]. Diagnoses included acute diastolic heart failure, essential hypertension, and osteoarthritis. Review of the MDS assessment, dated 05/16/25, revealed the resident was cognitively intact and required partial/moderate assistance with toileting, showering, lower and upper body dressing, personal hygiene, and applying footwear. Observation on 06/23/25 at 9:27 A.M. revealed Resident #42 in the recliner chair in the resident room and the call light on the floor near the bed. The call light was not within reach. Interview on 06/23/25 at 9:29 A.M. with Resident #42 verified she utilizes her call light. Interview on 06/23/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #284 verified the call light was on the floor and not within reach of the resident. Interview on 06/25/25 at 2:09 P.M. with Licensed Practical Nurse (LPN) #207 verified Resident #42 does utilize her call light. Review of policy, Call Lights: Accessibility and Timely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to notify the physician of medication error. This affected one resident (#54) reviewed for notification to provider of a change. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver, chronic kidney disease, peptic ulcer (ulcer in the lining of the stomach) and prostate cancer. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Interview on 06/24/25 at 9:09 A.M. with Resident #54 stated he does not recall receiving his bedtime medication on 06/23/25. Review of the nursing progress notes for Resident #54 revealed no documentation of physician notification of the missed medication. Interview on 06/24/25 at 4:29 P.M. with Licensed Practical Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure podiatry care services. This affected one (#22) of one resident reviewed for podiatry. The facility census was 57. Findings include: Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing, type two diabetes mellitus without complications, unilateral primary osteoarthritis, bilateral primary osteoarthritis of hip, chronic systolic (congestive) heart failure, adult failure to thrive, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 06/09/25, revealed the resident was moderately cognitively impaired. Observation on 06/25/25 at 1:58 P.M. revealed Resident #22's left foot toes were long, thick, and curling under the toes. Interview on 06/25/25 at 2:50 P.M. with Licensed Social Worker (LSW) #299 verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered as ordered. This affected one (#54) resident reviewed for medication error. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver, chronic kidney disease, peptic ulcer (ulcer in the lining of the stomach) and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Review of the current physician orders from 06/25 for Resident #54 revealed he was ordered the following medication for bedtime: lantus insulin 12 units subcutaneously (subQ) (used to control diabetes mellitus), patoprazole sodium delayed release 40 milligrams (mg) (used for stomach ulcers), rifaximin 550mg (used 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, resident interview, staff interview, medical record review, and review of the facility policy the facility failed to ensure significant medications were administered as ordered. This affected one (#54) resident reviewed for significant medication error. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver with ascites (fluid build up in the abdomen from a failing liver), chronic kidney disease, and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Review of the current physician orders from 06/25 for Resident #54 revealed he was ordered the following medication for bedtime: lantus insulin 12 units subcutaneously (subQ) (used to control diabetes mellitus), rifaximin 550mg (used for cirrhosis of the liver), lactulose oral solution…

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

Based on record review, review of late medication report, interview, and policy review, the facility failed to ensure medications were administered in a timely manner. This affected four (#2, #33, #36, and #54) of four residents reviewed for late medications. The facility census was 56. Findings include: 1. Review of medical record for Resident #2 revealed an admission date of 03/30/25 with diagnoses including but not limited to hypertensive heart disease with heart failure, chronic kidney disease, atrial fibrillation, congenital malformation of the heart, hypertension, and fibrothorax. Review of current physician orders revealed furosemide 40 milligrams (mg) daily at 7:00 A.M. (water pill), Jardiance 10 mg daily at 8:00 A.M. (diabetes), metoprolol tartrate 25 mg twice daily at 9:00 A.M. and 9:00 P.M. (blood pressure), amiodarone 200 mg daily at 9:00 A.M. (heart), and apixaban 2.5 mg twice daily at 9:00 A.M. and 6:00 P.M. Review of late medication report dated 03/31/25 revealed the above listed medications were administered at 11:38 A.M. 2. Review of medical record for Resident #33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to ensure a resident had call light within reach while up in wheelchair. This affected one resident (#1) of nine residents reviewed for call lights. The facility census was 56. Findings include: Review of medical record for Resident #1 revealed an admission date of 05/08/24 with diagnoses including but not limited to dementia, unspecified psychosis, hypertension, anxiety, alcohol use with withdrawal delirium, depression, and need for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Resident #1 was dependent on staff for toileting. Observation on 04/02/25 at 1:35 P.M. revealed Resident #1 was sitting up in wheelchair in room. Call light was observed lying on the bed out of reach for the resident. Interview on 04/02/25 at 1:37 P.M. with Certified Nursing Assistant (CNA #174) verified Resident #1 call light was not within reach of the resident.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure timely orders were in implemented to address the care and needs of a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) affecting Resident #5, failed to ensure accurate and ongoing skin monitoring for Resident #39, and failed to ensure wound care recommendations were implemented for Residents #5 and #39. This affected two (#5 and #39) of three residents reviewed for pressure ulcers. The facility census was 52. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 06/28/24. Diagnoses included chronic kidney disease, type II diabetes mellitus, and a urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, independent for toilet and personal hygiene, was occasionally incontinent of urine, and had one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure the appropriate care and treatment of a resident's urinary catheter. This affected one (#13) resident of three residents reviewed for urinary catheters. The facility census was 52. Finding include: Review of the medical record for Resident #13 revealed an admission date of 04/24/24. Diagnoses included acute cystitis with hematuria, neuromuscular dysfunction of the bladder, and paraplegia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact, required maximal assistance from staff for toilet hygiene. Review of a nurse progress note dated 06/18/24 revealed Resident #13 was sent to the Emergency Department for evaluation of blood in urine. On 06/21/24 at 9:13 A.M., Resident #13 returned from hospital with an indwelling urinary catheter in place to gravity with yellow colored urine with sediment. The nurse progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of self-reported incidents, resident and staff interview, and review of facility policy, the facility failed to prevent misappropriation of resident funds. This affected one (#40) of one resident reviewed for misappropriation. The facility census was 55. Findings include: Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute respiratory failure with hypoxia, dysphagia, chronic kidney disease stage three, and major depressive disorder recurrent. Review of the Minimum Data Set (MDS) assessment, dated 03/31/24, revealed the resident was moderately cognitively impaired. Review of Self-Reported Incident (SRI) #242873, created 01/08/24 and completed on 01/12/24, revealed the Administrator was notified by Resident #40's financial administrator the resident's credit card was taken and used to make in person purchases at three stores (grocery and gas…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of self-reported incidents, staff interview, and review of facility policy, the facility failed to thoroughly investigate misappropriation of resident funds. This affected one (#40) of one resident reviewed for misappropriation. The facility census was 55. Findings include: Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute respiratory failure with hypoxia, dysphagia, chronic kidney disease stage three, and major depressive disorder recurrent. Review of the Minimum Data Set (MDS) assessment, dated 03/31/24, revealed Resident #40 was moderately cognitively impaired. Review of Self-Reported Incident (SRI) #242873, created 01/08/24 and completed on 01/12/24, revealed the Administrator was notified by Resident #40's financial administrator the resident's credit card was taken and used to make in person purchases at three stores (grocery and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident representative and staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for two (#21 and #47) of three residents reviewed for falls. In addition, the facility failed to ensure one (#28) of three residents reviewed for transfers were assisted by two staff for transfer with a mechanical hoyer lift. The facility census was 55. Findings include: 1. Review of the medical record review revealed Resident #21 was admitted on [DATE]. Diagnoses included fracture of neck, unspecified fracture of shaft of humerus left arm, malignant neoplasm of unspecified breast, and non-Hodgkin lymphoma. Review of the Minimum Data Set (MDS) assessment, dated 04/12/24, revealed the resident was cognitively intact. Review of the most recent care plan revealed Resident #21 was at risk for falls, with an actual fall on 3/9/24. Fall interventions, updated 03/13/24, included to keep the bed in the lowest position when in it to prevent…

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

Based on observation and staff interview, the facility failed to maintain the kitchen in a sanitary manner and failed to serve meals in a sanitary manner to potentially prevent foodborne illnesses. This had the potential to affect all 50 residents who received food from the kitchen. The facility census was 50. Findings include: 1. Observations and interview during an initial tour of the kitchen on 10/02/23 at 8:22 A.M. along with Director of Dietary (DD) #235 revealed the following concerns: • Two rolling large trash receptacles were observed to have no lid. DD #235 obtained one lid from behind a rolling metal cart. The lid was noted to have a large amount of oily looking grease on both sides and black substances on the rim. DD #235 placed the lid in the sink. • The smaller, reach-in refrigerator had a moderate amount of food particles laying on the floor, and a large amount of dried food smeared on the door, the door handles, and the inner frame. Small dessert dishes were stored on an open shelf with the inside facing up. • A small chest-type freezer, holding ice cream, had a small…

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

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure residents were provided a clean, comfortable, and homelike environment. This affected eight (#7, #17, #18, #22, #30, #36, #38, and #41) of 14 residents reviewed for environment. The facility census was 50. Finding include: 1. Review of the medical record for Resident #36 revealed an admission date of 04/30/21. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/25/23, revealed Resident #36 had intact cognition. Observation on 10/02/23 at 10:39 A.M. in Resident #36's room revealed there were several stains on the carpet as well as large wrinkles in the carpet. Interview on 10/02/23 at 10:39 A.M., with Resident #36 revealed the carpet had been in bad shape for around the past year. 2. Review of the medical record for Resident #41 revealed an admission date of 04/04/23. Review of the quarterly MDS assessment, dated 09/08/23, revealed Resident #41 had impaired cognition. Observation on 10/02/23 at 10:35 A.M. in Resident #41's room revealed there was…

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

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure refrigerated medications were stored at an appropriate temperature. This affected one (Resident #37) and had the potential to affect 12 residents with refrigerated medications. The facility identified 12 (Residents #1, #2, #5, #11, #14, #15, #22, #29, #30, #35, #37 and #41) who had refrigerated medications. The facility census was 50. Findings include: Review of the medical record for Resident #37 revealed an admission date of 04/07/22 and a readmission date of 04/21/23 with a diagnoses of type two diabetes mellitus. Review of a physician order dated 09/21/23 revealed Resident #37 received Novolog FlexPen Subcutaneous Solution Pen-Injector 100 units per milliliter (ml) (insulin aspart), inject 18 units subcutaneously one time a day related to type two diabetes mellitus. Observation and interview on 10/04/23 at 10:45 A.M. with the Interim Director of Nursing (IDON) revealed the locked medication room had one small and one large refrigerator for storing residents' medications.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and review of the menu spreadsheet, the facility failed to provide a pureed meal as approved by the dietitian for four (Residents #11, #21, #28, and #42) of four reviewed for pureed diets. The facility was 50. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 06/30/21. Review of the physician orders for Resident #11 revealed an order dated 08/06/21 for a regular diet, pureed texture. 2. Review of the medical record for Resident #21 revealed an admission date of 06/23/20. Review of the physician orders for Resident #21 revealed an order dated 07/14/22 for a regular diet, pureed texture. 3. Review of the medical record for Resident #28 revealed an admission date of 07/04/22. Review of the physician orders for Resident #28 revealed an order dated 07/30/22 for a regular diet, pureed texture. 4. Review of the medical record for Resident #42 revealed an admission date of 03/23/23. Review of the physician orders for Resident #42 revealed an order dated 05/01/23 for a regular diet,…

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

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure gloves were worn when obtaining a blood glucose level and injecting insulin to one resident (#35) of two observed for receiving insulin and having blood glucose level monitored. The facility further failed to ensure the glucometer was disinfected after use. Additionally, the facility failed to ensure staff appropriately completed hand hygiene following the completion of incontinence care. This affected one resident (#28) of six reviewed for activities of daily living (ADLs). The facility census was 50. Findings include: 1. Review of the medical record of Resident #35 revealed an admission date of 09/02/23. Diagnosis of type II diabetes mellitus without complications. Review of the physician order dated 09/07/23 for insulin Glargine inject 23 units subcutaneously daily for diabetes mellitus. Observation on 11/03/23 at 7:40 A.M. revealed Licensed Practical Nurse (LPN) #256 obtained a glucometer from the medication cart and used it to monitor the blood glucose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility policy, the facility failed to ensure residents were offered the COVID-19 vaccine or booster vaccine. This affected four (Residents #22, #33, #41, and #47) of five residents reviewed for COVID-19 vaccination. The facility census was 50. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 01/19/23 with diagnoses of end stage renal disease and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the immunizations for Resident #22 revealed he received a COVID-19 booster vaccine on 10/22/21. 2. Review of the medical record for Resident #33 revealed an admission date of 01/02/21. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had impaired cognition. Review of the immunizations for Resident #33 revealed she received a COVID-19 vaccine on 01/04/21 and 01/25/21. Additionally, the…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to issue notifications to residents who receive Medicaid benefits when their funds accounts were 200 dollars ($) less than the resource limit. This affected three (#14, #16, and #33) of five residents reviewed for resident trust accounts. The facility census was 50. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 02/27/19 and a payor source of Medicaid. The facility identified Resident #14 had a Resident Trust Account with the facility. Review of the quarterly statements for Resident #14's Trust Account from 07/19/22 through 09/30/23 revealed a month-end balance on 12/31/22 of $1,826.87, on 04/30/23 of $1,815.18, on 05/31/23 of $1,870.78, on 06/30/23 of $1,926.88, on 07/31/23 of $1,982.93, on 08/31/23 of $2,014.55, and on 09/30/23 of $2,070.39. 2. Review of the medical record for Resident #16 revealed an admission date of 03/20/18 and a payor source of Medicaid. The facility identified Resident #16 had a Resident Trust Account with…

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident advance directives for code status were accurate. This affected one (#33) of 12 residents reviewed for advance directives. The facility census was 50. Findings include: Review of the medical record revealed Resident #33 had an admission date of 05/19/20 and a readmission date of 01/02/21. Resident #33's diagnoses included atrial fibrillation, cerebral infarction, dementia, chronic pain, and chronic obstruction pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/26/23, revealed Resident #33 had intact cognition. Review of a physician order, dated 11/10/21, revealed Resident #33 had elected a full code status. Review of the electronic medical record code status line for Resident #33 revealed Resident #33's code status was a full code. Review of a physician order, dated 09/12/23, revealed Resident #33 had elected for a Do Not Rescuscitate (DNR) comfort care arrest (DNRCC-A) code status (the provider would treat Resident #33 as any other resident…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the comprehensive person centered care plan adequately addressed resident activity preferences/interests and activities of daily living. This affected two residents (#31 and #42) of 15 residents reviewed for care plans. The faciity census was 50. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 09/11/23 with a diagnosis of depression. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/15/23, revealed Resident #31 had impaired cognition and required limited assistance of one person for transfers and locomotion. Resident #31 did not exhibit rejection of care. Resident #31 was not interviewed for her activity preferences. Review of the active care plan for Resident #31 revealed the care plan did not address activities and/or Resident #31's activity preferences. Interview on 10/11/23 at 8:40 A.M. with the Administrator confirmed Resident #31's care plan did not address Resident #31's interests or desired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were bathed/showered as scheduled and requested. This affected one (Resident #7) of three residents reviewed for bathing. The facility census was 50. Finding include: Review of Resident #7's medical record revealed Resident #7 had an admission date of 02/21/23. Resident #7's diagnoses included chronic obstructive pulmonary disease, anxiety, depression, and fibromyalgia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/21/23, revealed Resident #7 had impaired cognition. Resident #7 required extensive assistance of two staff for personal hygiene. The assessment indicated the bathing activity had not occurred in the look back period for Resident #7. Review of Resident #7's care plan, dated 03/19/23, revealed the resident had an activities of daily living (ADL) self care performance deficit related to limited mobility. There were no interventions specific to bathing or showering. Review of Resident #7's care plan, dated 09/01/23, revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of the facility policy, the facility failed to provide resident-centered activities for two (Residents #31 and #34) of three residents reviewed for activities. The facility census was 50. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 09/11/23 with a diagnosis of depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had impaired cognition and required limited assistance of one person for transfers and locomotion. Resident #31 did not exhibit rejection of care. Further review of Resident #31's MDS assessment revealed a section for addressing her preferences for customary routine and activities with the following instructions: Attempt to interview all residents able to communicate. If resident is unable to complete, attempt to complete interview with family member or significant other. The assessment was marked no indicating the resident was…

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

Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure residents received medications as ordered. This affected one (Resident #49) of six residents reviewed for medication administration. Further, the facility failed to separate and dispose of medications for discharged residents and expired residents. This affected three (Residents #306, #307, and #308) of three discharged residents and one (Resident #14) of one resident reviewed for expired medications. The facility census was 50. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of 08/09/23 with a diagnosis of type two diabetes mellitus. Review of a physician order dated 08/09/23 revealed Resident #49 should receive insulin glargine (to lower blood sugar) subcutaneous (below the skin) solution pen-injector 100 units per milliliter (ml); inject 20 units subcutaneously at bedtime for diabetes mellitus. Review of the October 2023 Medication Administration Record (MAR) for Resident #49 revealed a 9 documented on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to timely respond to pharmacist recommendations. This affected two (Residents #41 and #43) of five residents reviewed for pharmacy recommendations. The facility census was 50. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 01/10/23 with diagnoses of dementia, anxiety, restless legs, and mood disorder due to known physiological condition with major depressive-like episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was rarely/never understood and received an antidepressant seven times during the previous seven days. Review of a current physician order dated 03/06/23 revealed Resident #41 received Zoloft (an anti-depressant) 100 milligrams (mg) by mouth once daily for anxiety. Review of the progress notes for Resident #41 revealed she was seen by Psych Group #500 to manage her psychotropic (mood altering) medications on…

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

Based on observation of medication pass, staff interview, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (#35) of one observed to receive insulin. The facility identified four residents who receive insulin in the 100 hall. The facility census was 50. Findings include: Review of the medical record of Resident #35 revealed an admission date of 09/02/23 with a diagnosis of type II diabetes mellitus without complications. Review of the physician order dated 09/07/23 for insulin Glargine inject 23 units subcutaneously daily for diabetes mellitus. Observation on 10/04/23 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #256 obtained a blood glucose on Resident #35 of 123 millimeters of mercury. LPN #256 obtained a pen of Insulin Glargine from the medication cart, verified the resident's name and expiration date and dialed the pen to 23. LPN #256 proceeded to and inject the 23 units in the resident's left arm. LPN #256 did not prime the insulin pen prior to administration. Interview at the time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility policy, the facility failed to ensure residents were offered the pneumococcal vaccine. This affected three (Residents #22, #41, and #47) of five residents reviewed for pneumococcal vaccination. The facility census was 50. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 01/19/23 with diagnoses of end stage renal disease and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the immunizations for Resident #22 revealed no information regarding a pneumococcal vaccination. 2. Review of the medical record for Resident #41 revealed an admission date of 04/04/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 had impaired cognition. Review of the immunizations for Resident #41 revealed no information regarding a pneumococcal vaccination. 3. Review of the medical record for…

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

Based on record review, observations, resident interview, staff interview, and review of the facility's policy, the facility failed to ensure resident rooms were clean and sanitary. This affected two (#4 and #34) of 56 resident rooms reviewed for the environment. The facility census was 56. Findings include: Medical record review for Resident #4 revealed an admission date 03/28/18. Diagnoses included cerebrovascular disease and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/18/21, revealed the resident had intact cognition. Observation on 04/26/21 at 11:44 A.M. of Resident #4's bathroom shower wall revealed it had a large area of plaster and had not been painted. In the resident's room, the carpet had a large stain area located in front of the resident's bed. Interview on 04/29/21 at 11:42 A.M., with Resident #4 reported the bathroom wall had been that way for two years. It was fixed with plaster and never painted. The plaster fell out and was plastered again and had not been painted. 2. Medical record review for Resident #34 admission 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 review of the facility's Self-Reported Incident (SRI), medical record review, staff interviews and facility policy review, the facility failed to timely report allegations of misappropriation to the State Survey Agency as required. This affected two residents (#3 and #8) of three residents reviewed for misappropriation. The facility census was 56. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 10/09/19. Diagnoses included anxiety disorder and attention deficit hyperactivity disorder (ADHD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/21, revealed the resident had intact cognition. Review of the Medication Administration Records (MARs) revealed the Adderall 30 milligrams (mg.) was scheduled for before lunch and before dinner. The Xanax was scheduled daily at HS (hours of sleep/bedtime). Review of a Customer Concern Form, dated 03/01/21, revealed Resident #3 reported Licensed Practical Nurse (LPN) #202 tried to administer Adderall…

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

Based on record review, staff interview, and resident interview, the facility failed to provide proper wound care to residents as ordered by the physician. This affected one (#19) of two residents reviewed for wound care. The facility identified five residents with pressure ulcers. The facility census was 56. Findings included: Review of Resident #19's medical record revealed an admission date of 08/11/14. Diagnosis included multiple sclerosis, paraplegia, neuromuscular bladder, chronic kidney disease, diabetes mellitus, and malignant neoplasm of the palate. Review of the quarterly Minimum Data Set assessment, dated 02/22/21, revealed the resident had a high cognitive function. The resident was at a high risk for developing a pressure ulcer and did have one stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough), and two stage four pressure ulcers (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed). Review of the physician…

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

Based on record review, staff interview, and review of the facility's policy, the facility failed to ensure medications were available as ordered by the physician. This affected two (#3 and #8) of five residents reviewed for medications. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date of 10/09/19. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, asthma, fibromyalgia, pain in right shoulder, pain in left shoulder, and low back pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/21, revealed the resident had intact cognition. Review of the physician orders revealed Resident #3 was prescribed Lyrica (pain medication) 50 milligrams (mg.) orally three times a day, Incruse Ellipta Aerosol (used to treat respiratory ailments) 62.5 microgram per inhalation one puff once daily and Remeron (used to treat depression) 15 mg. orally once daily. Review of the medication administration records (MARs) for 02/2021 and 04/2021 revealed Lyrica, Incruse Ellipta Aerosol…

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

Based on record review, review of the facility's policy and staff interview, the facility failed to ensure the physician acted timely to address pharmacy recommendations. This affected three (Resident #2, #3 and #13) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 05/10/19 and a readmission date of 05/13/20. Diagnoses included major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 04/17/21, revealed the resident had intact cognition. Review of the pharmacy recommendations, dated 02/26/21, revealed Resident #2 was on Sertraline (antidepressant) 50 milligrams (mg.) by mouth daily. The pharmacist requested the physician consider a gradual dosage reduction for the medication. The physician declined and signed the recommendations on 04/27/21, which was 60 days after the medication review by the pharmacist. 2. Review of the medical record for Resident #3 revealed an admission date of 10/09/19. Diagnoses included anxiety…

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