Good Shepherd Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, staff and resident interviews, medical record review, diet tech audit review, and policy review, the facility failed to ensure food had a palatable taste and was served at an appetizing temperature. This affected four (#1, #16, #30, and #367) of six residents reviewed for dietary needs. The facility identified all residents eat food from the kitchen. The facility census was 65. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderate cognitive impairment with a Brief Interview Mental Status (BIMS) of 11. Interview on 04/29/25 at 4:32 P.M. with Resident #7 revealed food wasn't good and didn't have good taste. 2. Review of the medical record for Resident #367 revealed an admission date of 03/11/25. Diagnoses included chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 65 residents. The facility census was 65. Findings include: Observation of the walk in freezer on 04/28/25 at 8:49 A.M. revealed frozen waffles in a bag without a date. Ice was observed on the tops of boxes of Mighty Shakes and B/C Topping that were stored under the freezer condenser. Interview with the Kitchen Manger (KM) #237 confirmed that the frozen waffles did not have a date. KM #237 confirmed that the condenser appeared to be leaking and creating a build up of ice on the boxes stored below. Observation on 04/28/25 at 8:54 A.M. revealed Dietary Aide (DA) #284 testing the chemical dish machine with a chlorine test strip that appeared to be a light purple. Interview with DA #284 verified that the test strip showed that the chlorine concentration in the dish machine was at 25 parts per million (PPM). DA #284 verified that the dish machine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility list review, resident interview, staff interviews, and policy review, the facility failed to ensure residents' personal funds were available in a timely manner. This had the potential to affect 22 Residents (#2, #3, #4, #7, #11, #12, #13, #20, #22, #23, #24, #26, #37, #43, #46, #48, #52, #53, #54, #56, #266, #367) of 22 identified to have personal fund accounts with the facility. The facility census was 65. Findings include: Review of facility generated list of personal funds account revealed 22 Residents (#2, #3, #4, #7, #11, #12, #13, #20, #22, #23, #24, #26, #37, #43, #46, #48, #52, #53, #54, #56, #266, #367) identified to have personal fund accounts with the facility. Review of Resident #7's medical record revealed an admission date of 12/30/22. Diagnoses include anxiety, schizophrenia, hypothyroidism, major depressive disorder, Alzheimer's, heart failure, and kidney disease. Interview on 04/29/25 at 8:11 A.M., revealed a concern related to Resident #7 being able to access his personal funds. Resident #7 shared that he is unable 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 review of the medical records and staff interviews, the facility failed to develop care plans to meet the needs of the residents. This affected four (#30, #36, #266, and #366) of 24 residents reviewed for care plans. The facility census was 65. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 08/25/23. Diagnoses included dementia, major depressive disorder, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. This resident was assessed to require setup with eating, supervision with toileting, bathing, dressing, and transfers. Review of the physician order dated 03/12/25 revealed Resident #36 was ordered Ativan 0.5 milligrams (mg), give one tablet by mouth two times a day for anxiety. Review of the care plan for Resident #36 revealed she did not have a care plan for psychotropic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interviews, family interviews, staff interviews, and policy review, the facility failed to ensure care conferences were completed quarterly and the interdisciplinary team was present for five (#7, #13, #16, #26, and #55) of five residents reviewed for care conferences. The facility also failed to ensure revisions of care plans were updated for six (#7, #18, #30, #33, #51 and #62) of 24 care plans reviewed during the annual survey. The facility census was 65. Findings included: 1. Medical record review for Resident #7 revealed an admission date of 12/30/22. His medical diagnoses included arteriosclerotic heart disease, schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and convulsions. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was severely cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal assistance for toileting, supervision or touching assistance for bed mobility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders, staff interviews, Certified Nursing Practitioner interview, and review of policy, the facility failed to ensure physician orders were clarified when to contact the physician for a resident daily weight change for Resident #41. The facility failed to physician orders were followed to obtain blood sugars and contact the physician when blood sugars were out of the parameters for Resident #51. The facility failed to ensure coordination with hospice services were established for hospice care for Resident #30. The facility failed to ensure skin assessments and treatments were completed for Resident #13. This affected four (#13, #30, #41 and #51) of 24 residents records reviewed for quality of care . The facility census was 65. Findings include: 1. Review of medical record for Resident #41 revealed admission date of 01/09/23, with diagnoses including major depressive disorder, alcohol abuse, chronic viral hepatitis, anxiety and alcohol dependence. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff and resident interviews, and policy review, the facility failed to ensure safe water temperatures in resident rooms. This affected five (#18, #37, #51, #59, and #60) of five residents reviewed for water temperatures. The facility failed to ensure safe smoking parameters were in place for one (#20) of one resident reviewed for smoking. The facility census was 65. Findings include Observation on 04/28/25 at 10:20 A.M., revealed water temperatures of 144 degrees Fahrenheit (F) for the shared bathroom for Residents #18, #37, #51 and #60 had hot water temperatures. 1. Review of the medical record for Resident #51 revealed an admission date of 02/07/25. Diagnoses included shortness of breath, diabetes, and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15 and required supervision or touching assistance with toileting. 2. Review of the medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and resident interviews, review of Medscape resource website and policy review, the facility failed to ensure extended release medications were not crushed, administer medications as ordered and/or in a timely manner. This affected six (#1, #7, #26, #266, #366, and #367 ) of 11 residents reviewed for medication administration. The facility census was 65. Findings included: 1. Review of medical record for Resident #366 revealed admission date of 02/19/25. The resident was admitted with diagnoses including cellulitis, morbid obesity, type two diabetes mellitus, unstageable pressure ulcer of right heel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for eating, was dependent with toileting hygiene, maximum assistance for showers, transfers and moderate assistance for bed mobility. Review of the physician orders revealed an order for Coreg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview and policy review, the facility failed ensure medications were not left unattended in residents rooms and safely store medications. This affected three residents (#7, #9 and #41) directly and had the potential to affect the 16 residents who resided on Unit #2. The facility census was 65. Findings included: 1. Medical record review for Resident #7 revealed an admission date of 12/30/22. His medical diagnoses included arteriosclerotic heart disease, Schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and convulsions. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was severely cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal assistance for toileting, supervision or touching assistance for bed mobility and transfers. He was always incontinent for bladder and codes for a colostomy. He was coded for wandering. Observation on 04/28/25 at 2:59 P.M., revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, recipe review and diet tech audit review, the facility failed to ensure pureed food was made to the correct consistency and the menu was followed. This affected four (#27, #46, #54, and #62) of four residents who received purred diets. The facility census was 65. Findings include: Observation and interview on 04/29/25 at 11:14 A.M., with Dietary [NAME] #214 revealed she made four servings of pureed [NAME] chicken. She placed four, four ounce scoops into the blender along with one and a half cups of chicken gravy followed by an additional cup of gravy for a total of two and a half cups of gravy. Dietary [NAME] #214 revealed she was looking for a mashed potato consistency. The mixture was blended and poured into a container without ever scraping the sides. The final mixture was tasted by staff and surveyors and found several chunks of chicken which Dietary [NAME] #214 acknowledged. The mixture was returned to the blender and staff continued to blend to a…

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

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure COVID-19 vaccines were offered to residents, failed to ensure education was provided related to the vaccination, and further failed to ensure vaccines were administered as consented to. Additionally, the facility failed to ensure COVID-19 vaccination consent forms were thoroughly and accurately completed to reflect resident decisions related to the vaccination. This affected four (#7, #30, #33, and #53) of five residents reviewed for COVID-19 vaccination status. The facility census was 65. Findings include 1. Review of the medical record for Resident #7 revealed an admission date of 02/19/20. Diagnoses included heart disease, schizophrenia, diabetes, Alzheimer's disease and kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was cognitively impaired. Further review of the medical record revealed no evidence Resident #7 was offered or received the COVID-19 vaccination. Additionally, the medical record revealed no evidence 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, staff interview, medical record review and review of facility policy, the facility failed to ensure resident bathrooms were free from odors for five (#7, #18, #37, #51, and #60) five residents reviewed for clean and sanitary bathrooms. Additionally, the facility failed to ensure the corridors were free from pervasive odors. This affected all residents except for 16 residents (#2, #5, #6, #8, #14, #22, #23, #33, #39, #40, #41, #43, #52, #56, #58, #62) identified as living on the rehabilitation unit. The facility census was 65. Findings included: 1. Medical record review for Resident #7 revealed an admission date of 12/30/22. Diagnoses included arteriosclerotic heart disease, schizophrenia, Alzheimer's disease, diabetes, chronic kidney disease, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was severely cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal assistance for toileting, and supervision or touching assistance for bed mobility 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 and staff interview, the facility failed to ensure psychotropic medications were ordered for an approved diagnosis. This affected one (#9) of five residents reviewed for unnecessary medication. The facility census was 65. Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/08/25. Diagnoses included abdominal pain, spinal stenosis, gastritis and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment with a Brief Interview Mental Status (BIMS) of 9. Review of active physician orders dated 03/08/25 revealed an order for Aripiprazole oral tab 5 milligrams (mg) once daily in morning (scheduled at 8:00 A.M.) was ordered for Hypotension. This medication is a antipsychotic. Interview on 05/01/25 at 8:42 A.M., with Regional Nurse #500 and Regional Nurse #508 confirmed Ariprprazole (Abilify) was not used to treat hypotension and confirmed the order did not contain an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident family interview, observation, and policy review, the facility failed to implement the abuse policy for reporting and investigating an alleged injury of unknown origin. This affected one (#55) of three residents reviewed for abuse. The census was 65. Findings included: Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses was multiple sclerosis (MS) and non-Alzheimer's dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift. Review of the progress note dated 04/27/25 at 2:47 P.M., documented by Licensed Practical Nurse (LPN) #249, revealed the family approached the nurse regarding a discoloration to resident's left leg. There was bruising seen. The 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 medical record review, staff and resident family interview, observation, and policy review, the facility failed to report an alleged injury of unknown origin. This affected one (#55) of three residents reviewed for abuse. The census was 65. Findings included: Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses was multiple sclerosis (MS) and non-Alzheimer's dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift. Review of the progress note dated 04/27/25 at 2:47 P.M., documented by Licensed Practical Nurse (LPN) #249, revealed the family approached the nurse regarding a discoloration to resident's left leg. There was bruising seen. The family stated she gets her leg caught on the Hoyer lift 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 medical record review, staff and resident family interview, observation, and policy review, the facility failed to thoroughly investigate an alleged injury of unknown origin. This affected one (#55) of three residents reviewed for abuse. The census was 65. Findings included: Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses was multiple sclerosis (MS) and non-Alzheimer's dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift. Review of the progress note dated 04/27/25 at 2:47 P.M., documented by Licensed Practical Nurse (LPN) #249, revealed the family approached the nurse regarding a discoloration to resident's left leg. There was bruising seen. The family stated she gets her leg caught on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and family interview, and policy review, the facility failed to ensure a resident dependent on staff for assistance with activities of daily living was provided oral hygiene. This affected one (#55) of five residents reviewed for Activities of Daily Living (ADL). The facility census was 65. Findings included: Medical record review for Resident #55 revealed an admission date of 02/25/25. Her medical diagnoses was Multiple Sclerosis (MS) and non-Alzheimer's dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was rarely or never understood. Her functional status was substantial/maximal assistance for eating, dependent for toileting, bed mobility, and transfers were not attempted due to safety concerns. She used a Hoyer lift. Review of care plan dated 03/05/25 revealed Resident #55 was at risk for poor oral hygiene. Her intervention was to provide mouth care as per the ADL personal hygiene. Interview on 04/28/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure completion of physician ordered treatments to promote wound healing. This affected one (#33) of three residents reviewed for pressure ulcers. The facility census was 65. Findings include: Medical record review for Resident #33 revealed an admission date of 09/19/24. Medical diagnoses included sepsis and diabetes mellitus. Review of the care plan dated 10/22/24 for Resident #33 revealed the resident had the potential for pressure ulcers. Interventions were to administer treatments as orders and monitor for effectiveness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively impaired. Her functional status was dependent for eating, oral hygiene, toileting, bathing, dressing, and positioning in bed. Review of the physician's orders dated 03/25/25 revealed an order for the left buttock: cleanse with wound cleanser, apply hydrogel, calcium alginate, cover with border…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and policy review, the facility failed to ensure incontinence care was provided correctly. This affected one (#7) of one resident reviewed for incontinence care. The census was 65. Findings included: Medical record review for Resident #7 revealed an admission date of 12/30/22. His medical diagnoses included arteriosclerotic heart disease, Schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal assistance for toileting, supervision or touching assistance for bed mobility and transfers. He was always incontinent for bladder and codes for a colostomy. He was coded for wandering. Review of the care plan dated 03/16/25 for Resident #7 revealed the resident required staff intervention to complete self-care. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interviews, and policy review, the facility failed to adequately monitor and implement interventions timely for residents with significant weight loss. This affected three (#18, #26, and #53) residents of eight reviewed for nutrition. The facility census was 65. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 08/13/24. Diagnoses included dementia, emphysema, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers, and independent with bathing. Review of the care plan dated 02/04/25 revealed Resident #53 had a nutritional problem related to mechanical altered texture and consistency and underweight. Interventions included administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, review of the undated manufacture guidelines, and review of Medscape resource website, the facility failed to ensure the medication error rate did not exceed five percent when three medication errors were observed of 25 opportunities resulting in an error rate of 12 percent. This affected three (#26, #266, and #368) of four residents observed for medication administration. The facility census was 65. Findings include: 1. Review of medical record for Resident #266 revealed admission date of 06/24/24, with diagnoses including major depression disorder recurrent with severe psychotic symptoms, dementia and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed he had severely impaired cognition required set up assistance for eating and supervision for bed mobility, transfers and toileting hygiene. Observation of medication administration on 04/29/25 at 7:58 A.M., with Licensed Practical Nurse (LPN) #293, for Resident #266,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, review of physician orders, staff interview, and review of manufacture guidelines, the facility failed to ensure residents were free from significant medication errors. This affected two (#366 and #368) of five residents reviewed for medications. The facility census was 65. Findings include: 1. Review of medical record for Resident #366 revealed admission date of 02/19/25. The resident was admitted with diagnoses including cellulitis, morbid obesity, type two diabetes mellitus, unstageable pressure ulcer of right heel. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for eating, was dependent with toileting hygiene, maximum assistance for showers, transfers and moderate assistance for bed mobility. Review of the physician orders revealed an order for Lispro (fast acting insulin) 100 units per (/) milliliter (ml) sliding scale before meals and 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 medical record review, family interview, and staff interviews, the facility failed to ensure therapeutic rehabilitation services were provided as ordered. This affected one (#366) of one resident reviewed for reviewed for therapy services. Facility census was 65. Findings include Review of the closed medical record for Resident #366 revealed an admission date of 02/19/25 and discharge 03/28/25. Diagnoses included cellulitis, kidney disease, mood disorder, and diabetes. Review of Hospital referral dated 02/18/25 revealed resident needed skilled rehab stay for wounds and therapy (Physical and Occupational). Review of physician orders dated 02/19/25 for Physical/Occupational/Speech therapy (PT/OT/ST) to evaluate and treat. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #366 was cognitively intact with a Brief Interview Mental Status (BIMS) of 13 and was dependant with toileting, substantial /maximum assistance with oral hygiene, bathing, dressing and personal hygiene.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, staff interview, and review of the arbitration agreement, the facility failed to ensure residents understood the arbitration agreement in a simple manner for residents to understand. This affected three (#4, #10, and #57) of 39 residents who had arbitration. The facility census was 65. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 01/15/24. Diagnoses included type two diabetes mellitus (DM II), schizophrenia, and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the arbitration agreement dated 01/16/24 revealed Resident #4 signed the arbitration agreement. Interview 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, medical record review, staff interview and review of facility policy, the facility failed to ensure staff performed hand hygiene after providing resident care. This affected two residents (#7 and #266). Additionally, the facility failed to ensure proper disposal of personal protective equipment (PPE) following care provided to Resident #7, who was on enhanced barrier precautions (EBP). This affected two residents (#7 and #266) of two residents reviewed for infection control. The facility census was 65. Findings included: 1. Medical record review for Resident #7 revealed an admission date of 12/30/22. Diagnoses included arteriosclerotic heart disease, schizophrenia, Alzheimer's disease, diabetes, chronic kidney disease, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was severely cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal assistance for toileting, and supervision or touching assistance for bed mobility and transfers. Resident #7 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 medical record review, staff interview and review of facility policy, the facility failed to ensure influenza (flu) and pneumococcal vaccinations were offered to residents and further failed to ensure education on the vaccinations was provided to residents and/or their representatives. This affected one resident (#7) of five residents reviewed for vaccination status. The facility census was 65. Findings include: Review of the medical record for Resident #7 revealed an admission date of 02/19/20. Diagnoses included heart disease, schizophrenia, diabetes, Alzheimer's disease and kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 03/08/25, revealed Resident #7 was severely cognitively impaired. Further review of the medical record revealed no evidence Resident #7 was offered or received the flu or pneumococcal vaccinations or that the resident or resident representative received education on the vaccination. Interview on 05/01/25 at 8:39 A.M. with the Director of Nursing (DON) verified the facility had no evidence of the flu and pneumococcal vaccinations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration record review, staff schedule review, staff interview, agency staff interview, resident interview, and policy review, the facility failed to ensure there was enough staff available to pass medications in a timely manner. The affected 51 (#1, #2, #3, #5, #6, #7, #9, #10, #11, #12, #14, #15, #16, #17, #18, #20, #22, #24, #25, #26, #27, #28, #35, #36, #37, #38, #39, #41, #42, #43, #45, #46, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #62, #63, #65, #67, #68, #69, #70, and #72) of 51 residents reviewed for staffing needs. The census was 71. Findings included: Review of the electronic Medication Administration Record (MAR) on 03/19/25 between 11:11 A.M. and 2:00 P.M., revealed 51 (#1, #2, #3, #5, #6, #7, #9, #10, #11, #12, #14, #15, #16, #17, #18, #20, #22, #24, #25, #26, #27, #28, #35, #36, #37, #38, #39, #41, #42, #43, #45, #46, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #62, #63, #65, #67, #68, #69, #70, and #72) had not received the physician ordered mediations as ordered for the morning of 03/19/25. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, computer medication administration record review, staff schedule review, staff interview, agency staff interview, and resident interview and policy review, the facility failed to ensure the continuity of staff to administer medications within the physician ordered time frames. The affected 51 (#1, #2, #3, #5, #6, #7, #9, #10, #11, #12, #14, #15, #16, #17, #18, #20, #22, #24, #25, #26, #27, #28, #35, #36, #37, #38, #39, #41, #42, #43, #45, #46, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #62, #63, #65, #67, #68, #69, #70, #72) of 51 residents reviewed for late mediations. The census was 71. Findings included: 1. Medical record review for Resident #1 revealed an admission date of 02/07/25. Medical diagnoses included coronary artery disease, (CAD) heat failure, diabetes mellitus (DM), and renal insufficiency. Review of the monthly physician orders for March 2025 revealed on 03/19/25, Resident #1 was ordered to receive Tylenol 325 milligram (mg) to be given 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, observation, interview with wound clinic physician, staff interview and policy review, the facility failed to complete physician ordered dressing changes to promote wound healing. This affected one (#18) of three residents reviewed for pressure ulcers. The census was 71. Findings included Medical record review for Resident #18 revealed an admission date of 07/02/24. Medical diagnoses included coronary artery disease, heart failure, hypertension, renal insufficiency, diabetes and Alzheimer's disease. Review of the care plan dated 12/19/24 for Resident #18 revealed the resident had the potential for pressure ulcers. Interventions were to administer treatments as orders and monitor for effectiveness. If the resident refuses the treatments confer with the Interdisciplinary Team (IDT) and family to determine why and try an alternative method to gain compliance and document alternative methods. An update to the care plan dated 03/16/25 revealed the resident would remove his dressings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure Infection Control practices were followed during a pressure ulcer dressing change. This affected one (#18) of three residents reviewed for infection control with pressure sores. This census was 71. Findings included: Medical record review for Resident #18 revealed an admission date of 07/02/24. Medical diagnoses included coronary artery disease, heart failure, hypertension, renal insufficiency, diabetes and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was severely cognitively impaired. His functional status was setup or clean-up assistance for eating, substantial/maximal assistance for toileting, supervision or touching assistance for bed mobility and transfers. He was always incontinent with his bladder and had an ostomy. Observation of a dressing change for Resident #18, on 03/19/25 at 9:25 A.M., with Licensed Practical Nurse (LPN) #144,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record reviews, review of grievance forms, observations, staff interviews, review of two employee files, and policy review, the facility staff failed to implement their policy and provide appropriate and timely resolution to one resident's responsible family member's grievance concerning safe Hoyer transfers. This affected one (Resident #1) of five residents reviewed for grievances. The facility census was 61. Findings include: 1. Clinical record review for Resident #1 revealed an admission date of 12/30/22 with diagnoses including stroke, diabetes, aphasia, anxiety, and bi-polar disorder. He received hospice services since 05/10/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition and could not respond or be interviewed. Review of the care plan revised 11/20/23 revealed the resident was at high risk for falls and required staff total assistance for all activities of daily living including Hoyer transfers. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of grievance forms, observations, staff and resident interviews, review of two employee files, and policy review, the facility staff failed to provide safe and appropriate lift transfers and failed to complete an investigation when staff transferred a resident alone with a Hoyer lift. This affected one (Resident #1) observed for safe Hoyer lift transfers. Additionally, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (Resident #26) of one resident reviewed for elopements. The facility census was 61. Findings include: 1. Clinical record review for Resident #1 revealed an admission date of 12/30/22 with diagnoses including stroke, diabetes, aphasia, anxiety, and bi-polar disorder. He received hospice services since 05/10/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to monitor blood sugar levels as ordered. This affected one (#60) out of three reviewed for monitoring of blood sugar levels. The facility census was 50. Findings included: Review of the medical record for Resident #60 revealed an admission date of 10/13/23 with medical diagnoses of hepatic encephalopathy, abdominal pain, diabetes mellitus (DM), hypertension (HTN), and chronic kidney disease (CKD). Review of the medical record for Resident #60 revealed an admission Minimum Data Set (MDS), dated [DATE], which indicated Resident #60 was cognitively intact and required partial/moderate staff assistance with bathing, supervision with toileting and bed mobility, and was independent with transfers. The MDS indicated Resident #60 received seven days of insulin injections. Review of the medical record for Resident #60 revealed a physician order dated 11/06/23 to complete accu checks (finger blood sugar level checks) daily before each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, review of manufacturer's instructions and policy review, the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 25 opportunities or a 12 percent (%) medication error rate. This affected two (#54 and #68) out of the seven residents reviewed for medication administration. The facility census was 50. Findings included: 1. Review of the medical record for Resident #54 revealed an admission date of 01/14/21 with medical diagnoses of gastrointestinal bleed, emphysema, osteoporosis, anemia, gastric esophageal reflux disease (GERD), bipolar disorder, anxiety, and hypertension (HTN). Review of the medial record for Resident #54 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #54 was cognitively intact and required supervision with activities of daily living (ADL's). Review of the medical record for Resident #54 revealed physician orders dated 11/02/23 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 medical record review, observations, staff interviews, review of manufacturer's instructions and policy review, the facility failed to ensure an insulin pen was primed per manufacturer's instructions prior to insulin administration resulting in a significant medication error. This affected one (#68) out of three residents reviewed for insulin administration. The facility census was 50. Findings included: Review of the medical record for Resident #68 revealed an admission date of 07/24/23 with medical diagnoses of diabetes mellitus (DM), severe protein calorie malnutrition, and anemia. Review of the medical record for Resident #68 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #68 was cognitively intact and was independent with activities of daily living (ADL's). The MDS indicated Resident #68 received seven days of insulin injections. Review of the medical record for Resident #68 revealed a physician order, dated 08/16/23, for Humalog Kwikpen subcutaneous (SQ)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure medications were stored and prepared in a safe manner. This affected five (#14, #15, #18, #19, and #24) of five residents reviewed for medication storage. The census was 51. Findings included: Observation of the medication cart on 10/16/23 at 4:40 P.M. revealed Licensed Practical Nurse (LPN) #136 was standing at her cart and removed a pre-poured cup of medication for Resident #14 that had the resident's initials written on the side of the cup. Further observation revealed there were two pre-poured medication cups sitting on top of the medication cart as well. Interview with LPN #136 on 10/16/23 at 4:43 P.M. revealed she had two resident's pre-poured medication cups, with initials of residents on the side of the cups, sitting on top of the medication cart and pulled out two more medication cups with resident's initials on the side of those cups out of the drawer of the cart. LPN #136 confirmed she pre-poured the medication for five (#14, #15, #18, #19, and #24) residents, and stated she thought she could pre-pour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with staff, the physician and the local ombudsman, the facility failed to follow up with a resident's Power of Attorney's concerns/grievances related to the resident's care. This affected one resident (#12) out of three residents reviewed. The facility census was 48. Findings include: Review of the medical record for Resident #12 revealed a readmission date of 04/30/23. Diagnoses included diabetes mellitus, protein caloric malnutrition, neuromuscular, dysfunction of bladder, aphasia, depression, Parkinson's disease, and heart disease. Review of most recent Minimum Data Set (MDS) assessment 3.0 dated 08/01/23 for Resident #12, revealed the resident had severe cognitive deficits and was nonverbal. Assessment revealed the resident received hospice services. Review of the Healthcare Power of Attorney (POA) dated 08/07/20, revealed Resident #12 and Resident #12's two children established the Healthcare POA. Resident #12 delegated her daughter as agent number one and the resident's son as agent number two. Review of the facility documents titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents were notified when their account exceeded the Supplemental Security Income (SSI) resource limit and failed to convey a resident's funds after the resident expired. This affected four (#15, #37, #19, and #221) of six resident funds accounts reviewed. The facility census was 69. Findings include: Review of Resident #15's personal funds account revealed a balance of $3,429.00. Record review revealed Resident #15 was a Medicaid recipient. There was no evidence Resident #15 was provided with a notice to spenddown their funds. Review of Resident #19's personal funds account revealed a balance of $4,241.30. Record review revealed Resident #19 was a Medicaid recipient. There was no evidence Resident #19 was provided with a notice to spenddown their funds. Review of Resident #37's personal funds account revealed a balance of $2,521.40. Record review revealed Resident #37 was a Medicaid recipient. There was no evidence Resident #37 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and policy review, the facility failed to ensure a resident receiving dialysis treatments had a dialysis care plan. This affected one resident (#65) of one resident reviewed for dialysis. The census was 69. Findings include: Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses include nondisplaced fracture of the right femur, left pubis, lumbar vertebra, and right pubis related to an accidental discharge of a firearm, end stage renal disease requiring hemodialysis, hemiparesis, type two diabetes, attention deficit disorder, essential hypertension, and anemia. Review of Resident #65's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and as independent with eating, required limited assistance with bed mobility and required extensive assistance with locomotion, dressing and personal hygiene. Resident #65 received hemodialysis. Review of Resident #65's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews and policy review, the facility failed to have an effective administration by ensuring staff implemented their Leave of Absence (LOA) policy when a resident frequently left the faciity on LOA's. This affected one (#64) out of three residents reviewed for elopement. The facility census was 69. Findings include: Review of the medical record for the Resident #64 revealed an admission date of 08/17/22. Diagnoses included respiratory failure, cardiac arrest, chronic obstructive pulmonary disease, abnormal laboratory values, dysphasia, cardiac pacemaker. The medical record also revealed Resident #64's wife as an emergency contact and not his power of attorney or guardian. Resident #64 discharged to home on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated 08/24/22, revealed the resident had a brief interview for mental status (BIMS) score of eight out of 15 indicating impaired cognition. The assessment identified Resident #64 to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to ensure vials of insulin were discarded when they became out of date. This had the potential to affect six out of six residents (#14, #23, #25, #46, #69, and #178) who resided on unit one who received insulin. The facility identified there were 14 residents who received insulin. The census was 79. Findings included: Observation of medication storage for insulin for the unit one cart on 01/21/20 at 4:17 P.M. revealed there was a vial of opened Lantus with a date of opening of 12/17/19 and two vials of opened Humalog with the date of opening of 12/23/19 and 12/14/19. The vials of insulin did not have resident identification. Interview with Registered Nurse (RN) #70 on 01/21/20 revealed she thought the date of expiration on the vials of the above mentioned insulin was 30 days and said she would have to look at the policy to be sure. RN #70 confirmed the opened insulin vials did not contain resident identification; however, there were six (#14, #23, #25, #46, #69 and #178) residents that could use the insulin…

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

Based on observations, review of facility menus and resident and staff interviews, the facility failed to follow prepared menus for the residents. This had the potential to affect 78 out of 79 residents residing in the facility, one (#54) resident was identified as receiving nothing by mouth (NPO). Facility census was 79. Findings include: 1. Interview on 01/21/20 at 10:20 A.M., revealed Resident #62 reported the facility changes their weekly scheduled meal menus and residents are not aware of any changes from day to day. Observation on 01/21/20 at 12:01 P.M., revealed lunch menu documented the facility was serving pork chops, sweet potato souffle, zucchini, dinner roll and fruit cup. Observations revealed the residents received green beans instead of zucchini and apple sauce instead of fruit cup. Interviews on 01/21/20 at 12:01 P.M., with six (#6, #27, #35, #38, #39, and #62) residents revealed they were not aware of the substitutions made to weekly menu. The resident's reported the weekly menus change daily. 2. Observation on 01/21/20 at 4:31 P.M., revealed dinner menu documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to label, date, and discard expired food items form the walk-refrigerator and freezer and the facility also failed to serve food in a sanitary environment. This had the potential to affect 78 out of 79 residents residing in the facility, one (#54) resident was identified as receiving nothing by mouth (NPO). Facility census was 79. Findings include: 1. On 01/21/20 from 8:26 A.M. to 8:50 A.M., an initial tour of the kitchen was conducted with Dietary Manager (DM) #56. During the observation the following concerns were observed, and all the concerns were verified during an interview with DM #56: a) In the freezer there was a plastic bag of diced chicken with no date or use by date. b) In the freezer there was a plastic bag of Salisbury steak with no date or use by date. c) In the freezer there was a plastic of chicken tenders with no date or use by date. d) In the freezer there was a plastic bag of sausage opened and not covered with no date or use by date. e) In the refrigerator there was a bag of shredded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and resident and staff interviews the facility failed to ensure staff provided a dignified dining experience regarding providing timely assisting a cognitive impaired resident during a meal. This affected one (#73) of three residents observed for dignity. The facility census was 79. Finding include: Review of medical record revealed Resident #73 was admitted to the facility 05/04/19. Diagnoses included dementia in other diseases classified elsewhere, essential hypertension, major depressive disorder, glaucoma, cardiomegaly, chronic kidney disease, type 2 diabetes mellitus without complications, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/03/20, revealed Resident #73 had severely impaired cognitive deficits and required extensive assistance activity of daily living. Observation on 01/21/20 at 12:30 P.M., revealed Resident #73 had his lunch in front of him but with a lid covering it. There were three State Tested Nursing Assistants (STNA's) observed assisting and cueing residents in the dining room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview and policy review, the facility failed assist a resident with personal hygiene including ensuring facial hair was removed during bathing. This affected one (#54) out of one residents reviewed for activities of daily living. Facility census was 79. Findings included: Medical record review for Resident #54 revealed an admission date of 12/11/19. Medical diagnoses included heart failure, renal failure, and diabetes. Review of admission Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired. Functional status was extensive assistance for bed mobility and toilet use and total dependence for transfers and bathing with a two-person assistance. Eating was limited assistance with one-person assistance. Observation was conducted on 01/21/20 at 11:15 A.M. which revealed Resident #54 had chin and lip hairs that were approximately half an inch long. Further observation on 01/22/20 at 10:36 A.M. revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure an appetite stimulant was implemented as recommended and approved by the dietician. This affected one (#77) of five residents reviewed for significant weight loss. The facility identified there were 11 residents who had significant weight loss. Facility census was 79. Findings included: Medical record review for Resident #77 revealed an admission date of 03/06/17. Medical diagnoses included Alzheimer's and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Her functional status was extensive assistance for bed mobility, transfers, and toileting. She was limited assistance for eating with one-person assistance. Review of physician orders dated 12/03/20 and signed off on by the physician on 12/10/20 revealed no order for Mirtazapine. Further review of the Medication Administration Record (MAR) for the same time frame revealed no order for Mirtazapine. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and policy review, the facility failed to ensure a gait belt was utilized for transporting Resident #128 in accordance with the facility policy. This affected one (#128) of one resident's reviewed for accidents during the annual survey. Facility census was 79. Findings included: Medical record review for Resident #128 revealed an admission date of 01/17/20. Medical diagnoses included Alzheimer's disease and dementia. Review of care plan dated 01/18/20 for Resident #128 revealed he was at risk for falls related to confusion, gait/balance problems, psychoactive drug use and unaware of safety needs. Observation on 01/21/20 at 10:44 A.M. revealed Resident #128 was being ambulated to his room by State Tested Nursing Aide (STNA) #40. During the observation STNA #40 was holding Resident #128 under his left arm with her left hand and had her right hand on the back of his jeans waist band while he was leaning onto her and dragging his feet to keep from falling.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to follow infection control practices during a wound dressing change. This affected one (#55) of two reviewed for pressure ulcers. The census was 79. Findings include: Review of Resident #55's medical record revealed an admission date of 07/08/19. Diagnoses included hypertension, major depressive disorder, macular degeneration, type II diabetes mellitus, and renal insufficiency. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 had one pressure ulcer that was unstageable due to slough. Wound care for Resident #55 was observed on 01/22/20 at 1:28 P.M. The observations revealed Licensed Practical Nurse (LPN) #70 washed hands at a nursing station sink. LPN #70 obtained supplies and entered Resident #55's room. LPN #70 donned gloves and then removed dressing that was on Resident #55's right heel. LPN #70 then cleansed right heel wound with dermal wound cleanser, applied ordered treatment, and wrapped…

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