Stellar Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, and staff interview the facility failed to document advance directives for a resident. This affected one resident (#2) of eighteen residents reviewed for advanced directives. The facility census was 36.Findings include:Review of the medical record for Resident #2 revealed admission to the facility on [DATE] for diagnoses including a stroke with left side paralysis, atrial fibrillation (irregular heartbeat), bilateral above the knee amputations, high blood pressure, anxiety and depression, schizophrenia (mental disorder with delusion thoughts and/or hallucinations), diabetes, and congestive heart failure.Further review of the medical record for Resident #2 revealed no current order for code status. Review of discontinued orders revealed an order to discontinue full-code status on 10/27/25. Interview on 01/21/26 at 10:40 A.M. with licensed practical nurse (LPN) #38 revealed that Resident #2's code status should be listed under the orders screen in the electronic…

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

Based on review of beneficiary liability notices and staff interview, the facility failed to ensure residents and/ or their representatives signed the liability notices provided acknowledging their skilled services were ending for coverage under Medicare (MCR) Part A services. This affected two residents (#2 and #36) of three residents reviewed for liability notices. Findings include:1.) Review of Resident #2's liability notices revealed the resident's last covered day for MCR Part A services was on 09/05/25. Notice of non-coverage was documented on a Centers for Medicare and Medicaid Services (CMS) form 10123, titled Notice of MCR Non-Coverage (NOMNC) and was dated for 08/25/25. The form included a place for the residents or their representatives to sign acknowledgement of receiving that notice, but was only signed by two facility employees (Admissions Director #49 and MDS Coordinator #47), and not the resident or their representative. There was no documented evidence on the NOMNC of the resident or their representative having been notified their skilled service was ending or that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to ensure residents with the diagnosis of dementia did not receive an anti-psychotic medication without an adequate indication for use. This affected two residents (#5 and #33) of five residents reviewed for unnecessary medications. Findings include:1.) Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included unspecified dementia (moderate) with agitation and depression. Review of Resident #5's acknowledgement/ consent for psychoactive medications dated 02/15/25 revealed the resident's representative signed consent for the use of the Seroquel that had previously been indicated to be used for dementia with behavioral disturbances on a prior acknowledgement/ consent dated 03/30/24. The target behaviors it was previously used for included anxiety and agitation. The more recent acknowledgement/ consent form did not include a diagnosis or condition that warranted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident and/ or their representative was provided a transfer notice in writing and a bed hold notice at the time of a transfer to the hospital. This affected one resident (#1) of three residents reviewed for hospitalizations. Findings include:Review of Resident #1's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a stroke, acute respiratory failure, and pneumonitis due to the inhalation of food and vomit into his lungs. Review of Resident #1's progress notes revealed a nurse's note dated 09/11/25 at 9:40 A.M. that indicated the nurse went into the resident's room to administer his medications and was unable to arouse the resident. He did not respond to tactile stimuli and remained unresponsive. The facility's Director of Nursing (DON) was notified and it was decided to send the resident to the emergency room. He was transported to the emergency room via squad at 10:05 A.M. The facility was asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure accuracy of minimum data set (MDS) assessments for residents. This affected two residents (#3, #33) of 18 residents reviewed for accuracy of assessments. The census was 36. Findings include:1.Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, cardiac pacemaker, type two diabetes, hypertension, and gastro esophageal reflux disease. Review of Resident #3 orders revealed an order to admit the resident to hospice active 11/20/24. Review of Resident #3 care plan completed 09/10/25 revealed the resident is receiving hospice services. Initiated on 09/10/25. Goals, include the resident needs, will be met with comfort and dignity through end-of-life services. interventions include coordinating care with hospice. Review of Resident #3 annual minimum data set (MDS) completed on 01/01/26 revealed a brief interview for mental status (BIMS) score of 04 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure residents received complete treatment for infections including antibiotic therapy and failed to ensure physician prescribed weight loss treatment was completed. This affected two residents (#3, #17) of 16 residents reviewed for quality of care. The census was 36. Findings include:1.Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, cardiac pacemaker, type two diabetes, hypertension, and gastro esophageal reflux disease. Review of Resident #3's annual minimum data set (MDS) completed on 01/01/26 revealed a brief interview for mental status (BIMS) score of 04. Review of Resident #3's orders revealed an order to clean left index finger around the nail bed with IHWC, pat dry, apply triple antibiotic ointment (TAO) and cover with band aid daily until resolved. Review of Resident #3's orders revealed an order for Doxycycline hyclate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure catheter care was completed for Resident #17, urinary outputs were monitored as ordered for Resident #27, and Resident #36 completed their full course of prescribed antibiotics for a urinary tract infection (UTI). This affected three residents (#17, #27, #36) of four residents reviewed for urinary catheters and UTIs. The census was 36. Findings Include:1.Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, chronic obstructive pulmonary disease, hyperlipidemia, insomnia, morbid obesity, and depression. Review of Resident #17's minimum data set (MDS) completed on 12/26/25 revealed the resident had an indwelling urinary catheter. Review of Resident #17's orders revealed an order to maintain 16 French (F) with 10 milliliter (ML) balloon catheter in place, to be changed every 30 days as needed to maintain patency. Review of Resident #17 record revealed…

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

Based on medical record review, resident observations, and staff interviews, the facility failed to provide adequate hydration for Resident #36. This affected one resident (#36) of two residents reviewed for hydration status. The facility census was 36.Findings include:Review of the medical record for Resident #36 revealed admission to the facility on 7/28/25 for diagnoses including Atrial Fibrillation (an irregular heartbeat), congestive heart failure, contractures (stiffing of the joints preventing them from bending) of the bilateral hands and knees, Rheumatoid Arthritis, and dementia (impaired memory and cognition). Review of the Minimum Data Set (MDS) 3.0 quarterly assessment completed on 11/24/25 revealed Resident #36 required set up assistance and supervision with meals, was dependent in several areas including bathing, dressing, toileting, and utilized a specialized wheelchair to be pushed by staff. Further review of the MDS assessment for Resident #36 revealed a brief interview for mental status (BIMS) score of 3/15 indicating significant cognitive impairment.Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice and the residents care plan. This affected two residents (#10, #17) of three residents reviewed for respiratory care. The census was 36.Findings include:1.Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including dementia, metabolic encephalopathy, type 2 diabetes, heart failure, hypertension, and acute kidney failure. Review of Resident #10's orders revealed an order for oxygen (O2) at 2-4 liters (L) per nasal cannula (NC) to maintain oxygen saturation above 90% as needed for shortness of breath and low oxygen saturations (sats), active as of 11/28/25. Review of Resident #10's admission minimum data set (MDS) completed 12/01/25 revealed a brief interview for mental status score of 03 and the resident required oxygen therapy.Review of Resident #10's admission care…

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

Based on observation, interview, review of facility contracts and personnel files, the facility failed to provide administration of an intravenous (IV) medication by a competent licensed nurse to Resident #38. This affected one resident (#38) of two residents reviewed for IV medications. The facility census was 36.Findings include:Record review of Resident #38 revealed admission to the facility on 1/13/26 for diagnoses of post operative wound infection with central line placement for intravenous (IV) antibiotic therapy, diabetes, liver disease, high blood pressure, anemia (low blood count), depression, and history of stroke. Further review of the medical record for Resident #38 revealed an order written on 01/13/26 for cefepime hcl (antibiotic used for wound infection) 2 grams (GM) in 100 milliliters (ml) normal saline to be administered three times a day intravenously through 02/20/26.Review of the medical record for Resident #38 revealed a peripherally inserted central catheter (PICC) was placed in the residents right upper arm while in the hospital prior to admission to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations that identified irregularities during monthly medication regimen reviews were appropriately addressed by the physician/ nurse practitioner and/ responded to timely. This affected two residents (#5, #33) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #5's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (moderate) with agitation and depression. Review of Resident #5's monthly medication regimen reviews revealed the resident's medications were reviewed monthly by the consulting pharmacist to identify any irregularities in his medication regimen. Irregularities were noted during two of the 11 months reviewed. Review of Resident #5's pharmacy recommendations revealed the pharmacist noted an irregularity when reviewing the resident's medications on 04/17/25. The pharmacist indicated 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.

Based on medical record review and staff interviews, the facility failed to obtain ordered laboratory tests and report results to provider for one resident. This affected one resident (#36) of one resident reviewed for laboratory services. The facility census was 36.Findings include: Review of the medical record for Resident #36 revealed admission to the facility on 7/28/25 for diagnoses including atrial fibrillation (an irregular heartbeat), congestive heart failure, contractures (stiffening of the joints preventing them from bending) of the bilateral hands and knees, rheumatoid arthritis, and dementia (impaired memory and cognition). Review of the Minimum Data Set (MDS) 3.0 quarterly assessment completed on 11/24/25 revealed Resident #36 was dependent in several areas including bathing, dressing, toileting, and utilized a specialized wheelchair to be pushed by staff. Further review of the MDS assessment for Resident #36 revealed a brief interview for mental status (BIMS) score of 3/15 indicating significant cognitive impairment.Review of Resident #36's provider orders revealed she…

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

Based on observations, staff interviews, review of medical records, and facility policies and procedures review, the facility failed to follow infection control practices to prevent the spread of infection. This affected one resident (#38) of five residents reviewed for medication administration and one resident (#10) of one resident reviewed for transmission-based precautions. The facility census was 36.Findings include:1.Record review of Resident #38 revealed admission to the facility on 1/13/26 for diagnoses of post operative wound infection with central line placement for intravenous (IV) antibiotic therapy, diabetes, liver disease, high blood pressure, anemia (low blood count), depression, and history of stroke. Further review of the medical record for Resident #38 revealed an order written on 01/13/26 for cefepime hcl (antibiotic used for wound infection) 2 grams (GM) in 100 milliliters (ml) normal saline to be administered three times a day intravenously through 02/20/26. Review of the medical record for Resident #38 revealed a peripherally inserted central catheter (PICC)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's infection control logs, staff interview, and policy review, the facility failed to ensure a resident, who was admitted to the facility on an antibiotic medication, was reviewed to ensure there were laboratory tests that supported the use of an antibiotic to treat a urinary tract infection (UTI), and the resident met criteria under the facility's antibiotic stewardship program for such treatment. This affected one resident (#48) of five residents reviewed for UTI's. Findings include: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following a stroke affecting her right dominant side, adult onset diabetes mellitus, and a urinary tract infection. Review of Resident #48's hospital records for her hospital stay prior to her admission into the facility on [DATE] revealed an After Visit Summary (AVS) dated 11/05/25 that revealed the resident was diagnosed with acute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility billing/financial information, review of the Facility Assessment, and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services. This had the potential to affect all 35 residents residing in the facility.Findings include:Although there was no evidence of any current shut-off for services at the time of the investigation, the risk for interruption of services was identified. The facility failed to provide evidence of fund availability and systems in place to ensure bills/invoices were paid timely and as due. Review of the following vendor/suppliers invoices/billing documentation and interviews completed as part of the State agency investigation revealed the following facility financial solvency concerns included but not limited to: Review of an invoice from the State Fire Marshal revealed an amount of $50 was due on 09/03/23 related to an inspection completed on 07/20/23.Review of 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 record review, observation, interview, review of the activity calendar and job description review, the facility failed to assess and meet the activity needs of residents. This affected all 35 residents residing in the facility. Findings include: 1. Review of activity calendars dated April 2025 through September 2025 revealed on Sundays, Tuesdays, Thursdays, Fridays and Saturdays, the first two activities of the day are beverage cart and sit and chat. The third activity on Sunday is church, and throughout the rest of the days the third activity is a game of some sort. On Mondays from 8:30 A.M. to 3:30 P.M., beauty shop was listed as the activity and either resident council at 2:00 P.M. or movies in the evening at 6:00 P.M. There were no other days with activities in the evenings. On Wednesdays, from 8:00 A.M. to 11:00 A.M. was resident shopping and at 2:00 P.M. was cards. Observation on 09/15/26 at 1:26 P.M. during resident council meeting, the council stated they would like to have some more activities.…

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

Based on observation, interview, record review, and review of the facility assessment tool, the facility failed to ensure sufficiency nursing staff was available to provide timely and appropriate nursing and nursing-related services to residents. This had the potential to affect all residents. The facility census was 35. Findings include: Interview on 09/15/25 at 8:19 A.M. with anonymous staff member #170 revealed there were a lot of times where Certified Nursing Assistants (CNA) were on the floor by themselves, and on the weekends the facility had a lot of staff call off. Anonymous staff member #170 reported there were not enough CNAs to care for the residents as there were so many residents who were completely dependent on staff for activities of daily living (ADLs). The staff member continued that a lot of tasks and care for residents, such as bathing and oral care could not be completed in a timely manner, and feeding assistance provided to residents was rushed due to a lack of staff. Anonymous staff member #170 reported call lights take a long time to answer as the limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy review, the facility failed to provide specialized memory care services as advertised. This affected seven residents (#10, #14, #20, #25, #26, #29, and #35) of seven residents residing on the memory care unit. The facility census was 35. Findings include:Record review revealed Resident #10 admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and major depression. Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including dementia and major depression. Record review revealed Resident #20 admitted to the facility on [DATE] with diagnoses including dementia and depression. Record review revealed Resident #25 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and anxiety disorder. Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including depression and dementia. Record review revealed Resident #29 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Administrator job description, review of vendor invoices, and interviews, the facility failed to have systems in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Additionally, based on observation, interviews, review of dietary schedules and the facility assessment, the facility administration failed to ensure the facility employed sufficient dietary staff in accordance with the facility assessment. This affected 35 of 35 residents residing in the facility. The facility census was 35. Findings include:1.Review of an invoice from the Fire Marshal revealed an amount of $50 was due on 09/03/23 related to an inspection completed on 07/20/23. Review of an invoice from the Fire Marshal revealed an amount of $75 was due on 09/30/23 related to an inspection completed on 08/16/23. Review of an invoice from the Fire Marshal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Assessment, interviews, record reviews, and observations the facility failed to conduct an accurate and thorough facility assessment to determine appropriate resources were available to provide necessary care and services the residents required during both day-to-day operations and emergencies, including nights and weekends. This had the potential to affect all residents. The facility census was 35.Findings include: Review of [NAME] Care Center Resident Analyzer and Resident Minimum Data Set (MDS) information revealed there were 15 residents (Residents #3, #5, #7, #9, #10, #20, #22, #24 #23, #25, #26, #30, #31, #33, and #34) who were dependent on staff for toileting . Review of [NAME] Care Center Resident Analyzer and Resident Minimum Data Set (MDS) information revealed there were 14 residents (Residents #3 , #4, #5, #6, #9, #10, #22, #24, #25, #26, #30, #31, #33, and #34) who were dependent on staff for dressing . Review of [NAME] Care Center Resident Analyzer and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, they facility failed to ensure residents received comprehensive, resident centered care related to skin assessments, supplement orders, physician orders and physician notification related to weight gain. This affected four residents (Resident #5, #30, #8 and #24) of 24 residents reviewed for quality care. The census was 35. Findings include: 1. Record review revealed Resident #05 admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, hypertension, vitamin D deficiency, vitamin B deficiency, hyperlipidemia, gastro-esophageal reflux disease (GERD), neuromuscular bladder dysfunction, and benign prostatic hyperplasia. a. Record review of Resident #05 quarterly Minimum Data Set (MDS) completed 08/01/25 revealed a brief interview for mental status score (BIMS) of 08, and has no exhibited or displayed behaviors. MDS revealed Resident #5 had Moisture related skin damage (MASD) , had a pressure reducing device for bed and chair, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of facility policy, and material safety data sheet (MSDS) review, the facility failed to ensure fall interventions were in place for Resident #26 and failed to ensure a post-fall assessment was completed after Resident #27's unwitnessed fall. This affected two residents (Resident #26 and Resident #27) out of five residents reviewed for falls. Additionally, the facility failed to properly store hazardous chemicals. This had the potential to affect seven residents (#10, #14, #20, #25, #26, #29, and #35) out of seven residents residing on the memory care unit. The facility census was 35.Findings Include:1. Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia, hypertension, insomnia, anxiety, and vitamin D deficiency.Review of Resident #26's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 01 indicating cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interview the facility failed to ensure comprehensive discharge instructions were provided and failed to ensure documentation of a discharge was located in the medical record. This affected one (Resident #27) of one resident reviewed for discharge process. The census was 35.Findings Include: Closed record review revealed Resident #27 discharged from the facility on 07/24/25 with diagnoses including cerebral infarction, type two diabetes mellitus, cognitive communication deficit, chronic kidney disease, hypertension, hyperlipidemia, heart failure, gastro-esophageal reflux disease, hyperkalemia, and insomnia.Review of Resident #27 Multidisciplinary discharge summary revealed Resident #27 was discharged on 07/24/25 to their home. Review of Resident #27 discharge summary revealed an incomplete discharge instructions with no evidence of education regarding diet or activities provided to Resident #27 or their representative. Record review revealed no documentation of a discharge note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission to the facility. This affected two (#8 and #27) of two residents reviewed for care planning. The facility census was 35. Findings include:1. Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy. Review of an assessment titled Care Conference Summary dated 09/16/25 revealed attendees included Resident #8, dietary staff, social services, activities, and therapy. The plan of care was reviewed with Resident #8. Review of Resident #8 ' s care plan revealed the dietary care plan was initiated on 09/15/25, but the rest of the care plan was not completed until 09/23/25. Interview on 09/23/25 at 3:05 P.M. with Administrator confirmed baseline care plans should be completed with 48 hours of admission to the facility. Administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure showers were given to residents based on their preferences and shower schedules. This affected two (#24 and #28) of five residents reviewed for activities of daily living (ADLs). The facility census was 35. Finding include:1. Record review revealed Resident #24 admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease, chronic obstructive pulmonary disease, and hypertension.Review of a minimum data set (MDS) dated [DATE] revealed Resident #24 had no behaviors and was dependent on staff for bathing.Review of a care plan initiated on 09/05/25 revealed Resident #24 was at risk or had an ADL self-performance deficit related to cognition deficit, impaired vision, and weakness. Interventions included but were not limited to use a mechanical lift and assist of two staff, dependent on staff for toileting, and dependent on staff for bathing.Review of a shower schedule revealed Resident #24 receives showers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure oxygen was administered under a physician order. This affected one (#8) of one resident reviewed for oxygen. The facility census was 35. Findings include: Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy. Review of a nursing note dated 09/09/25 at 6:15 P.M. by Licensed Practical Nurse (LPN) #8 revealed Resident #8 admitted to the facility by ambulance with oxygen in place at 2 liter per minute (lpm).Review of a Minimum Data Set, dated [DATE] revealed Resident #8 received oxygen therapy. Review of Resident #8's orders revealed there was no order in place for oxygen.Interview and observation on 09/22/25 at 3:57 P.M. with Resident #8 revealed she had an oxygen concentrator set to 2 liters per minute (lpm) and was wearing a nasal cannula. Resident #8 confirmed she had oxygen in place, and the tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, interview, the facility failed to ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. This affected one (Resident #2) of one resident reviewed for pain management. The census was 35. Findings include:Resident #2 admitted to the facility on [DATE] with diagnoses including lung cancer, chronic obstructive pulmonary disease, type two diabetes mellitus, brain cancer, weakness, chronic pain, and heart failure. Record review revealed an order placed on 09/10/25 for Tramadol 50 milligram (mg) (opioid pain medication) tablet one tablet by mouth every six hours as needed for pain. Record review revealed an order placed 09/10/25 for acetaminophen one tablet (analgesic) by mouth every eight hours as needed for pain of head, neck, and trunk extremities. Record review of Facility Audit report revealed Tramadol 50 mg 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 record review and interviews, the facility failed to ensure residents received medically related social services. This affected one resident (#30) of one resident reviewed for psychosocial well-being. The facility census was 35. Findings include:Record review revealed Resident #30 admitted to the facility on [DATE] with diagnoses including major depression, anxiety disorder, and alcohol dependence in remission. Review of a Minimum Data Set (MDS) completed on 08/09/25 revealed Resident #30 had mildly impaired cognition and no behaviors. Review of a care plan dated 08/21/25 revealed Resident #30 was at risk for a psychosocial well-being problem related to social isolation, depression and left side hemiplegia. Interventions included but were not limited to psych services as needed, allow the resident time to answer questions and to verbalize feelings and fears, and provide opportunities for the resident to make his own decisions. Review of a psychiatric note dated 09/10/25 by Nurse Practitioner (NP) #822…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and facility policy review, the facility failed to provide pharmaceutical services to meet the needs of each resident. This affected two residents (#30 and #2) of 24 resident's records reviewed for pharmaceutical services. The facility census was 35. Findings include:1. Record review revealed Resident #30 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, gastroesophageal reflux disease (GERD), anxiety, major depression disorder, hyper cholesterol, chronic obstructive pulmonary disorder (COPD), cerebral infarction, hypothyroidism, hypertension, constipation, and osteoporosis. Review of Resident #30's June 2025 medication administration record (MAR) revealed an order for Debrox Otic Solution (Carbamide Peroxide (Otic) Instill five drops in both ear two times a day for ear wax removal for three days, irrigate on the fourth day. From 06/11/25 through 06/14/25, Resident #30's MAR for Debrox was marked as 9 for other/see nurses notes. Review of…

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

Based on observation, record review and interview, the facility failed to ensure residents received nutritive, palatable food. This affected two Residents (Resident #23 and Resident #28) of two residents reviewed for food. The census was 35.Findings include: 1. 1. Record review revealed Resident #23 admitted to the facility 12/10/24 with diagnoses including osteoarthritis, chronic obstructive pulmonary disease (COPD) , anemia, heart failure, urinary tract infection, and adjustment disorder.Record review of Resident #23's quarterly Minimum Data Set (MDS) assessment completed 08/08/25 revealed severe cognitive impairment, no displayed or exhibited behaviors, and the resident has an ordered mechanically altered diet and an ordered therapeutic diet. Resident #23 had a weight loss of five percent or more in the last month or loss of ten percent or more in the last six months and was not on a physician prescribed weight loss regimen. Record review of Resident #23's care plan revised 09/05/25 revealed the residents at risk for malnutrition/ alteration in nutritional status related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure food was prepared in a form to meet individual resident needs. This affected two residents (Resident #5, and Resident #23 ) of two residents reviewed for food. The facility census was 35.Findings include: 1.Record review revealed Resident #05 admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, hypertension, vitamin D deficiency, vitamin B deficiency, hyperlipidemia, gastro-esophageal reflux disease (GERD), neuromuscular bladder dysfunction, and benign prostatic hyperplasia.Record review of Resident #05's quarterly Minimum Data Set (MDS) 3.0 assessment completed 08/01/25 revealed cognitive impairment, a mechanically altered diet and therapeutic diet. Review of Resident #05's orders revealed an order placed 12/08/24 for a low concentrated sweets diet (LCS), with mechanical soft texture.Review of Resident #05's care plan revealed a plan of care revised on 09/15/25 stating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident records and documentation were accurate. This affected one (#5) of two residents reviewed with an indwelling urinary device. The census was 35.Findings include: Record review revealed Resident #05 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, hypertension, vitamin D deficiency, vitamin B deficiency, hyperlipidemia, gastro-esophageal reflux disease, neuromuscular bladder dysfunction, and benign prostatic hyperplasia.Record review of Resident #05's quarterly Minimum Data Set (MDS) assessment completed 08/01/25 revealed a brief interview for mental status score (BIMS) of 08, and the resident had no exhibited or displayed behaviors. Resident #05 had an indwelling catheter, a suprapubic catheter. The resident had bilateral upper and lower extremity range of motion (ROM) impairment, used a wheelchair, and was dependent on staff or required maximal assistance for activity of daily living (ADL) care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure infection control practices were in place when a resident's catheter bag was oberved on the ground. This affected one (#9) of two residents reviewed for catheter care. The facility census was 35. Findings include:Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including quadriplegia, pure hypercholesterolemia, and neuromuscular dysfunction of bladder. Review of an order dated 02/28/25 revealed Resident #9 had an indwelling catheter with 18 french and 30 cc balloon in place to be changed every 30 days and as needed.Review of a care plan dated 08/08/25 revealed Resident #9 had severely impaired cognition and was frequently incontinent of bladder.Observation on 09/16/25 at 9:38 A.M. revealed Resident #9 was resting with his bed in a low position and his catheter bag was laying on the floor.Observation on 09/16/25 at 10:15 A.M. revealed Resident #9 was resting in bed and his catheter bag remained on 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, policy review and interview, the facility failed to maintain appropriate infection control practices during a wound treatment. This affected one resident (#14) of one observed for a dressing change. The census was 32. Findings include: Medical record review revealed Resident #14 was admitted on [DATE] with diagnoses including quadriplegia, diabetes mellitus, neurogenic bladder and peripheral vascular disease. Review of the electronic Physician Orders dated 04/17/25 revealed Resident #14 was receiving daily treatments including pressure ulcer treatments to an unstageable right hip pressure ulcer. The resident had an indwelling urinary catheter and was ordered enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organism that involves the use of a gown and gloves during high-contact resident care activities i.e. residents with wounds or indwelling medical devices). On 04/17/25 between 2:19 P.M. and 2:58…

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

Based on observation, record review, policy review and interview, the facility failed to ensure the resident environment remained free of accident hazards when medication carts and treatment carts were left unlocked and unattended. This had the potential to affect seven residents (#26, #27, #28, #29, #30, #31 and #32) residing on the locked memory care unit. The census was 32. Findings include: Medical record reviews revealed Resident #26, #27, #28, #29, #30, #31 and #32 were all severely impaired for daily decision-making and resided on the locked, memory care unit. On 04/21/25 at 8:07 A.M., observation with Licensed Practical Nurse (LPN) #76 revealed the medication cart and treatment cart were unsupervised and unlocked at the nurses' station upon arrival to the memory care unit. Certified nurse assistant (CNA) #78 was observed in the dining room serving breakfast trays, and the medication and treatment carts were not within view of the CNA. There was no nurse or staff observed at the nurses' station at the time of the observation. Interview with LPN #76 at the time 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 medical record review and interview, the facility failed to ensure required components of the comprehensive assessments were completed as required. This affected one resident (#14) of four residents sampled. The census was 32. Findings include: Medical record review revealed Resident #14 was admitted on [DATE] with diagnoses including quadriplegia, chronic pain, diabetes mellitus, neurogenic bladder, major depressive disorder and peripheral vascular disease. Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident's Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview were not completed as required. Review of the quarterly MDS assessment dated [DATE] revealed the Pain Assessment interview was not completed as required. On 04/21/25 at 12:25 P.M., interview with Assistant Director of Nursing #85 verified the above. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00164581.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to develop comprehensive care plans as required. This affected two residents (#23 and #33) of four sampled residents. The census was 32. Findings include: 1. Closed medical record review revealed Resident #33 was admitted on [DATE] with diagnoses including hypertension, pancreatic disorder and colostomy. The resident was discharged home on [DATE]. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact for daily decision-making, denied pain, his overall goal was to return to the community, there was no active discharge plan, no referrals had been made and the local contact agency was unknown. Further review of the record revealed no other MDS assessments were completed for review. a. Review of the Physician Orders dated 03/12/25 revealed Resident #33 was ordered routine Tylenol 650 milligrams three times a day for complaints of pain to the head, neck, trunk and extremities. 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, policy review, wound dressing guideline review and interview, the facility failed to provide appropriate care and services to treat pressure ulcers. This affected one resident (#14) of one reviewed for wound care. The census was 32. Findings include: Medical record review revealed Resident #14 was admitted on [DATE] with diagnoses including quadriplegia, chronic pain, diabetes mellitus, neurogenic bladder, major depressive disorder and peripheral vascular disease. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #14 had no skin impairments. Review of the Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 04/06/25 revealed the resident was at moderate risk for skin breakdown. Review of the nurse practitioner Skin and Wound Initial Evaluation dated 04/08/25 and 04/15/25 revealed three new facility acquired pressure ulcers including an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure colostomy care was provided as ordered. This affected two residents (#23 and #33) of four residents sampled. The census was 32. Findings include: 1. Closed medical record review revealed Resident #33 was admitted on [DATE] with diagnoses including hypertension, pancreatic disorder and colostomy. The resident was discharged home on [DATE]. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact for daily decision-making and had a surgical wound. Review of the Physician Orders dated 02/11/25 revealed colostomy care was to be provided once a shift. Review of Resident #33's Treatment Administration Records (TAR) revealed the following: a. Dated February 2025 revealed colostomy care was completed on 18 of 35 opportunities. b. Dated March 2025 revealed colostomy care was completed on 53 of 62 opportunities. c. Dated April 2025 revealed colostomy care was completed on 24 of 30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure the facility's medication error rate was not 5 percent or greater. This affected two residents (#19 and #30) of three residents observed for medication administration with seven errors out of 26 opportunities resulting in an error rate of 26.9%. The census was 32. Findings include: 1. Medical record review revealed Resident #19 was admitted on [DATE] with diagnoses including chronic atrial fibrillation, cerebrovascular disease, hypertension, congestive heart failure and diabetes mellitus. Review of the electronic Physician Orders dated April 2025 revealed Resident #19 was ordered the following medications to be administered at 9:00 A.M.: glipizide (diabetes) 5 milligrams (mg), metformin 500 (mg), Eliquis 2.5 (mg) and Metoprolol tartrate 25 (mg). On 04/17/25 between 10:22 A.M. and 10:50 A.M., observation revealed Registered Nurse (RN) #100 prepared and administered glipizide (diabetes), metformin (diabetes),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers for Resident #13 and Resident #22. This affected two residents (#13 and #22) of five residents reviewed. The facility census was 32. Findings include: 1. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including hyperlipidemia, hypertension, and altered mental status. Review of a care plan revised on 06/26/24 revealed Resident #13 required (staff) assistance with activities of daily living (ADLs) related to dementia, heart disease and fatigue. Interventions included requiring extensive assist to total dependence from one to two staff to complete bed mobility and toileting, check incontinence garments every two to three hours, change per product recommendations and provide peri-care as needed. Review of Resident #13's assessment dashboard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and policy review, the facility failed to ensure foods were stored and served in a sanitary manner. This had the potential to affect 33 of 33 residents who receive food from the facility. Findings included: 1. Continuous observations during an initial tour of the kitchen on 11/04/24 from 8:29 A.M. to 8:44 A.M. revealed two cartons of cream with an expiration date of 11/01/24 in the walk-in refrigerator; an undated gallon Ziploc bag of beets, an undated Styrofoam container of leftovers, a bag of cookies dated 10/16/24, six undated cups of coleslaw, four undated cups of fruit, two undated bowls of salad, and two undated cups of dessert in the standing refrigerator; two 48 ounce jars of Dijon mustard with an expiration date of 10/20/24 and half of a five pound container of chili powder with an expiration date of 09/08/24 were in the dry storage area; and after running the dish washer four times, the machine would not heat past 175 degrees to the required rinse temperature of 180 degrees. Interview on 11/04/24 at 8:31 with [NAME] #537 confirmed 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, interview, and review of facility invoices, the facility failed to ensure the facility floors, walls, air vents and rooms were maintained, clean, and free of insects. This affected five residents (Resident's #5, #24, #29, #30, and #32) out of 24 residents reviewed in the initial pool. The facility census was 33. Findings include: Observations and interviews on 11/06/24 at 1:31 P.M. with the Administrator confirmed the following environmental concerns: a. The tile and grout around the base of Resident #24's toilet was a discolored dark brown/black color. b. The air vent going into the bathroom of Resident #30's room was rusty. There was a hole in the wall above the baseboard on the right side of the door. The tile and grout around the base of Resident #30's toilet was a discolored dark brown/black color. c. The wall above the vinyl baseboard in Resident #5's bathroom was torn around the entire perimeter of the bathroom. d. Resident #32's bed was positioned long-ways against the wall. The wall had scraped drywall and paint removed in eight areas, all measuring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure Resident #186 had an order in place for advanced directives and Resident #7's was listed correctly throughout the medical record. This affected two (#7 and #186) of two residents reviewed for advanced directives. The facility census was 33. Findings include: 1. Record review revealed Resident #186 admitted to the facility on [DATE] with diagnoses including displaced bimalleolar fracture of right lower leg, muscle weakness, difficulty in walking, hypothyroidism, and severe intellectual disabilities. Review of Resident #186's orders from 10/04/24 revealed there were no orders in place for the residents code status in the physical chart or in the electronic chart. Interview on 11/05/24 at 2:31 P.M. with Director of Nursing (DON) confirmed Resident #186 did not have an order in place for her code status until an audit was completed after being made aware of another concern with advanced directives. The DON stated there should 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurate regarding a psychiatric diagnosis. This affected one resident (Resident #7) of one resident reviewed for PASRR. Findings include: Review of Resident #7's medical record revealed an admission date of 05/25/19 with diagnoses including major depressive disorder and unspecified psychosis not due to a substance or known physiological condition. Resident #7's care plan revealed care plans were in place for depression and psychosis. Review of Resident #7's PASRR documentation revealed only a PASRR document dated 05/24/19. The diagnosis for major depressive disorder and unspecified psychosis were not indicated on the PASRR documentation in section D of the document (indications of serious mental disorder). Review of Resident #7's Minimum Data Set (MDS), dated [DATE], revealed in section A: Pre-admission Screening and Resident Review 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 2. Review of Resident #4's medical records revealed an admission date of 12/28/22 and diagnoses of cerebral infarction, atherosclerotic heart disease, hypertension and hyperlipidemia. Review of Resident #4's physician orders revealed an order for Eliquis (an anticoagulation medication used to reduce the risk of blood clots) oral tablet 2.5 milligrams (mg) with instructions to administer 2.5 mg by mouth two times a day related to cerebral infarction. Review of Resident #4's care plan revealed there were no care plans present for anticoagulation medications or for the increased risk of bruising and bleeding related to the medications use. Interview on 11/06/24 at 2:30 P.M. with the Director of Nursing (DON) verified that there were no anticoagulation or risk for bleeding care plans present in Resident #4's medical record. Review of a policy titled Care Planning dated 08/2023 revealed the facility's interdisciplinary team was responsible for the development of an individualized comprehensive care plan for 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 record review, observation, interview, and review of policies and procedures, the facility failed to ensure a dependent resident received assistance with bathing, showers, shaving, and oral care. This affected one (Resident #32) of three residents reviewed for activities of daily living. The census was 33. Findings include: Review of Resident #32's record revealed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, myocardial infarction, acute kidney failure, gastroesophageal reflux disease, Alzheimer's disease, muscle weakness, repeated falls, cognitive communication deficit, malignant neoplasm of bronchus or lung, chronic gout, and osteoarthritis. Review of the quarterly Minimum Data Set Assessment (MDS) assessment, dated 10/10/24, revealed Resident #32 was moderately impaired for daily decision making, had difficulty focusing, was easily distractible or had difficulty keeping track of what was said, he had behavior fluctuations, had no rejection of care,…

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

Based on observation, family interview, staff interview, review of the facility assessment, and review of facility policy and procedure, the facility failed to ensure activities were available for resident participation. This affected one resident (Resident #30) out of three residents reviewed for activities. The census was 33. Findings include: Review of Resident #30's medical record revealed an admission date of 12/14/23 with diagnoses including mild protein calorie malnutrition, abnormalities of gait, anxiety, vitamin D deficiency and alcohol dependence. Review of the admission Minimum Data Set Assessment (MDS) assessment, dated 12/18/23, revealed it was somewhat important for the resident to listen to music, to do things with groups of people, to do favorite activities, to go outside to get fresh air, and attend religious services; music and bingo were a current interest, and watching movies were a past interest. The Quarterly MDS assessment, dated 09/06/24, revealed the resident was moderately impaired for daily decision making, had no behaviors, and utilized a walker. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure skin prevention interventions were implemented for a resident with a known pressure ulcer per the plan of care. This affected one resident (Resident #28) of one resident reviewed for pressure ulcers. Findings include: Review of Resident #28's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included an unstageable pressure ulcer to an unspecified site, history of a right femur fracture, reduced mobility, muscle weakness, difficulty in walking, protein- calorie malnutrition, unspecified dementia, and adult failure to thrive. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment, dated 09/17/24, revealed the resident had clear speech and minimal difficulty hearing, she was able to understand others and was usually able to make herself understood, her cognition was severely impaired and she had a functional limitation in her range of motion on one side of her lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for residents at risk for falls. This affected three (Resident #5, #11, and #28) of five residents reviewed for accidents/supervision. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included mild dementia without behavioral disturbances, adult onset diabetes mellitus, hypertension, and osteoarthritis. Review of Resident #5's admission Minimum Data Set (MDS) assessment, dated 08/28/24, revealed the resident had clear speech, she was able to make herself understood, and was usually able to understand others. Her cognition was severely impaired and she displayed verbal behaviors directed at others 1 to 3 days over the seven day assessment period. The resident required a substantial to maximum assistance for going from a sitting to a lying position, lying to sitting on the side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to adequately assess, monitor, and manage Resident #33's pain after a fall. This affected one (#33) of one resident reviewed for pain. The facility census was 33. Findings include: Record review revealed Resident #33 admitted to the facility on [DATE] with diagnoses including dementia, hypothyroidism, anxiety disorder, and insomnia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33's cognition was impaired and she did not have pain. Review of a medication administration record for October 2024 revealed Resident #33 had an order in place starting on 09/19/24 for Acetaminophen tablet 325 milligrams take two tablets by mouth every eight hours as needed for pain. Review of a progress note dated 10/21/24 at 9:29 P.M. by Registered Nurse (RN) #512 revealed Resident #33 was found in her room at 5:45 P.M. laying on the floor on her back, was assessed for injuries and vitals were obtained. Resident #33 was assisted into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 abnormal involuntary movement scale (AIMS) assessments were completed on a resident receiving antipsychotic medication to monitor for side effects associated with antipsychotic medication use. This affected one (Resident #5) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included mild dementia without behavioral disturbances, major depressive disorder, and hallucinations. Review of Resident #5's physician's orders revealed the resident was ordered to receive Seroquel 25 milligrams (mg) by mouth (po) every morning and 50 mg po every night at bedtime for hallucinations. The medication had been ordered since 09/03/24. Resident #5's medical record was absent for any evidence of the resident having an AIMS assessment (a 12 item rating scale used to assess the severity of abnormal movements in residents…

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

Based on observation, record review, review of the daily census, review of staff postings and staff schedules and review of the facility assessment, the facility failed to ensure adequate staffing levels to meet resident needs. This had the potential to affect all 33 residents residing in the building. Findings included: Observation and interview on 08/26/24 at 8:07 A.M. revealed there was only one State Tested Nursing Assistant (STNA) #53 on the Memory Lane secure unit to provide care for ten (10) residents. The STNA verified she was the only staff member on the unit due to the nurse administering medication on the connected assisted living (AL) (located on the first floor and the memory care unit is located on the second floor). STNA #53 revealed she usually worked 6:00 A.M. until 6:30 P.M. day shift on the secured unit and the nurse always went to the AL first around 6:30 A.M. to administer medications, leaving her alone on the unit to provide morning care (incontinence care and assist residents with activities of daily living), assist residents out of bed for breakfast, pass…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure a clean, safe, and homelike environment. This affected 25 residents (#2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #15, #17, #18, #19, #20, #22, #23, #25, #27, #28, #29, #30, #31, #32 and #33) of 33 residents in the facility. Findings include: 1. Observation of the environment in the second floor secured Memory Care Unit, 08/26/24 between 8:07 A.M. and 9:38 A.M. included: a. Toilet paper holders were missing from rooms 202, 204, 205, 208 and 211. b. room [ROOM NUMBER]'s door frame into the bathroom needed painted bilaterally from the floor up three feet due to the paint being scratched off. c. room [ROOM NUMBER] was missing a cover on the air conditioner. d. room [ROOM NUMBER] had drywall damage in the bathroom, a one and half foot by one foot area, was loose with a hole. The drywall was falling apart. There was a mouse trap underneath the heating/air conditioning unit. e. room [ROOM NUMBER] left of the bathroom door the molding lining 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 interview, record review, and review of the facility policy the facility failed to ensure a resident's physician was provided accurate information regarding a discharge Against Medical Advice (AMA), and failed to provide the resident or resident representative with required documentation upon transfer. This affected two residents (#34, and #36) of three residents reviewed for transfer. The facility census was 33. Findings include: 1. Review of Resident #36's closed medical record revealed an admission date of 07/01/24 with diagnoses that included aftercare following joint replacement surgery, moderate protein calorie malnutrition, depression, gastroesophageal reflux disease, polyosteoarthritis, osteoarthritis, dizziness and giddiness, artificial left knee, dementia, hypertension, unsteady on feet, and muscle weakness. The resident was discharged to another nursing facility on 08/14/24. Review of the Minimum Data Set (MDS) annual assessment, dated 06/18/24, revealed the resident was moderately 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.

Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation (concise summary) of the resident's stay at the facility, was completed. This affected three residents (#34, #35 and #36) of three residents reviewed for discharge. The facility census was 33. Findings include: 1. Review of Resident #36's closed medical record revealed an admission date of 07/01/24 with diagnoses that included aftercare following joint replacement surgery, moderate protein calorie malnutrition, depression, gastroesophageal reflux disease, polyosteoarthritis, osteoarthritis, dizziness and giddiness, artificial left knee, dementia, hypertension, unsteady on feet, and muscle weakness. The resident was discharged to another nursing facility on 08/14/24. Review of the Minimum Data Set (MDS) annual assessment, dated 06/18/24, revealed the resident was moderately impaired for daily decision making. Review of the medical record revealed the resident did not have a Discharge Planning form. The resident was given a Release of Responsibility for Discharge…

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

Based on record review and interview, the facility failed to ensure a resident with edema was provided ordered medication for the treatment of edema related to the medical condition of congestive heart failure, skin ointments were applied for open skin lesions, weights obtained for a resident with edema, and intake and output assessed. This affected two residents (#21, #32) of three residents reviewed for medications. The facility census was 33. Findings include: 1. Review of Resident #21's medical record revealed a 02/27/24 admission with diagnoses including dementia with behavioral disturbance, vitamin B deficiency, osteoarthritis, respiratory failure with hypoxia, chronic gout, localized edema, myocardial infarction, acute kidney failure Stage 3, hypertension, nutritional deficiency, hypo-osmolality and hyponatremia, acute and chronic combined systolic and diastolic congestive heart failure (CHF), Alzheimer's disease, muscle weakness, abnormalities of gait and mobility, and malignant neoplasm of unspecified part of bronchus or lung. A 05/28/24 Quarterly Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to provide comprehensive pressure ulcer care timely and as ordered. This affected two residents (#14 and #26) of three residents reviewed for pressure ulcer care and services. The facility census was 33. Findings included: 1. Review of Resident #26's medical record revealed a 08/21/24 admission with diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia and hypercapnia, ulcerative colitis, severe protein calorie malnutrition, hypertension, hypothyroidism, depression, restless legs syndrome, polyneuropathy, scoliosis, gastroesophageal reflux disease, lupus erythematosus and spondylosis of lumbar region. Review of the 08/21/24 admission note included the resident had a Stage 1 pressure ulcer (defined as intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews the facility failed to ensure residents received physician ordered nutritional supplements for identified nutritional needs. This affected two residents (#26 and #32) of four residents reviewed for nutritional care and services. The census was 33. Findings included: 1. Review of Resident #26's medical record revealed a 08/21/24 admission with diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia and hypercapnia, ulcerative colitis, severe protein calorie malnutrition, hypertension, hypothyroidism, depression, restless legs syndrome (RLS), polyneuropathy, scoliosis, gastroesophageal reflux disease, lupus erythematosus and spondylosis of lumbar region. The resident was not due for a comprehensive Minimum Data Set (MDS) assessment. Review of a Nutrition assessment dated [DATE] (1:59 P.M.) included the resident diagnoses included metabolic encephalopathy, Chronic Obstructive Pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interview, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected one resident (#19) of four residents observed for medication administration. The census was 33. Findings include: Review of Resident #19's medical record revealed a a 07/29/20 admission with diagnoses including Alzheimer's disease, cataract, anxiety disorder, depressive disorder, hyperlipidemia, chronic obstructive pulmonary disease (COPD), hypothyroidism, gastroesophageal reflux disease, osteoarthritis, hypertension, vitamin D deficiency and insomnia. Physician orders included an order dated 12/28/22 for Albuterol nebulizer 0.63 milligrams (mg) and 3 milliliters (ml) inhale one vile via nebulizer every six hours as needed rinse mouth after each use. Physician orders included an undated treatment to change nebulizer set weekly and as needed for soiling on Sundays. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, manufacturer guidelines, policy review, and interview, the facility failed to ensure a medication error rate of five percent or less when the facility had 26 opportunities for administration with two errors resulting in a 7.69 percent medication error rate. This affected one resident (#19) of four residents observed for medication administration. The facility census was 33. Findings include: Observation of medication administration on 08/26/24 at 8:38 A.M. with Licensed Practical Nurse (LPN) #42 revealed medications were administered to Resident #19. Oral medications were administered initially. At 9:13 A.M. the nurse returned to the resident to administer the first of two respiratory medications; Ventolin HFA Aerosol Solution micrograms (mcg) per activation (ACT) (Albuterol Sulfate HFA) two puffs inhale orally two times a day related to chronic obstructive pulmonary disease (COPD) was administered first. The nurse opened a new box of inhaler, shook it, held it to the resident mouth and activated the inhalation canister, asking the resident to breathe in. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure laboratory tests were obtained as ordered. This affected three residents (#3, #19, and #21) of four residents reviewed for laboratory testing. The facility census was 33. Findings include: 1. Review of Resident #19's medical record revealed a a 07/29/20 admission with diagnoses including Alzheimer's disease, cataract, anxiety disorder, depressive disorder, hyperlipidemia, chronic obstructive pulmonary disease (COPD), hypothyroidism, gastroesophageal reflux disease, osteoarthritis, hypertension, vitamin D deficiency and insomnia. Physician orders included a 01/28/24 order for a Basic Metabolic Panel (BMP), Complete Blood Count (CBC), Vitamin D, B12, and Folate levels every three months. A 04/01/24 physician order included a Hemoglobin A1C and Lipid Level every six months. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] included the resident was severely impaired for daily decision making, had COPD and shortness of breath.…

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

Based on record review, observation, review of the daily census and staff postings, review of staff time punches/timecards, review of the facility assessment, review of resident notes, and interviews the facility failed to ensure adequate staffing levels to meet resident needs. This had the potential to affect all 37 residing in the building. Findings included: 1. Observation and interview on 07/10/24 at 7:24 A.M. revealed there was only one State Tested Nursing Assistant (STNA) #173 on the secure unit to provide care for 10 residents. The STNA confirmed she was the only staff member on the unit due to the nurse administering medication on the connected assisted living (located on the first floor and the memory care unit is located on the second floor). The STNA confirmed she usually worked day shift on the secured unit and the nurse always went to the AL first to administer medications, leaving her alone on the unit to provide morning care (showers/incontinence care/dress residents), assist residents out of bed for breakfast, pass breakfast trays, and assist with resident meals.…

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

Based on review of the staffing schedules, timecard review, review of the daily census and staff postings, review of the facility assessment, and interviews the facility failed to ensure there was eight consecutive hours of Registered Nurse (RN) coverage seven days a week. This had the potential to affect all 37 residents residing in the facility. Findings included: Review of the staffing schedule dated 06/01/24 to 06/30/24 revealed on (Sunday) 06/09/24, (Saturday) 06/22/24, and (Sunday) 06/30/24 there was no RN scheduled to work. Review of the staffing time sheets, dated 06/09/24, 06/22/24, and 06/30/24, revealed there was no evidence an RN worked on 06/09/24 or 06/22/24. On 06/30/24, RN #113 clocked in at 6:52 A.M., however, there was no time entered for the end of the RN's shift that date. Review of the daily postings dated 06/09/24, 06/22/24, and 06/30/34 revealed no evidence an RN worked on those dates. Interview on 07/02/24 at 9:21 A.M., the Staffing Scheduler #102, confirmed there may be some days in June there was no RN coverage due to the facility only having one RN, 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 observation, personnel file review, job description review, facility assessment review, time sheet review, daily census and staff posting review, schedule review, medical record review, infection log review, policy review and interview the facility failed to maintain an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility including but not limited to staffing needs, complete and accurate medical records, staff education and certification renewal to ensure the total care needs of all residents, residing in the facility, are met as planned. This had the potential to affect all 37 residents residing in the facility. Findings include: 1. Review of State Tested Nursing Assistant (STNA) #108's personnel file revealed the STNA's certification to work in a long term care facility was verified with the nurse aide registry (keeps track of those individuals who have met written and skills test criteria to be certified 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, review of e-mail correspondence, observation, and interview the facility failed to ensure medical records were accurate and complete. This affected four (Resident #9, #14, #24, and #50) of four records reviewed but had the potential to affect all 37 residents residing in the building. Findings included: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, delusional disorders, anxiety, major depression, Vitamin B 12 and D deficiency, suicidal ideations, insomnia, and protein-calorie malnutrition. Review of Resident #9's physician progress notes for 2024 revealed no evidence the physician progress notes were filed in the resident's paper medical record or scanned into the electronic medical record (EMR) Interview on [DATE] at 9:50 A.M., with Registered Nurse (RN) #180 and the Administrator, confirmed the physician had visited the resident on [DATE], [DATE], [DATE], and [DATE] however, the progress notes had…

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

Based on infection control log review, interviews and policy review the facility failed to maintain a comprehensive infection control program responsible for tracking and trending infections. This had the potential to affect all 37 residents residing in the facility. Findings included: 1. Review of the infection control log dated 04/24 to 06/24 revealed no evidence infections were being trended. Further review revealed all the infections listed on the log were treated with antibiotics. There was no documented evidence of infections not treated with antibiotics. 2. Further review revealed no evidence staff illnesses were being tracked/monitored. 3. Review of the facility policies revealed no evidence an infection control policy and procedure was readily available for staff reference. Interview with Infection Preventionist (IP)/Registered Nurse (RN) #167 on 07/03/24 at 8:33 A.M., revealed she had not trended infections for the last six months or so and she doesn't always include the organism on the tracking log. The IP nurse reported she was told by someone (would not provide name)…

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

Based on review of the infection control logs, interview, and policy review the facility failed to ensure infections met criteria for treatment with antibiotics. This affected seven residents (Resident #8, #15, #21, #22, #36, #52 and #53) of 37 residents residing in the facility. Findings included: 1. Review of April 2024 infection control log revealed: Resident #53 was treated with Cipro 250 milligrams (mg) twice daily for 10 days for a urinary tract infection (UTI). There was no documented evidence the resident meet McGeer Criteria (provide standardized guidance for infection surveillance activities and research studies in nursing homes and similar facilities). for treatment of the UTI. The physician was not notified regarding the antibiotic use. 2. Review of May 2024 infection control log revealed: a. Resident #8 had an oral infection and was treated with an erythromycin dose pack. There was no documented evidence the resident met McGeer Criteria for treatment or the physician was updated regarding treatment. b. Resident #21 was treated with Bactrim DS twice a day for eight days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 certificate of training, review of the facility assessment, and interview the facility failed to ensure the Infection Preventionist (IP) had specialized training in infection prevention and control from 09/23 through 07/02/24. This had the potential to affect all 37 residents residing in the facility. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course certificate revealed Register Nurse (RN) #167 completed the course on 07/02/24. Interview on 07/02/24 at 8:50 A.M., with the Director of Nursing (DON) revealed she was hired about seven months ago and the IP nurse had been RN #167 since she (the DON) started. Interview on 07/02/24 at 1:16 P.M. and 07/03/24 at 11:46 A.M. with RN #167 revealed she had been the IP nurse for about one year now, however she just started the IP training a little over a week ago (06/23/24). She thought she had completed the course, however when she logged into the system today…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel file review, review of the facility assessment, and interview the facility failed to ensure State Tested Nursing Assistants (STNA) received the required 12 hours of in-service training per year. This had the potential to affect all 37 residents residing in the building. Findings included: 1. Review of STNA #154's personnel file revealed STNA #154 was hired on [DATE]. There was no documented evidence the STNA had in-service hours for 2023 or 2024. 2. Review of STNA #138's personnel file revealed STNA #138 was hired on [DATE]. There was no documented evidence the STNA had in-service hours for 2023 or 2024. 3. Review of STNA #110's personnel file revealed STNA #110 was hired on [DATE]. There was no documented evidence the STNA had in-service hours for 2023 or 2024. 4. Review of STNA #153's personnel file revealed STNA #153 was hired on [DATE]. There was no documented evidence the STNA had in-service hours for 2023 or 2024. 5. Review of STNA #162's personnel file revealed STNA #162 was hired on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident assessments were completed accurately on admission. This affected one (Resident #14) of three residents reviewed for accuracy of assessments. The facility census was 37. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including femur fracture, left wrist fracture, cirrhosis, esophageal varices, pancytopenia, and hypertension. Review of Resident #14's hospital Discharge summary dated [DATE] revealed no evidence the resident had pressure ulcers. Review of Resident #14's admission history of physical dated 05/07/24 revealed no evidence the resident had pressure ulcers. Review of Resident #14's nursing admission assessment dated [DATE] revealed the resident had a surgical incision (right wrist and right hip), scattered bruising throughout the body. The note indicated the resident had no other skin issues noted. Review of Resident #14's five-day admission Minimum 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 medical record review, observation, interview, and policy review the facility failed to provide comprehensive pressure ulcer care timely and as ordered. This affected one (Resident #14) of three reviewed for care and services. The facility census was 37. Findings included: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including femur fracture, left wrist fracture, cirrhosis, esophageal varices, pancytopenia, and hypertension. Review of Resident #14's hospital Discharge summary, dated [DATE], revealed no evidence the resident had pressure ulcers. Review of Resident #14's admission history of physical, dated 05/07/24, revealed no evidence the resident had pressure ulcers. Review of Resident #14's nursing admission assessment dated [DATE] revealed the resident had surgical incisions (right wrist and right hip) and scattered bruising throughout the body. The note indicated the resident had no other skin issues noted. Review of Resident #14's skilled 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 closed record review and interviews the facility failed to ensure a resident was provided a comprehensive, resident centered plan for urostomy care This affected one (Resident #50) of one residents residing in the facility with a urostomy. The facility census was 37. Findings included: Closed record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, cardiomyopathy, hypertension, ventricular tachycardia, urinary tract infections, atrial fibrillation, acute kidney failure, retention of urine, and mixed hyperlipidemia. The residence expired on [DATE]. Review of Resident #50's hospital Discharge summary, dated [DATE], revealed the resident had acute cystitis secondary to Escherichia. Coli (bacteria found in feces) due to cystostomy catheter (surgical connection between the urinary bladder and the skin used to drain urine) malfunctioning urostomy (surgical procedure that creates a stoma (artificial opening) for the urinary system). It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interviews the facility failed to ensure residents received physician ordered nutritional supplements for identified nutritional needs. This affected one (Resident #50) of three residents reviewed for care and services. The census was 37. Findings included: Closed record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, cardiomyopathy, hypertension, ventricular tachycardia, urinary tract infections, Escherichia coli (E. coli), atrial fibrillation, acute kidney failure, retention of urine, and mixed hyperlipidemia. Review of Resident #50's hospital Discharge summary, dated [DATE], revealed the resident had moderate malnutrition and anasarca (general swelling throughout the body). Ensure (a nutritional supplement) three times a day was ordered for hypoalbuminmenia (when your body doesn't produce enough of the protein, albumin) and anasarca secondary to poor intakes from ileus and would need increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed and open medical record review, review of the facility investigation, interview, and policy review the facility failed to ensure medications were administered per physician orders resulting in significant medication errors. This affected two (Resident #6 and #25) of 11 residents reviewed for medications. The facility census was 37. Findings included: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia, transient ischemic attack (TIA), Vitamin D deficiency, acute cystitis, anemia, anxiety, epilepsy, chronic pain, glaucoma, peripheral vascular disease, gastroenteritis, osteoporosis, overactive bladder, falls, long term use of anticoagulants, and history of venous thrombosis and embolism. Review of Resident #6's progress notes, dated 05/28/24, revealed the nurse was walking down the hall with medication and forgot which room Resident #28 was in and the STNA (unidentified) said the resident was in the room (specific location was provided in…

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

Based on observation, record review and interview the facility failed to store refrigerated food and frozen food in a sanitary method. This had the potential to affect all residents residing in the facility. The facility census was 32. Findings include: During the initial kitchen tour on 05/30/23 at 8:30 A.M. observation of the freezer revealed a closed plastic bag filled with frozen sausage patties with no date located on the bag. Further observation of the freezer revealed a cardboard box of pre-made biscuits with a plastic bag full of biscuits which was left open to air. Observation of the walk-in cooler on 05/30/23 at 8:35 A.M. revealed a cardboard box of beef franks with one beef frank in a plastic bag which was left open to air. Further observation revealed a cardboard box of individually sealed butter packets with a partially covered quarter stick of butter wrapped in the original paper wrapper left open to air. A cardboard box of individually wrapped sticks of butter were observed with a partially wrapped half stick of butter left open to air. Interview with Dietary Staff…

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

Based on record review and interview, the facility failed to provide evidence or documentation of the Infection Preventionist's (IP) specialized training in infection prevention and control. This had the potential to affect all 32 residents residing in the facility. Findings include: Record review revealed a Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course certificate for Corporate Registered Nurse (RN) #160. Interview on 05/30/23 at 4:15 P.M., the Director of Nursing (DON) confirmed she is the facility's designated Infection Preventionist but does not have a certificate or documentation indicating completion of the required specialized training. The DON further confirmed the Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course certificate provided to the survey team was issued to Corporate Registered Nurse (RN) #160 who is not the facility's infection preventionist and does not work at the facility at least part-time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure Resident #13's advanced directive form was dated by the physician and failed to ensure Resident #286's advanced directive form was properly signed and matched the physician order. This affected two (Resident #13 and Resident #286) of seventeen residents reviewed for advanced directives. Findings include: 1. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia, diabetes mellitus, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/23, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS further revealed Resident #13 required limited, one-person assistance with personal hygiene, toileting, dressing, and bed mobility. Review of Resident #13's Do Not Resuscitate (DNR) Comfort Care Form was signed by the physician, however, there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to notify the resident representative of a change in health status. This affected one (Resident #13) of one resident reviewed for notification of change. The facility census was 32. Findings include: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia, diabetes mellitus, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/23, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS further revealed Resident #13 required limited, one-person assistance with personal hygiene, toileting, dressing, and bed mobility. Review of the plan of care, dated 01/02/23, revealed the resident had a potential for alteration in respiratory status related to impaired breathing patterns such as shortness of breath related to COPD with interventions including to…

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

Based on observations, medical record review and staff interview the facility failed to ensure residents utilizing a reclining wheelchair were assessed to determine if the device was utilized as a potential restraint. This affected one of one residents (Resident #27) reviewed for potential restraint use. The facility census was 32. Findings include: Observations of Resident #27 on 05/30/23, 05/31/23, and 06/01/23 revealed the use of a tilt-in-space (allows the whole chair to tilt up to 30 to 60 degrees keeping the knees and hips at a 90 degree angle) reclining wheelchair. Review of Resident #27's medical record revealed an admission date of 10/20/21 with diagnoses that included cerebrovascular accident with hemiplegia and hemiparesis and diabetes mellitus. Further review of the medical record found no evidence of physician's orders for the use a reclining tilt-in-space wheelchair. There was no evidence of any type assessment found to determine if the tilt-in-space wheelchair was a potential restraint or a resident safety enabler used for positioning and comfort. On 05/31/23 at 2:13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete a significant change assessment for a resident receiving hospice services. This affected one resident (Resident #23) out of two residents reviewed for receiving hospice services. The facility census was 32. Findings include: Review of Resident #23's medical record revealed Resident #23 was admitted to the facility on [DATE] with admitting diagnoses including anxiety disorder, dementia, bipolar disorder, major depressive disorder. Review of Residents #23 physician orders revealed order dated 12/29/21 for hospice services via Incare Hospice related to senile degeneration of the brain. Review of Resident #23 care plan revealed the facility hospice care plan revised 04/25/22, included collaboration of care for Resident #23 between the facility and hospice. Further review revealed Resident #23 was recertified to continue hospice services and the hospice plan of care revised on 04/23/23 for the continuation of hospice services through 06/23/23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident assessments were completed accurately to reflect physical behaviors, type of falls, medication use and frequency. This affected two (Resident #29 and #30) of twelve residents reviewed for accuracy of assessment. The facility census was 32. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 09/02/22 with diagnoses that included dementia with psychotic disturbance, delusional disorder and diabetes mellitus. Further review of the medical record included nursing progress notes revealed on 11/04/22 Resident #29 was involved in an altercation with Resident #14, when Resident #29 pushed Resident #14 to the ground and then kicked him. Staff members intervened immediately and separated the residents. At this time Resident #29 was placed on one on one observations and physician notified. The physician indicated to send Resident #29 for a mental health evaluation. On 11/05/22 Resident #29 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 record review and interview, the facility failed to revise and update Preadmission Screening and Resident Review (PASARR) for major mental disorder diagnosis and prescribed psychotropic medications. This affected three residents (Resident #31, Resident #284, Resident #286) out of three residents reviewed for PASARR. The facility census was 32. Findings include: 1. Review of Resident #284's medical record revealed Resident #284 was admitted to the facility on [DATE] with the admitting diagnoses including bipolar disorder, hemiplegia, chronic obstructive pulmonary disease (COPD) and Diabetes Mellitus type 2. Review of Resident #284 physician orders revealed Resident #284 was ordered an antipsychotic medication Seroquel 50 milligrams two times a day for bipolar disorder. Review of Resident #284 Preadmission Screening and Resident Review (PASARR) dated 05/25/23 revealed in section E - Indications of Serious Mental Illness question number one was marked for having a diagnosis of panic or other severe 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure resident's nutritional plans of care were revised to include adaptive equipment and/or revised to include the correct adaptive equipment used by the residents. This affected three residents (#10, #27, and #33) of three residents reviewed for adaptive equipment. Findings included: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including blindness in right and left eye and gastro-esophageal reflux disease (GERD). Review of Resident #10's orders dated September 2023 revealed on 06/23/23 the resident was ordered a scoop plate and scoop bowl for all meals. Review of Resident #10's plan of care including the nutritional plan of care initiated on 06/07/23 and the blindness plan of care initiated on 06/16/23 revealed no evidence of the scoop plate and scoop bowl for all meals per the residents' orders on 06/23/23. Interview on 09/11/23 at 11:17 A.M., with the Director of Nursing (DON) confirmed Resident #10's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the physician order indicated a specific topical antibiotic for a wound treatment and failed to discontinue a physician order for one-to-one supervision following readmission from the hospital. This affected two (Resident #13 and Resident #29) of 13 residents reviewed. The facility census was 32. Findings include: 1. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia, diabetes mellitus, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/23, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS further revealed Resident #13 required limited, one-person assistance with personal hygiene, toileting, dressing, and bed mobility. Review of a nursing progress note, dated 05/25/23 at 9:00 A.M., revealed the resident was seen in the emergency room 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 interview, record review and policy review, the facility failed to provide nutritional intervention to facilitate healing to a resident with an unstageable suspected deep tissue injury as ordered by the physician. This affected one Resident (#31) of one resident reviewed for pressure ulcer/injury. The facility census was 32. Findings included: Review of Resident #31's medical record revealed she was admitted to the facility on [DATE] with diagnoses including pneumonia, generalized muscle weakness, difficulty in walking, fibromyalgia, and bipolar disorder. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed she was cognitively independent. Further review revealed she had two unstageable deep tissue injuries (persistent non-blanchable deep red, maroon or purple discoloration; intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue), had pressure reducing devices for her chair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents with poor nutrition received nutritional supplements as recommended and ordered. This affected two residents (#5 and #25) of three residents reviewed for nutritional supplements. Findings included: 1. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including lung cancer, severe protein-calorie malnutrition, anorexia, chronic obstructive pulmonary disease, heart failure, and depression. Review of Resident #25's nutrition assessment dated [DATE] revealed the resident had inadequate oral intakes and intakes not meeting estimated needs to maintain weight as evidence by varied intakes. Recommend house supplement daily and monitor. Review of Resident #25's orders dated September 2023 revealed no evidence of a physician order for house supplement daily. Review of Resident #25's medication/treatment administration records dated September 2023 revealed no evidence house…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to ensure psychotropic medications were ordered with appropriate diagnoses and Abnormal Involuntary Movement Scale (AIMS) assessments were completed for a resident receiving antipsychotic medications. This affected one resident (#31) of one resident reviewed for Preadmission Screening and Resident Review. The facility census was 32. Findings included: Review of Resident #31's medical record revealed she was admitted to the facility on [DATE] with diagnoses including pneumonia, generalized muscle weakness, difficulty in walking, fibromyalgia, and bipolar disorder. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed she was cognitively independent, had an active diagnosis of bipolar disorder, and during the seven day look back period received an antidepressant for six days and an antipsychotic for five days. 1. Review of Resident #31's physician order, dated 04/08/23, identified risperidone (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.

Based on medical record review and staff interview, the facility failed to ensure physician's orders for laboratory testing was followed and completed as ordered. This affected one (Resident #29) of five residents reviewed for medication use. The facility census was 32. Findings include: Review of Resident #29's medical record revealed an admission date of 09/02/22 with diagnoses that included dementia with psychotic disturbance, delusional disorder and diabetes mellitus. Further review of the medical record including physician's orders revealed on 01/10/23 the physician ordered the following laboratory testing: complete blood count (CBC), base metabolic profile (BMP), lipid panel, vitamin D level and HgbA1c level. Review of laboratory results found no evidence labs were obtained as ordered on 01/10/23. On 05/31/23 at 2:11 P.M., interview with the facility Administrator verified no labs were completed as ordered on 01/10/23 for Resident #29.