Senior Suites Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for 1 (#91) of 20 sampled residents reviewed for comprehensive care plans.The administrator identified 74 residents resided in the facility.Findings:A facility Care Plans, Comprehensive, Person-Centered policy, dated March 2022, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy showed the comprehensive care plans were to be completed within seven days of completion of the required MDS assessment and no more than 21 days after admission to the facility.An admission record for Res #91, dated 10/07/25, showed the resident had been admitted to the facility on [DATE] and discharged on 11/23/25.An admission assessment for Res #91, dated 10/14/25, showed the resident was admitted to the facility on [DATE]. A review of 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 observation, record review, and interview, the facility failed to have a qualified activity director. The administrator identified 74 residents resided in the facility.Findings:On 02/09/26 at 2:42 p.m., residents were observed in the dining area playing bingo with an automated bingo machine that was calling the bingo numbers with CMA #3 sitting at the table.On 02/11/26 at 12:02 p.m., the activity board was observed. The board showed the facility was to have coffee and conservations every Monday and Friday at 10:45 a.m., bible study every Tuesday at 10:45 a.m., and stretch every Thursday at 10:45 a.m.On 02/11/26 at 1:15 p.m., residents were observed sitting at various tables playing bingo with an automated game that called out the numbers for the game.An undated facility Resident Rights poster showed the facility would provide a program of activities designed to meet the residents needs and interests.On 02/11/26 at 1:40 p.m., the social worker stated either they or another staff member would assist with activities. They stated they did not know how long the facility had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure refrigerator temperatures were recorded for 1 (medication room [ROOM NUMBER]) of 2 medication refrigerators observed for safe storage of medication.The DON identified two medication rooms with medication storage refrigerators in the facility.Findings:On 02/10/26 at 9:33 a.m., medication room [ROOM NUMBER] was observed with the DON. Inside the medication room was a full-size refrigerator that contained medications and did not have a temperature record log attached for February 2026. A facility Storage of Medications policy, dated 2001, read in part, Drugs and biologicals used in the facility are stored in locked compartments and under proper temperature, light and humidity controls.On 02/10/26 at 10:11 a.m., the DON stated they searched and were unable to locate the missing temperature log for the medication refrigerator located in medication room [ROOM NUMBER]. They stated the log should have been kept on the refrigerator 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 and interview, the facility failed to ensure a urine sample was not stored in a refrigerator used to store resident food for 1 (medication room [ROOM NUMBER]) of 2 sampled medication room food storage refrigerators observed for infection control.The administrator identified 74 residents resided in the facility.Findings: On 02/10/26 at 9:33 a.m., a mini refrigerator located in medication room [ROOM NUMBER] was observed to have a box of bacon, two protein shakes, one individual sized ice cream, two mighty shakes, and one urine specimen cup filled halfway with a yellow substance and sealed in a plastic lab bag. The cup had the name of a former resident written on it. The specimen cup and bag were laying on top of the ice cream and mighty shakes container. On 02/10/26 at 9:37 a.m., DON stated the food inside the mini refrigerator located in medication room [ROOM NUMBER] was to store resident food items. They stated the urine specimen cup should not have been stored in that refrigerator. They…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the call light was operational for 1 (#94) of 3 sampled residents whose call lights were tested.The administrator identified 74 residents resided in the facility.Findings:On 02/10/26 at 9:05 a.m., Res #94 was observed to push their call light to test it. The light outside of the resident's room above the door did not light up or sound. The resident had no bell to ring for assistance.On 02/10/26 at 9:06 a.m., the monitor connected to the call lights at the nurses' station did not display Res #94's room number.On 02/11/26 at 9:24 a.m., an observation of the maintenance logbook at the nurses' station showed no call lights that needed to be fixed.On 02/11/25 at 9:25 a.m., CNA #5 was observed to document in the maintenance logbook that the call light in Res #94's room was not working, and the call light in room [ROOM NUMBER] was not working.An Answering the Call Light policy, dated 09/01/22, read in part, Ensure that the call light is…

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

Based on observation and interview, the facility failed to ensure protected health information was secure for 1 (station 3 medication/treatment cart) of 2 medication/treatment carts on station 3. The administrator identifed 95 residents resided in the facility. On 05/30/25 at 9:15 a.m., a computer on top of an unattended medication/treatment cart at nurses station 3, was observed to be open and showed protected health information. On 05/30/25 at 9:20 a.m., CMA #1 closed the computer and stated they did not know where the nurse assigned to the cart was. On 05/30/25 at 9:30 a.m., the administrator stated the computer should not have been left open with resident information visible. On 05/30/25 at 9:36 a.m., RN #1, who was assigned to the medication/treatment cart, stated the computer should have been closed and not showing protected health information.

Based on observation, record review and interview, the facility failed to ensure medications were secure for 1 (station 3 medication/treatment cart) of 2 medication/treatment carts on station 3. The administrator identifed 95 residents resided in the facility. Findings: On 05/30/25 at 9:15 a.m., the station 3 nurses medication/treatment cart was observed to be unlocked and unattended at the nurses station. On top of the cart was a bottle Hysept wound cleanser and a medicine cup containing an unidentified gel. An undated policy titled Medication Labeling and Storage, read in part, 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 05/30/25 at 9:20 a.m., CNA #1 locked the cart and stated they did not know where the nurse assigned to the cart was. On 05/30/25 at 9:30 a.m., the administrator stated the medication/treatment cart 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.

Based on record review and interview, the facility failed to administer a cardiac medication as prescribed for one (#50) of 10 residents observed during a medication administration pass. The facility administrator identified 48 residents who were prescribed cardiac medications. Findings: Resident #50 had diagnoses which included atrial fibrillation. A physician's order, dated 09/12/24, documented the resident was to receive 100 milligrams amiodarone (antiarrhythmic medication) daily for atrial fibrillation. The order documented to monitor blood pressure for hypotension and heart rate for increased rate. The September 2024 MAR documented the resident missed six of 18 doses of amiodarone from 09/13/24 through 09/30/24. The October 2024 MAR documented the resident missed 11 of 31 doses of amiodarone. The November 2024 MAR documented the resident missed four of seven doses of amiodarone from 11/01/24 through 11/07/24. On 11/07/24 at 9:55 a.m., CMA #2 did not administer the amiodarone for Resident #50. On 11/07/24 at 1:10 p.m., CMA #2 stated the amiodarone was given to raise 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 and interview, the facility failed to ensure the physical environment of the kitchen and kitchen equipment were kept clean and maintained in good repair. The administrator identified 83 residents ate meals prepared in the kitchen. Findings: On 11/06/24 at 10:15 a.m., cook #1 was observed to puree pork. [NAME] #1 placed cut pieces of pork into a bladed container, placed the container on the base, and the lid on top of the container. The container was observed to be cracked and missing sections of the bottom edge which secured the container to the base. On 11/06/24 at 10:15 a.m., cook #1 stated the container was broken and they had to hold the container down onto the base to get the unit to puree foods. On 11/06/24 at 10:20 a.m., observations of the kitchen and ice machine were conducted: a. there was standing water on the floor below the dish machine, the drying rack, the walk way in front of the drying rack, and to the dry goods storage room; b. a box fan with a screen was covered in dust. The box fan blew air across the food preparation stations; c. a ceiling…

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

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for the use of bed rails prior to installation for one (#11) of one resident who was reviewed for bed rails. The administrator identifed 52 residents using bed rails. Findings: Resident #11 had a diagnosis which included dementia. A review of Resident #11's medical record did not reveal the resident was assessed for the use of bed rails. On 11/06/24 at 2:18 p.m., bed rails were observed to be up on both sides of the resident's bed. On 11/07/24 at 4:07 p.m., the administrator stated the bed rail assessment page did not automatically populate, so the nurses had to manually pull that up. They stated it did not get done for Resident #11.

Based on observation, record review, and interview, the facility failed to to adhere to enhanced barrier precautions while providing wound care for one (#187) of one sampled resident reviewed for wound care. The administrator identified 83 residents resided in the facility and eight residents on enhanced barrier precautions. An undated facility Enhanced Barrier Precautions policy, documented high contact resident care activities such as wound care required the use of gown and gloves. Resident #187 had diagnoses which included a sacral pressure ulcer. On 11/07/24 at 10:19 a.m., RN #1 and LPN #3 prepared to treat Resident #187's pressure ulcer. Both sanitized their hands and donned gloves. Before wound care began, RN #1 was asked if there was any other infection control measures to take before starting wound care. RN #1 stated, No. RN #1 and LPN #3 did not don gowns. They proceeded with wound care. On 11/07/24 at 11:06 a.m., LPN #3 stated for regular wound care, they just wore gloves, if MRSA they wore a gown and mask. On 11/07/24 at 11:11 a.m., the administrator stated gowns were 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 record review and interview, the facility failed to secure a surety bond with sufficient coverage for the account balance. The Business office manger identified 15 residents that have money in the trust account and were current residents. Findings: A review of the current surety bond for the resident trust account documented the surety bond had coverage of $10,000 The resident trust account monthly bank statement, 07/11/24, documented the account balance was $18,330.30. On 07/11/24 at 3:01 p.m., the corporate regional manager confirmed the surety bond was only for $10,000. They stated the previous month they had noticed the surety bond did not cover the trust account balance and had contacted the insurance company, but it had not been corrected.

Based on record review and interview, the facility failed to deposit resident personal funds in excess of $50 in an interest bearing account that is separate from the facility's operation accounts for one (# 1) of three residents reviewed for facility funds. The Business office manger identified 15 residents that have money in the trust account and were current residents. Findings: A review of resident accounts balances documented Resident # 1 had a credit balance of $1,471.00 in the facility's accounts receivable account from 01/19/24 carried through to the current date. Resident # 1 did not have funds in the facility's trust account. On 07/11/24 at 11:22 a.m., the corporate business office manager stated the money was left in the operating system per the family. They then stated the operating system was not an interest bearing account. On 07/11/22 at 3:01 p.m. the corporate regional manager stated resident funds are not to be commingled with operating funds.

Based on record review and interview, the facility failed to ensure medications were available for one (#5) of three residents reviewed for medication availability. The Administrator identified 76 residents in the facility who required medications. Findings: A Facility policy titled Medication Orders read in parts, .Emergency/STAT Medication Order (Medication NOT Contained in Emergency Medication Supply) .the medication is scheduled to be given as soon as received or within 4 hours, whichever is sooner . Resident #5 had diagnoses which included acute kidney failure. On 01/05/24 Resident #5 returned to the facility from a local hospital. Discharge orders from the hospital documented the resident was discharged back to the facility at 5:30 p.m., with an order for the medication cefepime (an antibiotic) 2,000 mg in sodium chloride 0.9% 50 ml IVPB every 12 hours. The MAR for Resident #5 documented the medication was administered on 01/06/24 at 1900. On 2/28/24 at 1:52 p.m., the ADON stated antibiotics are considered a STAT order to pharmacy and, depending on the time ordered, should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have an administrator of record. The administrator identified 76 residents who resided in the facility. Findings: On 02/26/24 at 2:00 p.m. the Administrator stated the previous administrator left their position with the facility on 11/23/23. They stated their first day as Administrator at the facility was 01/18/24. The Administrator stated they would check to see who was the acting administrator during the interim between 11/23/23 and 01/18/24. On 02/28/24 at 2:38 p.m. the Administrator stated they were unable to determine if anyone was the interim administrator for the facility. They stated that as far as they could determine, no one occupied that position between 11/23/23 and 01/18/24. By the end of the survey, requested documentation related to administration coverage for the facility was not provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents received showers as scheduled for four (#23, 34, 63, and #231) of five residents reviewed for ADLs. The Resident Census and Conditions of Residents form, dated 09/21/23, documented 79 residents resided in the facility. Findings: 1. Res #23 was admitted to the facility 07/15/23 with diagnoses which included multiple sclerosis. An MDS assessment for Res #23, dated 07/29/23, documented the resident was totally dependent on staff for bathing. The assessment documented the resident's cognition was intact. The care plan for Res #23, dated 05/11/23, read in part, .I have an ADL self care performance deficit, AEB impaired balance with surface transitions, poor decision making and muscle weakness/wasting R/T progression of multiple sclerosis .I require limited assist of one staff for bed mobility, bathing, dressing and hygiene . On 09/21/23 at 4:35 p.m., Res #23 reported getting a shower that day but stated it had been a…

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

Based on observation, record review, and interview, the facility failed to provide showers, incontinent care, and answer call lights in a timely manner for six (#34, 63, 23, 64, 65, and #231) of six residents reviewed for sufficient staffing to meet the needs of residents. The ''Resident Census and Conditions of Residents'' form, dated 09/21/23, documented 79 residents resided in the facility. The form documented 15 residents were dependent on staff for bathing, 60 residents required one or two staff assistance with bathing, and 64 residents required assistance of one or two staff with toileting. Findings: On 09/21/23 at 1:42 p.m., Res #34 reported they would ask a nurse for a shower, they would write the resident's name down to get one, but most of the time they still wouldn't get a shower. On 09/21/23 at 3:40 p.m., Res #63 reported they occasionally got a shower if they could get a CNA to help with one. On 09/21/23 at 4:35 p.m., Res #23 reported they had received a shower that day but it had been a week since their previous shower. The resident stated they were scheduled to get a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were available, per the pharmacy policy and procedure, for one (#233) of five residents reviewed for medication administration. The Resident Census and Conditions of Residents form, dated 09/21/23, documented 79 residents resided in the facility. Findings: The facility policies and procedures, Medication Orders and Receipt Record, read in part .medications should be ordered in advance the receiving nurse shall record medication orders received . The facility admission Check List, read in part, .meds must be completed in the first 2 hours . Res #233 was admitted on [DATE] with diagnoses which included diabetes mellitus, hypertension, atrial fibrillation, anxiety disorder, and delusional disorder. A hospital discharge reconciliation report, dated 09/25/23, documented the date and time the resident's medications were last given and a list of medications to continue at home. A facility ''Order Summary Report, for Res #233, documented…

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

Based on interview and record review, the facility failed to implement their abuse policy and procedures by failing to screen and obtain a background check on one (CMA #1) of five employees reviewed for screening upon hire. The Resident Census and Conditions of Residents form, dated 09/21/23, documented 79 residents resided at the facility. Findings: The facility Abuse, Neglect, Exploitation and Misappropriation Prevention policy, read in part, .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives .Conduct employee background checks . On 09/27/23 at 1:10 p.m., the employee file for CMA #1 was reviewed. The file documented the CMA was hired on 08/18/23 and had signed a copy of the facility's abuse policy. The file did not contain a background or offender/registry check. On 09/27/23 at 1:25 p.m., administrator #2 (an administrator from a sister facility), reported the normal procedure for any new applicant was to try and obtain all new-hire paperwork and implement background…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a baseline care plan, within 48 hours of admission, for one (#231) of three residents reviewed for baseline care plans. The Resident Census and Conditions of Residents form, dated 09/21/23, documented 79 residents resided in the facility. Findings: Res #231 was admitted to the facility on [DATE] with diagnoses which included multiple fractures due to trauma, depression, chronic obstructive pulmonary disease, acute pain due to trauma, and a surgical wound. An MDS assessment for Res #231, dated 09/15/23, documented their cognition was intact and limited assistance was required for most ADLs. A temporary care plan for Res #231, dated 09/15/23, read in part .Upon admission staff will perform systematic and continuous collection, organization, validations, and documentation of data to optimize my abilities, maximize by comfort and dignity through personalizing my plan of care through daily choices and preferences .Assess/evaluate resident's needs:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain registry verification for one (CMA #1) of five employee files reviewed for registry verification. On [DATE] at 1:10 p.m., the employee file for CMA #1 was reviewed and documented the CMA's certification had expired on [DATE]. The file documented the employee was hired on [DATE] to work as a CMA. On [DATE] at 1:25 p.m., administrator #2 reported the normal procedure for any new applicant was to try and obtain all new-hire paperwork and implement background checks within the first 24 hours. Administrator #2 stated he wasn't sure what happened with CMA #1 or why the proper protocol wasn't followed. The administrator stated if the proper protocol had been followed, the expired CMA certificate would have shown up. The administrator confirmed the CMA's certificate had expired on [DATE] and the CMA's hire date was [DATE].