The Springs Skilled Nursing And Therapy

Based on observation, record review, and interview, the facility failed to ensure an assessment for the use of bed rails had been completed for 1 (#11) of 1 sampled resident reviewed for bed rails.Quality Manager Nurse #2 identified 25 residents utilized bed rails. Findings:On 09/17/25 at 10:46 a.m., a bed rail was observed on the right side of Resident #11's bed in the up position.A significant change assessment, dated 08/19/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of depression.A care plan, updated 09/08/25, did not show Resident #11 utilized a bed rail to the right side of the bed.Review of the electronic clinical record, dated 09/01/24 through 09/24/25, did not show Resident #11 had been assessed for the use of bed rails or consent had been obtained.On 09/24/25 at 2:12 p.m., quality manager nurse #2 stated they did not have a policy for the use of bed rails, but they were to complete an assessment, obtain consent, obtain a physician order, update the care plan and document 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 ensure regular inspection of bed rails as part of their maintenance program for 1 (#11) of 1 sampled resident reviewed for bed rails.Quality Manager Nurse #2 identified 25 residents utilized bed rails. Findings:On 09/17/25 at 10:46 a.m., a bed rail was observed on the right side of Resident #11's bed in the up position.A significant change assessment, dated 08/19/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of depression.On 09/24/25 at 3:04 p.m., the maintenance supervisor stated they applied bed rails to beds as indicated by the DON, but they did not regularly inspect them after installation. On 09/24/25 at 3:11 p.m., the administrator stated they did not have a policy related to bed rails, bed safety, or inspection of resident beds. They stated maintenance installed bed rails, but did not regularly inspect them as part of the maintenance program. The administrator stated Resident #11 had an enabler bar 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 record review and interview, the facility failed to ensure resident assessment were completed within the required timeframe for 10 (#11, 12, 15, 17, 33, 55, 59, 62, 64 and #78) of 11 residents whose transmission reports were reviewed. The Administrator identified 79 residents who resided in the facility Findings: The CMS Transmission Report, dated 05/28/24 documented the following resident assessments were completed late/more than 14 days after the assessment reference date. a. Res #11's quarterly assessment dated [DATE]. b. Res #12's quarterly assessment dated [DATE]. c. Res #15's quarterly assessment dated [DATE]. d. Res #17's quarterly assessment dated [DATE]. e. Res #33's annual assessment dated [DATE] and quarterly assessment dated [DATE]. f. Res #55's admission assessment dated [DATE] and end of skilled assessment dated [DATE]. g. Res #59's quarterly assessment dated [DATE] and 01/21/24. h. Res #62's quarterly assessment dated [DATE]. i. Res #64's quarterly assessment dated [DATE] and 01/23/24. j.…

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 oxygen and humidifier tubing was changed monthly for three (#11, 40, and #78) of three sampled residents whose respiratory care was reviewed. The Administrator identified six residents who require oxygen. Findings: The Respiratory Equipment Changeout Schedule policy, last revised on 11/11/19, read in part, .Changeout Schedule .O2 Humidifier one time per month, Cannulas one time per month . 1. Res #11 had diagnoses which included COPD A physician's order, dated 06/09/23, documented oxygen nasal cannulas/tubing and humidifiers should be changed on the 15th of each month and as needed. On 05/28/24 at 10:45 a.m., Res #11's oxygen was in use with their cannula/tubing dated 02/13/24. Res #11's oxygen humidifier was empty and dated 04/30/24. On 05/29/24 at 11:02 a.m., Res #11's oxygen was in use with their cannula/tubing dated 05/28/24. Res #11's oxygen humidifier was empty and dated 04/30/24. 2. Res #40 had diagnoses which included COPD A physician's order, dated 08/25/23, documented oxygen 2-4 liters via…

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 adequate staffing to ensure residents received their baths as scheduled for two (#34 and #71) of three sampled residents whose bathing documentation was reviewed. The administrator identified 79 residents who resided in the facility. Findings: 1. Res #34 had diagnoses which included end stage renal disease and congestive heart failure. The Inventory/Task Schedule documented Res #34 was scheduled to receive a bath on Monday and Wednesday each week. The Documentation Survey Report v2 for May 2024 documented Res #34 only received a bath on the following days: 05/01, 05/06, 05/15, 05/20 and 05/29/24. Res #34 did not receive a bath on the following scheduled days: 05/08, 05/13, 05/22, and 05/27/24. On 05/28/24 at 11:41 a.m., Res #34 reported they don't get baths when they are scheduled. Res #34 reported they were supposed to have a bath yesterday (05/27/24) and asked for one but was told by staff no one working could give them a bath. Res #34 reported the staff always say there aren't enough people when needing…

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 medication was administered as ordered for one (#83) of five sampled residents reviewed for medications. The Administrator identified 79 residents resided in the facility. Findings: A Specific Medication Administration procedure, date January 2022, read in part, .To administer oral medications in a safe, accurate, and effective manner . A Physician's Order, dated 02/08/24, documented to administer Levothyroxine Sodium Oral Tablet 88 MCG one tablet by mouth one time a day related to hypothyroidism. An April 2024 MAR documented blanks for the 6:00 a.m. Levothyroxine 88 mcg on 04/09, 04/10, 04/12, 04/16, 04/19, 04/20, 21, 04/23, 04/25, 04/27, and 04/28/24. A May 2024 MAR documented blanks for the 6:00 a.m. Levothyroxine 88 mcg on 05/04, 05/09, 05/13, 05/18, 05/21, 05/22, 05/26, 05/27, and on 05/31/24. On 05/30/24 at 10:09 a.m., CMA #1 was asked what the process was for administering medications. They stated they would look at the medication card and check it against the MAR. CMA #1 was asked how they documented when…

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: a. monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on steam table during a meal service. b. the facility servings sizes were appropriate for each item served. c. food served to residents was palatable. The Resident Census and Conditions of Residents form documented 91 residents resided in the facility. Findings: On 08/23/23 at 4:55 p.m., staff were observed delivering plates of food to residents. The plates were stacked on an open cart and had plastic wrap to cover them. Multiple plates were observed stacked together as a staff member was working delivering them on the 300 hall. The plates had no mechanism to prevent heat loss from the food being served which appeared to be a ravioli dish. On 08/24/23 at 10:00 a.m., Res #1 stated if it was not for friends bringing the resident food they would starve because of the palatability, quality, and serving sizes. On 08/24/23 at 12:40 p.m., the DM was asked how the staff delivered meals to the residents who…

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 medications were available for one (#10) of 15 residents observed for medication pass and failed to administer medications as ordered for two (#1 and #5) of four residents reviewed for medication administration. The Census and Conditions of Residents report, documented 91 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included atrial fibrillation, seizures, and GERD. A quarterly assessment, dated 05/24/23, documented the resident was intact with cognition and required limited assistance with most ADLs. On 08/24/23 at 9:50 a.m., Res #1 was observed sitting in their wheelchair in their room and stated they had missed nine pills and the nurse, after finishing on the 100 and 200 halls, came and gave them their medication. Res #1 stated they would have stayed at the nurses station all night to get the medication if they had to. The review of the resident MAR for August, 2023 reveled on 08/03/23 one medication was not marked as administered. On 08/08/23 the MAR documented 11…

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, it was determined the facility failed to ensure residents' care plans were reviewed and revised for six (#5, 10, 15, 33, 69, and #86) of 27 residents whose care plans were reviewed. The facility failed to update the residents' care plans: a. with new interventions in response to position and mobility for residents #69 and #86. b. with new interventions in response to the residents' falls for #5, 10, 15, and #33. c. with ADL cares and oxygen for resident #10. The Resident Census and Conditions of Residents documented 86 residents resided in the facility. Findings: 1. Res #5 had diagnoses which included history of falling, COPD, diabetes mellitus, and schizophrenia. A nurse note, dated 03/12/23, documented the resident had a fall in the dining room. The intervention was to place the resident on PRN incontinent care checks. A care plan, revised 03/12/23, documented an intervention was in place for incontinent care checks as needed. A Medicare 5 day assessment,…

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 ADL care was provided to dependent residents for five (#10, 26, 51, 145, and #148) of eight residents reviewed for ADL care. The Resident Census and Conditions of Residents form documented 86 residents resided in the facility. Findings: 1. Res#10 had diagnoses which included chronic respiratory failure with hypoxia, COPD, and atrial fibrillation. A significant change assessment, dated 03/20/23, documented the resident was severely impaired with cognition and required limited assistance with most ADLs and total assistance with bathing. A care plan, last revised 03/30/23, for ADL care documented when bathing the resident to avoid scrubbing and pat dry sensitive skin, check nail length, and trim and clean the nails on bath day. The care plan documented the resident required limited staff participation with bathing and the resident would be provided a sponge bath when a full bath or shower could not be tolerated. The care plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined the facility failed to provide a sufficient number of staff to ensure residents received the needed care and services. The Resident Census and Conditions of Residents, form documented 86 residents resided in the facility. Findings: 1. On 04/13/23 at 3:05 p.m., a resident council meeting was conducted. The residents expressed concerns of call lights not being answered in a timely manner stating it sometimes it would be hours before any staff came to check on them. Another concern expressed was staffing with one aide per hall stating it was not enough staff to meet the needs of the residents. 2. On 04/10/23 at 11:27 a.m., Res #10 stated she received showers but the staff did not take care of her facial hair. Res #10 rubbed her chin and stated she would like them to. The resident facial hair was observed to be long on the resident's chin. On 04/11/23 at 2:24 p.m. the DON observed the facial hair on the resident's chin. He stated it looked like…

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 were free from significant medication errors for four (#33, 45, 69, and #144) of five residents reviewed for medications. The Resident Census and Conditions of Residents form documented 86 residents resided in the facility. Findings: 1. Res #33's physician order, dated 09/26/22, documented to administer hydralazine hydrochloride (a medication used to dilate blood vessels) 25 mg four times a day. The order documented the staff were to obtain a B/P and hold the medication if the B/P reading was less than 100 for systolic reading or less than 60 for the diastolic reading and if the medication was held to notify the nurse/physician. The January 2023 MAR revealed no documentation the medication hydralazine was administered on 01/27/23 as well as multiple refusals. The February 2023 MAR revealed no documentation of obtaining blood pressures prior to administration of hydralazine on 02/11/23 for two doses, 02/12/23 for all doses, 02/18/23 for three doses, and 02/19/23 for all doses as well as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to have a call system which relayed the call directly to a staff member. The call system did not produce an audible sound and the call light boards which were located near each nursing station were often unmanned. The Resident Census and Conditions of Residents form documented 86 residents resided in the facility. Findings: On 04/06/23 at 4:31 p.m., Res #13 stated sometimes it took two to three hours on all shifts to answer the call light. Res #13 stated the wooden beam located on the ceiling outside of her door hid the call light so the staff could not see it and the call lights did not have sound. On 04/07/23 10:14 a.m., Res #74 stated their call light did not get answered. On 04/10/23 at 7:30 a.m., Res #28 stated about 2:35 a.m., he had to get up and had to go find an aide because other residents needed help and yelled out at night. He stated he did not turn his call light on as the staff never answered it. He stated he had witnessed the staff in 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 record review and interview, the facility failed to consistently notify the resident's representative when the resident fell for one (#15) of five residents reviewed for falls. The DON reported 68 residents had fallen in the previous six months. Findings: Res #15 had diagnoses which included vascular dementia, senile degeneration of the brain, paranoid schizophrenia, and a history of falling. An incident report, dated 11/21/22, documented the resident had fallen. The EHR did not document the resident's representative had been notified of the fall. An incident report, dated 12/28/22, documented the resident had fallen. The EHR documented the facility had attempted to contact the resident's representative and a message was left. The EHR did not document the resident's representative had returned the call or the facility had attempted further contact with the representative. An incident report, dated 01/28/23, documented the resident had fallen. The EHR documented the facility had attempted to contact the resident's representative and a message was left. The EHR did not…

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

Based on observation, record review, and interview, facility failed to ensure its employees did not neglect a resident by failing to provided assistance to reposition a resident to avoid the development of a pressure ulcer for one (#148) of two residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents form documented two residents residing in the facility had pressure ulcers. Findings: Res #148 had diagnoses which included congestive heart failure, kidney failure, rheumatoid arthritis, and osteoporosis without pathological fracture. An admission assessment, dated 03/17/23, documented the resident had no pressure areas or open wounds A care plan, dated 03/17/23, documented the resident had a risk for impaired skin integrity related to incontinence and decreased mobility. The care plan documented the staff were to implement skin interventions to minimize skin breakdown including, but not limited to, assisting the resident with turning and repositioning frequently and encourage the resident to turn and reposition frequently. The EHR documentation 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 the resident assessments accurately reflected the residents' status for two (#5 and #33) of 27 residents whose assessments were reviewed. The facility failed to accurately code: a. walking for Res #5. b. physician documentation of contraindication to a gradual dose reduction for Res #33. The Resident Census and Conditions of Residents form documented 86 residents resided in the facility. Findings: 1. Res #33 had diagnoses which included dementia with behavioral disturbance, anxiety disorder, recurrent depressive disorders, and unspecified psychosis. A physician order, dated 11/28/22, documented the facility was to administer quetiapine fumarate tablet, 25 mg two times a day for a diagnosis of unspecified psychosis not due to a substance or known physiological condition. A consultant pharmacist medication review, dated 12/08/22, asked for a reduction in either Zoloft (an antidepressant medication), Ativan (an antianxiety medication), or Seroquel (quetiapine fumarate). On 12/17/22 the consultant…

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, it was determined the facility failed to develop a comprehensive care plan related to the resident's enteral feeding tube for one (#6) of two residents who were sampled for enteral feeding tubes. The Resident Census and Conditions of Residents documented 86 residents resided in the facility. Findings: Res #6 had diagnoses which included encounter for attention to gastrostomy. An admission assessment, dated 02/28/23, documented the resident was cognitively intact, required extensive assistance with activities of daily living, and had a feeding tube. The care plan, dated 03/21/23, was reviewed and did not contain a plan of care related to the resident's enteral feeding tube. On 04/07/23 at 9:02 a.m., Res #6 was observed sitting in a wheelchair and lifted up her shirt to show the enteral tube feeding port. At that time, she stated she did not use it for feedings anymore and it was only used to administer medication. On 04/14/23 at 12:55 p.m., MDS coordinator #2 stated the enteral feeding tube was inserted during the last hospital stay…

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 a resident centered activity program was implemented to meet the resident's interest for one (#66) of three residents sampled for choices. The Resident Census and Conditions of Residents, documented 86 residents resided in the facility. Findings: Res #66 had diagnoses which included diabetes mellitus, atrial fibrillation, acute and chronic respiratory failure, and depression. A care plan, initiated on 10/21/21, documented Res #66 was to be assisted to activities as needed. The care plan also documented to introduce the resident to her peers, notify the resident of scheduled activities, and to remind the resident when activities were starting. A significant change assessment, dated 09/09/22, documented the resident was moderately impaired in cognition. The assessment documented the resident required extensive assistance with most ADLs. The assessment documented it was very important to the resident to participate in group activities and to participate in religious services. A quarterly assessment, dated…

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

Based on record review, observation, and interview, the facility failed to ensure residents were cared for in accordance with professional standards of practice for one (#86) of two residents sampled for mobility and range of motion and one (#6) of two residents sampled for nutrition. The facility failed to: a. to turn and reposition Res #86. b. obtain daily weights as ordered by the physician for Res #6. The Resident Census and Conditions of Residents report documented nine residents who were bed fast most of the time resided in the facility. Findings: 1. Res #86 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, and Parkinson's Disease. A care plan for transfer and mobility, last revised 12/03/22, documented the resident had an ADL self care performance deficit. The care plan documented the resident was independent to limited assist of one with transfers and bed mobility. A significant change assessment, dated 02/16/23, documented the resident was intact with cognition and required limited assistance with bed…

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 a resident received care consistent with professional standards of practice to prevent pressures ulcers for one (#148) of two residents sampled for pressure ulcer care. The Resident Census and Conditions of Residents form documented two residents residing in the facility had pressure ulcers. Findings: Res #148 had diagnoses which included congestive heart failure, atrioventricular block, acute kidney failure, rheumatoid arthritis, and hypertensive heart disease with heart failure. A care plan, dated 03/17/23, documented the resident was at risk for impaired skin integrity related to incontinence and decreased mobility. The care plan documented staff were to assist with turning and repositioning frequently and encourage the resident to turn herself and reposition herself frequently. The EHR documentation of turning and repositioning the resident did not reveal entries for the dates of 03/18/23, 03/22/23, and 03/23/23. The EHR documentation revealed the resident had been turned on one shift only on…

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

Based on observation, record review, and interview, the facility failed to ensure a resident with limited ROM received the appropriate treatment and services to increase or prevent further decrease in ROM for one (#69) of two residents sampled for ROM. Findings: Res #69 had diagnoses which included hemiplegia and hemiparesis. An annual MDS assessment for Res #69, dated 11/08/22, documented the resident was intact in cognition, required extensive to total assistance with ADLs, and had range of motion impairment on both sides of his upper and lower extremities. A care plan, dated 02/07/23, documented the resident had an ADL self care performance deficit. The care plan documented Res #69 was to maintain his current level of function in ADLs through the next review date. The care plan documented the restorative aide was to do passive range of motion with the resident's left hand daily. On 04/10/23 at 9:18 a.m., the resident was observed in his room in bed. The resident stated he did not receive any therapy or restorative. His left hand was observed with his fingers curved at the first…

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 physician order for oxygen for one (#10) of one sampled resident reviewed for oxygen. The Resident Census and Conditions of Residents form documented 21 residents received respiratory treatments. Findings: Res #10 had diagnoses which included chronic respiratory failure with hypoxia, COPD, atrial fibrillation, and HTN. A significant change assessment, dated 03/20/23, documented the resident was severely impaired with cognition and required limited assistance with most activities of daily living and total assistance with bathing. The assessment documented the resident received oxygen. A care plan for respiratory care, last revised 03/24/23, documented the resident had altered respiratory status related to COPD and acute and chronic respiratory failure with hypoxia. The care plan did not contain the amount of oxygen the resident was to receive. On 04/10/23 at 11:25 a.m., the resident was observed receiving four liters of oxygen per nasal cannula. A physician order, dated 04/11/23 at 11:00 p.m.,…

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

Based on observation, record review, and interview, the facility failed to ensure to maintain communication with the dialysis unit for one (#69) of two residents sampled who required dialysis. The Resident Census and Conditions of Residents form documented nine residents residing in the facility who required dialysis. Findings: A facility policy, titled Guideline for Dialysis After Care, dated 07/11/12, read in part.g. Schedule visits to Dialysis Center and coordinate care accordingly. Res #69 had diagnoses which included end stage renal disease and dependence on renal dialysis. The resident's hard chart only documented dialysis records for the months of July and August of 2022. An annual MDS assessment, dated 11/08/22, documented the resident was intact in cognition, required extensive assistance with most ADLs, and was receiving dialysis. A care plan, reviewed on 02/07/23, documented the resident had renal failure related to end stage renal disease, complications from dialysis, and to schedule visits to the dialysis center and coordinate care accordingly. A 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.

Based on record review and interview, the facility failed to administer medications as ordered for one (#86) of six residents whose medications were reviewed. The Resident Census and Conditions of Residents report documented 86 residents resided in the facility. Findings: Res #86's physician order, dated 02/02/23, documented to administer carbidopa-levodopa 25/100 mg three tablets TID related to Parkinson's Disease. A significant change assessment, dated 02/16/23, documented the resident was intact with cognition and required limited assistance with bed mobility and transfer. The March 2023 MAR documented the carbidopa-levodopa was not administered at the scheduled time of 6:00 a.m. four times, up until the 16th when the medication order was changed. A physician order, dated 03/16/23, documented to administer carbidopa-levodopa 25/100 mg three tablets QID related to Parkinson's Disease. The MAR for March 2023, documented the carbidopa-levodopa was not administered at the scheduled time of 6:00 a.m. two times, from the 16th until the 30th when the medication order was changed. 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 meet the nutritional needs of the residents for one meal observed. The Resident Census and Conditions of Residents report documented 86 residents resided in the facility. Findings: Menu cycle day 12, for 04/13/23, documented ham with macaroni and cheese 8 oz, sliced carrots 1/2 cup, bread of the day, and dessert of the day. On 04/13/23 at 11:39 a.m., a meal service was observed for the residents. The facility was observe to serve sliced ham, macaroni and cheese, a mixed vegetable, a roll, and dessert. The drinks and desserts are served to the residents before the meal service started. [NAME] #1 was observed serving the meal and plated a very thin slices of ham, one per plate, to the residents. On 04/13/23 at 12:01 p.m., the DM was asked about the thin slices of ham. She was asked to obtain a slice laying on top at this time and weigh the slice of ham. The DM stated the scale at this serving area was broke. She placed the slice of ham on a plate, covered it, and we walked to the 100 hall where she weighed 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 serve an alternate food item of the resident's choice for one (#28) of two residents who were reviewed for food choices. The Resident Census and Conditions of Residents report documented 86 residents resided in the facility. Findings: Res #28 had diagnoses which included diabetes mellitus with chronic kidney disease and end stage renal dialysis. A physician order, dated 06/14/22, documented a cardiac healthy heart diet with regular texture, thin liquids, and low concentrated sweets. A quarterly assessment, dated 02/17/23, documented the resident was intact with cognition and was independent with most ADLs. The assessment documented the resident had not had a weight gain or loss. On 04/05/23 at 12:46 p.m., during the initial tour of the kitchen, they did not have any pasteurized eggs at that time. The DM stated they were using bagged eggs for scrambled eggs. Several cartons of regular eggs were observed, the DM stated they were for Easter eggs on Friday. The DM stated they would get more pasteurized eggs when the truck came…

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 food was stored in a sanitary manner. The Resident Census and Conditions of Residents form identified 86 residents resided in the facility. Findings: On 04/05/23 from 12:46 p.m. through 1:05 p.m., an initial tour of the kitchen and food delivery areas or Bistros was conducted. [NAME] #2 was observed in the kitchen preparing to wipe down the counter tops with a bucket with sanitizer solution. At that time, she was asked to check the sanitizer level in the solution. The sanitizer in the sanitizer bucket did not register with the sanitizer solution strip. The DM told cook #2 to mix a new bucket of sanitizer solution. During inspection of the freezer, a pasteboard box of food was observed on the top shelf on the left of the door and was covered with ice and frost. The DM stated she had not looked up to notice the box. She stated it was for vegetarian meals. At 12:55 p.m., the refrigerator in the Bistro on hall 100 was observed with the DM. A open container of Thicket was observed in the refrigerator with an open 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.