Ranchwood Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to: a. ensure incontinent care was provided for 1 (#100), and b. ensure showers were provided for 1 (#127) of sampled 8 residents reviewed for activities of daily living.The DON identified 109 residents resided in the facility.Findings:1. A progress note showed Resident #127 was admitted to the facility on [DATE] and discharged on 04/24/25. Review of bath sheet forms for Resident #127 showed the resident received showers on 04/16/25, 4/20/25 and 04/23/25. There was no documentation to show showers were provided from 04/03/25 to 04/16/25. On 9/10/25 at 2:45 p.m., an unidentified charge nurse stated there was a shower list displayed at the nurse's station indicating the room numbers and the days showers were scheduled. The charge nurse stated once showers were complete, the charge nurse signed off on the sheet. The unidentified charge nurse acknowledged sometimes showers were missed if staff did not show up to work. On 9/10/25 at 4:00 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.

Statement of Deficiency:Based on record review and interview, the facility failed to notify the resident's legal guardian of a change in the resident's condition and treatment for 1 (#76) of 1 sampled resident reviewed for notification. The administrator identified 109 residents resided in the facility. Findings: A facility policy Change of Condition, dated 02/13/23, read in part, Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in the patient's condition or health status. A quarterly assessment for Resident #76, dated 08/15/25, showed a BIMS of 10, which indicated the resident was moderately cognitively impaired. A physician's order dated 08/20/25 showed the resident was to receive Ceftriaxone 2 g, intravenous. There was no documentation to indicate the legal guardian was notified. On 09/10/25 at 2:52 p.m., Resident #76's legal guardian stated they were not notified when the resident was diagnosed with a UTI and the need for IV antibiotic treatment on 08/20/25. On 09/11/25 at 10:00 a.m., the DON reported the resident'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 develop and implement a baseline care plan to provide effective and person-centered care for 1 (#126) of 1 sampled resident reviewed for baseline care plans. The administrator identified nine residents admitted to the facility in the previous 30 days. Findings:A Care Plan - Process policy, dated 03/27/23, read in part, The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process.Initiate a Baseline Care Plan and complete within forty-eight (48) hours of admission based on the physician's orders and nursing evaluation.The Baseline Plan of Care facilitates care until the comprehensive Care Plan is developed. Resident #126 was admitted to the facility on [DATE]. A baseline care plan, dated 09/03/25, showed Resident #126 had diagnoses which included infection and inflammatory reaction due to internal right knee…

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 care plan interventions were implemented to promote the healing of a pressure ulcer for 1 (#100) of 7 sampled residents reviewed for pressure ulcers. The DON identified 13 residents in the facility had pressure ulcers.Findings: On 09/09/25 at 11:03 a.m., Resident #100 was observed lying on their back in bed. The resident was observed with a gauze bandage on the left foot. The resident's heels were observed on the mattress and not offloaded.On 09/11/25 at 9:25 a.m., Resident #100 was observed in bed lying on their back. The resident's heels were on the mattress and not offloaded.On 09/11/25 at 11:33 a.m., the ADON entered Resident #100's room to provide wound care. The resident was in bed lying on their back and heels were not offloaded. The ADON performed wound care to the left heel per physician's orders. The ADON exited the room after the wound care was performed, and the resident's heels were not offloaded and no pressure relieving devices were in place.On 09/17/25 at 12:08 p.m., Resident #100 was…

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

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for 3 (#1, 2, and #3) of 3 sampled residents reviewed for assistance with activities of daily living. The administrator identified 115 residents resided in the facility. Findings: 1. On 04/07/25 at 1:07 p.m., Res #1 was observed lying in bed. The resident' s hair was kempt. No odors were observed. A policy titled Bathing, revised 02/12/20, read in part, Staff will provide bathing services for residents within standard practice guidelines .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record. Res #1 was admitted with diagnoses which included hemiplegia and hemiparesis. A quarterly assessment, dated 02/13/25, showed Res #1 had a BIMS score of 13 and was cognitively intact. The assessment showed Res #1 was dependent with bathing. The medical record documented Res #1 was to receive a bath/shower weekly on Wednesday and Saturday. There was no documentation for February 2025 Resident #1 received a bath/shower 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 record review and interview, the facility failed to ensure medications were administered according to physician orders for 3 (#1, 2, and #3) of 3 residents sampled for timely administration of medications. The administrator identified 115 residents resided in the facility. Findings: A policy titled Liberalized & Standardized Medication Administration, read in part, The licensed nurse and/or technicians (as allowed by state regulations) are responsible for adhering to the facility's standardized and liberalized medication administration schedules. Liberalized schedules - will allow for medication administration during the defined window of time; these are presented by a descriptor (e.g 'in the morning') or time frame (e.g '0700-0900') on the MAR/EMAR [medication administration record/electronic medication administration record]. Medications scheduled are considered timely as long as they are administered within one and a half hours before or after the defined time or window of time.If the medication is not available, the Director of Nursing or designee will be notified. 1.…

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's representative was notified when the resident experienced a fall requiring transport to the hospital for 1 (#2) of 3 sampled residents reviewed for accidents. The administrator identified 115 residents resided in the facility. Findings: On 04/08/25 at 1:00 p.m., Res #2 was observed being wheeled into the facility entrance by family member #1. Family member #1 was frowning and upset. Res #2 was observed with a swollen area of golf ball size above the left eye. A policy titled Change of Condition, revised 02/13/23, read in part, Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in a patient's condition or health status. Examples of circumstances of when it is appropriate to communicate information to these parties may include, but are not limited to: .b) transfer of a patient to another healthcare community for assessment, treatment, or care .d) significant injury or illness. Res #2 was admitted with diagnoses which 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, record review, and interview, the facility failed to maintain an infection control program for EBPs and ensure staff followed infection control guidelines to prevent the potential spread of disease during wound care for 1 (#7) of 3 sampled residents reviewed for wound care. The DON identified 30 residents with wounds and 33 residents on enhanced barrier precautions. Findings: On 04/09/25 at 1:14 p.m., wound care for Res #7 was observed. LPN #1 was observed performing hand hygiene and donning gloves prior to the wound care. LPN #1 was not observed to have donned a personal protective gown prior to or during the wound care. Res #7 was observed to have been incontinent of bowel upon removal of their brief for access to the wounds. LPN #1 was observed to have cleaned the bowel movement from Res #7 and then continued to perform wound care to the wound on Res #7's left lower back without having performed hand hygiene or donning clean gloves after incontinent care was completed. LPN #1 continued to perform wound care to Res #7's sacrum without completing hand hygiene…

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

Based on record review and interview, the facility failed to ensure bathing was provided for 1 (#2) of 3 sampled residents reviewed for bathing. The assistant director of nursing identified 117 residents resided in the facility. Findings: A Bathing policy, dated 02/12/20, read in part, Staff will provide bathing services for residents within standard practice guidelines. Resident #2 had diagnoses which included endocarditis (inflammation of heart valves). An admission resident assessment, dated 12/12/24, showed Resident #2 required substantial to maximum assistance with bathing. On 02/27/25 at 1:40 p.m., CNA #3 stated residents had shower schedules. CNA #3 stated they were not aware of what schedule Resident #2 would have been on during their stay in the facility. On 03/03/25 at 10:35 a.m., the traveling interim DON was asked to provide bathing records for Resident #2's stay in the facility. Resident #2 was in the facility during the month of December 2024. On 03/03/25 at 11:07 a.m., the traveling interim DON stated they were unable to find any documentation on Resident #2's bathing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct a thorough investigation after receiving an allegation of missing doses of medication for one (#8) of three sampled residents reviewed for medications being administered as ordered. The administrator reported there were 112 residents residing in the facility. Findings: An Abuse, Neglect and exploitation and misappropriation of resident property policy, reviewed 02/12/20, read in parts, All facility staff members have a duty to ensure that all alleged violations .including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator .Upon receiving an allegation .the Abuse Coordinator will .initiate an investigation into the allegation. Resident #8 had diagnoses which included type 2 diabetes mellitus and end stage renal disease. A physician's order, dated 12/23/24, documented Resident #8 was to receive Ozempic 2mg via subcutaneous injection every…

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 comprehensive MDS assessment within the required time frame for one (#6) of eleven sampled residents reviewed for MDS assessment completion. The DON identified 112 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated October 2024, documented an admission assessment must be completed no later than the 14th day of the resident's admission. Resident #6 was admitted on [DATE] with diagnoses which included type 2 diabetes mellitus and stage 4 pressure ulcer of sacral region. There was no documentation in the EHR that a comprehensive MDS assessment was completed for Resident #6. On 01/15/25 at 3:45 p.m., the DON was asked to review Resident #6's clinical record. After consulting with the MDS coordinator, the DON acknowledged no comprehensive MDS assessment had been completed for Resident #6 since their admission on [DATE].

Based on record review and interview, the facility failed to ensure a resident did not receive the wrong medications for one (#3) of three sampled residents reviewed for medication being administered as ordered. The administrator identified 112 residents resided in the facility. Findings A Medication Administration- General Guidelines policy, dated 01/2024, read in parts, Residents are identified before medication is administered using at least two resident identifiers .the resident's room number or physical location is not used as an identifier Resident #3 had diagnoses which included pneumonia and deep vein thrombosis. An incident report, dated 12/25/24 at 8:02 a.m., documented CMA #2 had given Resident #3 medications that belonged to another resident. A nurses note, signed 12/25/24 2:10 p.m., documented CMA #2 reported giving Resident #3 the following medications that belonged to another resident: aspirin 81mg (NSAID- reduce risk of heart attack), buspirone 10mg (anxiolytic- treats anxiety), linezolid 600mg (antibacterial- treats skin infection & pneumonia), and potassium…

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 maintain a home like environment during two of two observations by ensuring: a. carpets were in good repair and clean, b. walls were in good repair and not damaged, c. outlets and exposed wires were covered, d. tiles were in good repair and not torn or missing e. walls and ceilings were clean and free of debris and stains, and f. strong odors of urine were prevented. The DON identified 102 residents resided in the facility. Findings: The facility's Resident Room Cleaning policy, dated 11/2021, read in part, Purpose: To provide a clean, attractive, and safe environment for residents, visitors, and staff. The facility's Maintenance Work Order Log sheet document, dated 08/08/24, documented a work order for room [ROOM NUMBER]'s carpet being torn was submitted. It did not document the repairs were completed. On 09/06/24 at 1:54 p.m., the following observations were made in room [ROOM NUMBER]: the carpet was torn across the middle of the room…

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

Based on observation and interview, the facility failed to ensure safe food handling practices of covering food in a sanitary condition when on the tray line. The DON stated 101 residents received nutritional meals from the kitchen Findings: On 09/03/24 at 8:23 a.m., it was found that bowls of cereal were unwrapped, stacked and stored on tray line. The bottom of the bowls came in contact with cereal product. On 09/03/24 at 8:24 a.m., the Kitchen Aide #1 reported that the bowls of cereal are supposed to wrapped and not stacked on each other. On 09/10/24 at 9:43 a.m., the Dietary Manager reported the bowls of cereal was an infection control issue and not to serve the cereal to residents. On 09/10/24 at 9:44 a.m., the Dietary Manager reported we have no policy for this issue.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a catheter bag was covered with a vanity bag to maintain residents dignity for one (#96) of three sampled resident reviewed for catheter bags covered to maintain a residents dignity during two of two observations. The DON identified 9 residents had catheters in the facility. Findings: The facility's Insertion of a Straight or Indwelling Urinary Catheter policy, revised on 01/12/23, read in part, Cover drainage bag with privacy bag as necessary. Resident #96 was admitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia and cellulitis. A physicians order, dated 7/19/24, read in part, Foley Catheter Care every 2 shift privacy bag checked and verified Q Shift. On 09/03/24 at 9:20 a.m., Resident #96's catheter bag was observed hanging on the lower bedside from the hall while standing in the door way. The bag was not covered with a vanity bag. On 09/06/24 at 11:15 a.m., Resident #96's catheter bag 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 ensure residents were offered the choice to formulate an advanced directive for one (#4) of 32 sampled residents whose advanced directive acknowledgments were reviewed. The DON identified 102 residents resided in the facility. Findings: The facility's Advance Directive Management policy, revised 03/27/23, read in part, The Director of admission will ensure that the Advanced Directive Acknowledgment Form is completed during the admission process and scan the Acknowledgment Form into the resident's EMR. Resident #4 was admitted on [DATE] with diagnoses which included multiple sclerosis and paraplegia. Resident #4's EMR did not document the the resident was assisted with formulating an advanced directive. On 09/04/24 at 2:08 p.m., Corporate Nurse #1 was asked where Resident #4's advanced directive was located in the EMR. Corporate Nurse #1 stated they audited the charts the night before and Resident #4 did not have an advanced directive acknowledgment 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 record review and interview, the facility failed to document the alleged abuse for one (#44) of three sampled residents. The DON reported 101 residents resided in the facility. Findings: The facility's ABUSE, NEGLECT AND EXPLOITATION AND MISAPPROPRIATION OF RESIDENT PROPERTY dated 06/23/17, read in parts .The person receiving the report or designee must document all incidents of alleged abuse/neglect on incident reports, which are forwarded directly to the Abuse Counselor . Resident #44 had diagnosis of Hypertensive Chronic Kidney Disease and Anxiety Disorder. On 09/20/24 at 10:20 p.m., there was no records of initial report found. On 09/10/24 at 10:58 a.m., LPN # reported that CMA# had received allegation of abuse from Resident #44 and reported to me on 09/06/24 at 7:30a.m. during shift change. On 09/10/24 at 10:59 a.m., LPN# reported there was no documentation. On 09/1024 at 11:07 a.m., the DON reported the company policy and procedure states that the person receiving the allegation should fill out an incident report and no documentation was completed by the CMA # .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure quarterly assessments were completed within 92 days of the previous ARD for two(#1 and #75) of 32 sampled residents whose MDS assessments were reviewed. The DON identified 102 residents resided in the facility. Findings: The facility's Resident Assessment policy, revised 01/12/20, read in part, Quarterly assessments will be conducted not less than once every 3 months (92 days). 1. Resident #1 was admitted on [DATE] with diagnosis which included morbid obesity and hypotension. A summary of Resident #1's MDS Resident's MDS List document, dated 09/10/24, documented, a quarterly assessment with an ARD date of 04/25/24 was completed. The next assessment documented a significant change assessment with an ARD date 09/04/24 was completed. There was no documentation an MDS assessment was completed within 92 days on 07/25/24 of the 04/25/24 quarterly assessment. 2. Resident #25 was admitted on [DATE] with diagnoses which included epilepsy, major…

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 that Resident #102 MDS records accurately reflected the residents status of discharge. The DON stated 101 residents resided in the facility. Findings: On 09/09/24 at 10:40 a.m., the MDS assessment records inaccurately documented that Resident #102 discharged from the facility to the hospital. On 09/09/24 at 10:41 a.m., Resident #102 Nursing Notes dated, 06/03/24, documented Resident #102 phone call arrangements were made for resident to be discharged home on Sunday at 10 a.m On 09/09/24 at 10:42 a.m., Resident #102 Physician Orders dated 06/23/24, documented Resident #102 was discharged home. On 09/09/24 at 10:43 a.m., the MDS Coordinator #1 reported the MDS records were inaccurately coded resident discharged home and not to the hospital. On 09/09/24 at 11:01 a.m., the Administrator reported we do not have an policy for inaccurate MDS documentation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the residents carpet was not torn and frayed causing a resident to fall for one (#45) of one resident sampled for accidents and hazards. The DON identified 102 residents resided in the facility Findings: The facility's Fall Management policy, dated 01/12/18, read in part, If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls-complete the Incident/Accident Report in the EHR. The facility's Resident Room Cleaning policy, dated 11/2021, read in part, Purpose: To provide a clean, attractive, and safe environment for residents, visitors, and staff. A Maintenance Work Order Log Sheet document, dated 08/08/24 documented a work order was submitted to repair the floor torn. It did not document a repair was completed. Resident #45 was admitted on [DATE] with diagnoses which included Parkinson's disease, dementia, and bipolar…

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 allegations of abuse were reported to OSDH for seven (#1, #3, #4, #7, #9, #10, and #11) of 11 residents reviewed for allegations of abuse reported to the OSDH. The facility census was 115. Findings: An Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 06/23/17, read in parts, .comply with federal and state regulations .timely investigation of and reporting to state and local agencies .Upon receiving an allegation .report such allegation to the State Regulatory Agency, Adult Protective Services .Local law enforcement .not later than 2 hours after the allegation is made, if the events .involve abuse . 1. Resident #1 had diagnosis to include pleural effusion, ascities, and anxiety. A Progress Note, dated 12/26/23 at 6:43 a.m., read in part, .could hear resident shouting at a male and female CNA, 'Don't touch me! Go get the nurse, if you touch me I'm going to call 911' . An Incident Report was not completed or reported to OSDH or other required agencies. A Progress Note, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to fully investigate allegations of abuse for nine (#1, #2, #3, #4, #7, #9, #10, and #11) of eleven sampled residents reviewed for abuse. The facility census was 115. Findings: An Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 06/23/17, read in parts, .comply with federal and state regulations .timely investigation .Upon receiving an allegation .immediately begin an investigation . 1. Resident #1 had diagnosis to include pleural effusion, ascities, and anxiety. A Progress Note, dated 12/26/23 at 6:43 a.m., read in part, .could hear resident shouting at a male and female CNA, 'Don't touch me! Go get the nurse, if you touch me I'm going to call 911' . The records contained no documentation an investigation was not initiated. A Progress Note, dated 01/04/24 at 12:19 p.m., read in part, . Called nonemergency police dept. [sic] to come .resident wanting to make a report .states that during care CNA leaned on her…

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: a. remove discontinued medications from current medication supply for three (#5, 6, and #7), and b. use corresponding blister cards and controlled drug sheets when dispensing controlled medications for two (#8 and #9) of five sampled residents reviewed for medication administration. The Administrator identified 112 residents resided in the facility. Findings: A Disposal of Medications policy, read in parts, .Discontinued medications and/or medications left in the nursing care center after a resident's discharge .are identified and removed from current medication supply in a timely manner . On 01/26/24 at 10:00 a.m., the following observations were made on Hall 400 medication cart: 1. Blister card for Resident #6 containing Zolpidem 5mg 6 tabs remaining- order discontinued 10/09/23. On 01/26/24 at 10:15 a.m., the following observations were made on Hall 500 medication cart: 1. Blister card for Resident #7 containing Clonazepam 1mg 81 tabs remaining- order discontinued 01/16/24. On 01/26/24 at 11:00 a.m., 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, observation, and interview, the facility failed to ensure residents were safe to self-administer medication for two (#10 and #11) of two sampled residents reviewed for self-administering medications. The Administrator identified 112 residents resided in the facility. Findings: A Self-Administration by Resident policy, dated 11/2017, read in parts, .Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe .The decision that a resident has the ability to self-administer medication is subject to periodic assessment by the IDT . 1. Resident #10 was cognitively intact and had diagnoses that included type 2 diabetes. A physician order, dated 03/23/23, documented Resident #10 was to receive insulin detemir 14 units subcutaneously every 12 hours and insulin lispro 8 units subcutaneously before meals. On 01/25/24 at 2:36 p.m., Resident #10 was observed in their room. An insulin pen labeled detemir 100u/ml and an insulin pen…

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 provide care consistent with professional standards of practice for the administration of intravenous fluids for one (#4) of one sampled resident reviewed for intravenous fluid administration. The Administrator identified 112 residents resided in the facility. Findings: An Administration of IV Fluids and Medications policy, dated 08/2021, read in parts, .The nurse should monitor the patient for therapeutic response .Monitoring of patients should be ongoing .After spiking the bag of solution/medication, it must be infused or discarded within 24 hours . Resident #4 had diagnoses that included metabolic encephalopathy. A Physician's Order, dated 11/13/23 at 3:02 p.m., documented to administer normal saline 0.9% Inj 1 liter intravenously one time only infuse at 70ml/hr. A pharmacy packing slip documented a 1000 ml bag of Sod Chloride Inj 0.9% was received by the facility on 11/13/23. A Nurses Note, dated 11/13/2023 at 7:31 p.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure resident's family was notified of a room change for one (#50) of three sampled residents reviewed for notification of change. Resident Census and Conditions of Residents report, dated 06/01/23, documented 109 residents resided in the facility. Findings: A Resident Room Transfer policy, dated 01/12/20, read in parts, .Prior to the room transfer, the resident .and the resident's responsible party will be provided with information concerning the decision to make the room transfer .Documentation of a room transfer is recorded in the resident's medical record . Resident #50 had diagnoses which included dementia. On 06/05/23 at 8:17 a.m., Resident #50 was observed in room [ROOM NUMBER] next to the window. On 06/05/23 at 8:33 a.m., Resident #50's family member was asked if the facility notified them regarding changes in the resident's care. They stated the resident moved rooms in April, and they were not notified. There was no…

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 NOMNC and ABN was provided for a facility initiated discharge from Medicare Part A services with days remaining for one (#1) of three sampled residents reviewed for beneficiary notices. The Entrance Conference Worksheet, undated, documented 33 residents discharged from Medication Part A services with days remaining in the last six months. Findings: A SNF Beneficiary Protection Notification Review report, documented Resident #1 started Medicare Part A skilled services on 12/16/22 and the last covered day was 01/05/23. It documented the facility/provider initiated the Medicare Part A discharge. It documented a SNF ABN had not been provided to the resident, and there wasn't an answer documented if a NOMNC had been provided. On 06/05/23 at 2:44 p.m., MDS #1 stated they couldn't locate a SNF ABN or NOMNC had been provided to Resident #1.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised for one (#27) of 22 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 06/01/23, documented 109 residents resided in the facility. Findings: A facility policy titled, Care Plan Process, revised on 02/12/20, read in parts, .Interdisciplinary Team meets and reviews the care plan as follows .Quarterly and annually . Resident #27 had diagnoses which included malignant neoplasm of bladder, cardiac arrhythmia, and type 2 diabetes mellitus. A physician's order, dated 04/04/22, documented the resident was a full code. Resident #27's care plan conference/discharge planning, dated 01/09/23, documented the resident was a full code. Resident #27's care plan, dated 01/20/23, documented the resident was a full code. The care plan documented the following interventions: a. assure advanced directives were discussed and appropriate paperwork was obtained, and b. the facility staff will discuss and confirm the resident's advanced directives…

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 bathing was provided as scheduled for one (#96) of seven sampled residents reviewed for ADL care. The Resident Census and Conditions of Residents report, dated 06/01/23, documented 97 residents required assistance for bathing. Findings: A facility policy titled, Bathing (Not Partial or Completed Bed Bath), revision date 01/20/23, read in parts, .Staff will provide bathing services for residents within standard practice guidelines .Document bath in EHR .document the refusal in the record . Resident #96 had diagnoses which included weakness, repeated falls, and seizures. Resident #96's admission Assessment, dated 05/17/23, documented the Resident's cognition was moderately impaired. It documented Resident #96 required one person physical assistance with bathing. A bathing list provided to the CNAs, documented Resident #96 was scheduled for bathing on Mondays and Thursdays. Resident #96's CNA task charting, dated 05/15/23 through 06/05/23, documented the resident had not received a bath, six out of six…

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 obtain wound measurements to fully assess pressure wounds for healing or worsening for one (#102) of two sampled residents reviewed for pressure ulcers. The Resident's Census and Conditions of Residents report, dated 06/01/23, documented seven residents with pressure ulcers and the census was 109. Findings: Resident #102 admitted with diagnoses to include unspecified skin changes, moderate protein-calorie malnutrition, a history of a pressure ulcer of the sacral region - stage 3, and pain. A Skin Data form, dated 04/19/23, documented Resident #102 had discoloration with scabs on bilateral heels. It did not document the size of the scabs. A Skin Breakdown care plan, dated 04/19/23, read in parts, .Heel discoloration .Inspect skin complete body head to toe every week and document results . An admission Assessment, dated 04/27/23, documented Resident #102 had moderate cognitive impairment, required assistance of one staff for bed mobility, transfers, locomotion, dressing, toilet use, and hygiene; was at risk for…

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

Based on observation, record review and interview, the facility failed to ensure safe medication administration practices were followed for two (#78 and #88) of six sampled residents observed during medication administration. The Resident Census and Conditions of Residents report, dated 06/01/23, documented 109 residents resided in the facility. Findings: A facility policy titled, Medication Administration General Guidelines, dated 01/2023, read in part, .Medications are to be administered at the time they are prepared . 1. Resident #78 had diagnoses which included gastro-esophageal reflux disease without esophagitis. Physician's order, dated 03/07/22, documented famotidine 20 mg give one tablet by mouth one time per day. 2. Resident #88 had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms, and vitamin deficiency. Physician's orders, dated 03/09/23, documented a one daily multivitamin give two tablets by mouth one time per day. Physician's orders, dated 03/09/23, documented finasteride 5 mg give one tablet by mouth one time per day. Physician'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.

Based on observation, record review, and interview, the facility failed to ensure soiled linen were not placed on the floor to prevent the spread of infection for one (#10) of three sampled residents observed for linen handling. The Resident Census and Condition of Residents report, dated 06/01/23, documented 109 residents resided in the facility. Findings: An Infection Control policy, revised August 2018, read in part, .Soiled Laundry is .not to be placed on the floor, chairs, counters, or other surfaces . On 06/06/23 at 9:10 a.m., bed linen were observed on the floor near the bathroom door and doorway to the hallway in Resident #10's room. There was a strong smell of urine coming from the room. The linen were loose and not in a bag. On 06/06/23 at 9:15 a.m., LPN #2 was asked how soiled linen should be handled. LPN #2 stated it should be bagged and placed in a designated barrel. LPN #2 was asked if soiled linen should be placed on the floor. LPN #2 stated, No. On 06/06/23 at 10:03 a.m., the IP was asked what were the policies for handling soiled linen. The IP stated they were…

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.