Corvallis Manor Nursing & Rehabilitation Center

Based on observation, interview and record review the facility failed to provide immediate monitoring and documentation of the status of a resident's access site upon return from dialysis treatment for 1 of 1 sampled resident (#6) reviewed for dialysis. This placed residents at risk for delayed treatment and dialysis complications. Findings include: A review of the facility revised 3/2023 Quality of Care- Dialysis Policy revealed the following:-The facility will assess the resident's condition and monitor for complications before and after dialysis treatments received at a certified dialysis facility.-Facility staff will monitor and document the status of the resident's access site upon return from the dialysis treatment center to observe for bleeding or other complications.Resident 6 was admitted to the facility in 5/2025 with diagnoses including end-stage renal disease and dependence on dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly).The 1/12/26 dialysis care plan revealed Resident 6 went to dialysis treatment…

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, it was determined the facility failed to ensure adequate monitoring and indications for use of blood pressure medication for 1 of 5 sampled residents (#84) reviewed for unnecessary medications. This placed residents at risk for receiving blood pressure medications without adequate monitoring and indications for use. Findings include:Resident 84 was admitted to the facility in 12/2024 with diagnoses including stroke and hypertension (high blood pressure). Physician Orders revealed a 9/9/25 order for lisinopril 10 MG oral tablet given one time per day for hypertension. The order indicated to hold the medication if the systolic blood pressure (the top number in a blood pressure reading) was less than 120. The 3/2026 and 4/2026 MARs revealed Resident 84 received lisinopril five times in March and seven times in April with a systolic blood pressure reading under 120. All administrations were given by Staff 5 (Certified Medication Aide).A review of the resident's clinical record revealed no rationale for giving the lisinopril outside of the ordered…

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 it was determined the facility failed to provide cut up foods for 1 of 4 sampled residents (# 84) reviewed for food. This placed residents at risk for unmet individualized food needs. Findings include:Resident 84 was admitted to the facility in 12/2024 with diagnoses including stroke and chronic pain. The 6/13/25 revised Care Plan revealed Resident 84 was dependent on staff for meeting physical needs due to physical limitations.The 11/17/25 revised Care Plan revealed Resident 84 had an ADL self-care performance deficit due to residual right-side weakness from a history of stroke.The 12/26/25 Annual MDS indicated Resident 84 had upper and lower impaired range of motion on one side and required set-up assistance for eating.The 12/30/25 revised Care Plan indicated Resident 84 required assistance with set up for eating. A 4/22/26 Quarterly Care Conference note indicated Witness 4 (Family Member) expressed the need for Resident 84's food to be cut up due to her/his inability to cut her/his own food. Resident 84's Kardex indicated staff…

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

Based on interview and record review, it was determined the facility failed to investigate an unwitnessed fall and misappropriation of property for 2 of 13 sampled residents (#s 11 and 14) reviewed for falls and misappropriation. This placed residents at risk for stolen property and neglect. Findings include:1. Resident 11 was admitted to the facility in 6/2025 with diagnoses including muscle weakness and unsteadiness on feet. On 10/1/25, the State Agency received a public complaint alleging that Resident 11 slept in her/his wheelchair and staff did not transfer her/him to bed. The complaint further alleged that Resident 11 slipped out of the wheelchair onto the floor. A review of the facility's 10/1/25 Unwitnessed Fall investigation indicated that at 12:20 AM, staff found Resident 11 seated on the floor with the electric wheelchair positioned behind the resident. The investigation lacked witness statements, root cause analysis and documentation confirming whether the facility ruled out abuse or neglect. On 2/9/26 at 8:48 AM, Staff 24 (RN) stated she typically completed…

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 it was determined the facility failed to provide pain medications as ordered for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for unmanaged pain. Findings include:Resident 1 was admitted to the facility in 7/2025 with diagnoses including right hip pain and fractured thigh bone.The 7/30/25 hospital Discharge Orders directed staff to administer one tablet of hydrocodone-acetaminophen (narcotic pain medication) every eight hours as needed for pain for up to five days to Resident 1.The 8/4/25 admission MDS indicated Resident 1 received scheduled and as needed pain medication and was at risk for unrelieved pain. An 8/9/25 physician order revealed a renewed prescription for Resident 1's narcotic pain medication. An 8/14/25 provider communication revealed the facility requested a refill of Resident 1's narcotic pain medication. The 8/2025 MAR revealed Resident 1 was to receive her/his scheduled narcotic pain medication at 8:00 AM and 5:00 PM. -On 8/14/25 at 8:00 AM, the dose was NA (not available).-From 5:00 PM…

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 it was determined the facility failed to ensure sufficient nursing staff were available to meet the needs of residents in a timely manner for 2 of 3 sampled residents (#s 11 and 12) reviewed for staffing. This placed residents at risk for delayed care. Findings include: 1. Resident 11 was admitted to the facility in 10/2025 with diagnoses including stroke and dementia. The 10/2025 TAR revealed Resident 11 was to receive polyethylene glycol (laxative medication) as needed for constipation. A 10/22/25 revised care plan directed staff to check with Resident 11 frequently to ensure her/his needs were met. On 10/29/25 at 2:42 PM, Resident 11's call light was on. Witness 2 (Family Member) stated Resident 11 had been waiting since 2:25 PM for assistance and experienced discomfort during a recent bowel movement. On 10/29/25 at 2:48 PM, Staff 9 (Agency CNA) entered Resident 11's room and turned off the resident's call light. Staff 9 was observed talking to other CNAs in the hallway. On 10/29/25 at 2:50 PM and 5:06 PM, Staff 9 stated Resident…

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

Based on observation, interview, and record review it was determined the facility failed to ensure a dependent resident received ADL assistance for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for unmet needs and dignity. Findings include: Resident 1 was admitted to the facility in 8/2025 with diagnoses including stroke and language deficits. The 8/7/25 admission MDS revealed Resident 1 had a BIMS assessment score of 15 (cognitively intact), was dependent on two staff for toileting assistance, and required an interpreter for communication. A 9/29/25 Grievance Report filed on behalf of Resident 1 revealed the resident was left on the commode for 30 minutes and requested staff to not leave her/him on the commode. A 9/30/25 revised care plan indicated Resident 1 preferred to have staff stay with her/him while the resident was on the commode. A 10/2/25 Grievance Report indicated Resident 1 filed a complaint related to long call lights that occurred around 1:30 PM on 10/2/25 when the resident requested commode assistance. Resident 1 indicated she/he…

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 it was determined the facility failed to ensure physician orders for eye treatments were followed for 1 of 3 sampled residents (#4) reviewed for physician orders. This placed residents at risk for eye pain and complications. Findings include:Resident 4 was admitted to the facility in 6/2025 with diagnoses including complex regional pain syndrome and anxiety.The 7/2/25 Orders at Discharge directed staff to apply one drop of Optase (Glycerin) Comfort Dry Eye Solution to Resident 4's eye twice daily. The 7/2025 MAR indicated the following:-7/2/25 through 7/10/25 Optase was unavailable or on order.A 7/7/25 OT Treatment Encounter Notes revealed Resident 4 wanted her/his eye drops which added to her/his anxiety.A 7/7/25 EpicCare Link to the facility provider identified a request to use house stock Systane to replace Resident 4's order for Optase. On 7/7/25 Resident 4's physician agreed with the request.-A 7/8/25 order for Systane Solution (dry eye drops). -Systane Solution (dry eye drops) were administered on 7/9/25.On 10/8/25 at 2:24 PM, Staff 8 (CMA)…

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 it was determined the facility failed to follow a resident's care plan to prevent falls for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for injuries from falls. Findings include:Resident 1 was admitted to the facility in 8/2025 with diagnoses including stroke and language deficits. The 8/2/25 care plan indicated Resident 1 was at risk for falls and staff were to place the resident's call light within reach.The 8/7/25 admission MDS revealed Resident 1 had a BIMS assessment score of 15 (cognitively intact), was dependent on two staff for toileting assistance, and required an interpreter to communicate. A 9/26/25 Unwitnessed Fall investigation for Resident 1 was incomplete with no information related to the cause of the fall or a conclusion to the investigation.A 9/27/25 Nursing Post Fall Risk Evaluation indicated Resident 1 stated she/he fell from the commode on 9/26/25 because her/his call light was not within reach. The fall resulted in throbbing pain to Resident 1's left ankle.A 9/29/25 Grievance Report…

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 it was determined the facility failed to report injuries of unknown origin for 1 of 5 sampled residents (#10) reviewed for abuse reporting. This placed residents at risk for abuse and neglect. Findings include: Resident 10 was admitted to the facility in 2022, with diagnoses including dementia and weakness. Resident 10's 4/9/25 Care Plan revealed the resident was a two-person assist with turning and repositioning and the resident's call light was to be on the right side of the resident, clipped to blankets. A Progress Note dated 3/22/25 indicated Staff 17 (CNA) reported Resident 10 had bruising and discoloration on her/his leg (on the shin) and swelling around the left arm not observed the previous day. The Progress Note revealed Resident 10 was observed to have swelling around the left hand, pain at the shoulder, skin discoloration around the right leg not observed the previous day. An Injury of Known Cause form dated 3/22/25 revealed an investigation was initiated by Staff 16 and the DNS was notified. On 4/10/25 at 10:26 AM, Staff 10 (RN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 14 was admitted to the facility in 2/2025 with a diagnosis of diabetes. Per epocrates (online pharmacy resource) revealed insulin aspart (hormone to decrease blood sugars) was a fast acting insulin that started to work in about 15 minutes after injection, peaked in about one hour, and kept working for two to four hours. Instructions included you should eat a meal within 5 to 10 minutes. A 2/17/25 admission MDS revealed Resident 14 was cognitively intact. A 3/2025 Diabetic Administration Record (DAR) revealed on 3/13/25 Resident 14 received aspart at 12:00 PM. On 3/13/25 at 1:43 PM Resident 14 stated she/he just ate lunch at 1:20 PM. Resident 14 stated she/he did not have any symptoms of low blood sugars. On 3/14/25 at 8:48 AM Staff 8 (LPN) stated ideally residents should not receive fast acting insulin more than 30 minutes before they ate or they should be provided a snack at the time of the injection. Staff 8 stated on 3/14/25 she administered Resident 14 her/his insulin and lunch ended up being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure food temperatures were maintained for meals served from 1 of 1 facility kitchen and 2 of 4 sampled residents (#s 56 and 61) reviewed for food. This placed residents at risk for food that was not palatable, safe, or appetizing. Findings include: 1. The 12/12/24 Dining Committee Minutes indicated meat quality was a concern for residents and Staff 32 (Dietary Manager) was working to improve results. On 3/13/25 at 1:21 PM the lunch meal service was observed in process and Staff 32 acknowledged the lunch was delayed. Staff 32 indicated the oven temperature to cook the pizza was not maintained, so the process took longer. On 3/13/25 at 1:32 PM a test tray requested by the survey team was completed and placed in an insulated cart. On 3/13/25 at 1:34 PM multiple undelivered lunch trays for resident rooms were observed in Hall 300, stacked on top of the insulated cart. Staff indicated there was insufficient space in the…

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

Based on observation, interview and record review the facility failed to assess a resident for safe self-administration of medication for 1 of 1 sampled resident (#50) reviewed for anticoagulant medications. This placed resident at risk for adverse side affects. Findings include: Resident 50 was admitted to the facility in 12/2023 with diagnoses including somatization disorder (a form of mental illness that caused one or more bodily symptoms, including pain. They cause excessive and disproportionate levels of distress) and PTSD. A 1/27/25 Self-Administration of Medication indicated Resident 50 offered her/his medications to others. Staff determined the resident was not a candidate for self-administration. A 1/27/25 Nursing Note indicated Staff 2 (DNS) informed Resident 50 regarding her/his cogitative testing results which indicated she/he had cognitive impairment which suggested it was unsafe for her/him to self-administer medications without supervision. A 2/6/25 Risk Versus Benefit indicated Resident 50 was allowed access to one over the counter medication daily from 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 interview and record review it was determined the facility failed to provide a clean environment as well as functioning phones and lights for 2 of 6 sampled residents (#s 33 and 174) reviewed for environment. This placed residents at risk for an unclean, unsafe, and unhomelike environment. Findings include: 1. Resident 33 was admitted to the facility in 12/2024 with a diagnosis of heart disease. A care plan initiated 1/24/25 indicated Resident 33's goal was to discharge to an Assisted Living Facility. On 3/10/25 at 11:07 AM a white portable fan was observed on top of Resident 33's night stand. The fan blades were coated with a brown layer of dust. On 3/14/25 at 3:05 PM Staff 28 (Maintenance Director) acknowledged the fan blades were dusty and was not sure who cleaned the blades. On 3/17/25 at 9:15 AM Staff 11 (Housekeeping Manager) stated the outside of the fans were cleaned with daily dusting and and the blades were cleaned when residents moved out of a room. 2. Resident 174 was admitted in 12/2024 with diagnoses including diabetes and a surgical site infection. 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 interview and record review it was determined the facility failed to ensure grievances were acted upon timely for 1 of 5 sampled residents (#14) reviewed for dignity and missing property. This placed residents at risk for unresolved needs. Findings include: An undated facility Grievance Process Guide indicated all staff may complete grievances on behalf of residents and to provide a paper copy to residents who declined to file grievances online. Resident 14 was admitted to the facility in 2/2025 with diagnoses including fractures of the spine and pelvis. A 2/17/25 admission MDS indicated Resident 14 was cognitively intact. Facility Grievances from 2/2025 through 3/10/25 were reviewed, but no grievance form for Resident 14 was found. On 3/10/25 at 11:23 AM and 3/12/25 at 4:08 PM Resident 14 indicated her/his red cell phone was missing. Resident 14 stated staff were aware her/his phone was missing and no staff offered assistance to file a grievance. Resident 14 stated she/he purchased a new blue cell phone to replace the missing one; however, no follow-up was conducted…

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 it was determined the facility failed to incorporate PASARR (Preadmission Screening and Resident Review) Level II recommendations for 1 of 1 sampled resident (# 50) reviewed for PASARR coordination of care. This placed residents who have a mental health disorder at risk for delayed care and services to attain their highest practicable level of well-being. Findings include: Resident 50 was admitted to the facility in 12/2023 with diagnoses including anxiety and post-traumatic stress disorder (PTSD). A 1/25/25 PASARR Level II Mental Health Evaluation was conducted for Resident 50. The assessment included the following non-pharmacological recommendations: Resident 50 expressed interest in having a recliner-style chair placed in her/his room, stating that they spent most hours of the day and night in a wheelchair and experienced significant discomfort. On 3/10/25 at 4:00 PM Resident 50 reported prior to admission, she/he slept in a recliner chair. The resident stated several months earlier, psychological evaluation had been conducted,…

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 it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 4 sampled residents (#s 61 and 124) reviewed for ADLs. This placed residents at risk for lack of personal hygiene and skin injuries. Findings include: 1. Resident 61 was admitted to the facility in 12/2024 with diagnoses including stroke and muscle weakness. A 12/30/24 admission MDS indicated Resident 61's BIMs score was 13, signifying cognitive intactness. Resident 61 required substantial to maximal assistance with personal hygiene. A revised care plan dated 1/26/25 indicated Resident 61 required a high level of caregiver support to have needs met. Resident 61 required extensive assistance from one staff member to provide bathing and limited assistance with personal hygiene. On 3/10/25 at 12:02 PM, Resident 61 was in her/his room and was observed to have facial hair on her/his chin and upper lip, approximately an inch long. Resident 61 stated she/he would like to have the facial hair removed on their shower days. 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 interview and record review it was determined the facility failed to follow physician orders for treatment of a resident's pressure ulcer for 1 of 5 sampled residents (#20) reviewed for medications. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 20 was admitted to the facility in 1/2025 with diagnoses including chronic pain and a Stage 3 pressure ulcer (full-thickness skin loss). The 2/4/25 admission MDS indicated Resident had frequent pain and a Stage 3 pressure ulcer on admission. The 3/10/25 revised care plan indicated staff were to observe Resident 20's wound dressing every shift. A wound dressing change and documented observation of the wound was to occur three days per week. The 3/2025 TAR revealed a 3/13/25 revised order for wound care to Resident 20's sacrum which was to occur three times per week on Tuesday, Thursday and Saturdays. Staff were to first cleanse and prep the wound. A black foam was to cover the wound before the wound vac (medical devise to promote wound healing) was attached. On 3/16/25 a 9 (to see progress…

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 it was determined the facility failed to provide appropriate foot care for 1 of 2 sampled residents (#s 22) reviewed for skin. This placed residents at risk for infections. Findings include: Resident 22 was admitted to the facility in 10/2024 with diagnoses of diabetes and vascular dementia. A 10/24/24 admission MDS indicated Resident 22's BIMS was 10, signifying moderate cognitive impact. A 2/25/25 Alert Note revealed Resident 22's left big toe appeared red and swollen, with no drainage noted. The affected area was cleansed. Resident 22 denied pain but reported tenderness upon touch. No open wound or ulceration was observed. The physician was notified and awaiting further recommendations. A 2/25/25 Order Request Response indicated Resident 22 had redness and swelling of the left big toenail with no visible drainage. The physician response recommended continued monitoring and supportive care. Resident 22 was placed on physician's schedule to be evaluated on 2/28/25. No documentation was found in the clinical record for monitoring or evaluation…

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 it was determined the facility failed to ensure resident water temperatures were safe for 3 of 6 sampled residents (#s 2, 10, and 17) and 1 of 1 therapy gym reviewed for water temperatures. This placed residents at risk for burns. Finding include: 1. Resident 2 was admitted to the facility in 8/2024 with a diagnosis of heart disease. A care plan initiated 6/2022 revealed Resident 2 was incontinent and required the assistance of two staff and a mechanical device for transfers. On 3/12/25 at 11:16 AM Staff 42 (Maintenance) stated water temperatures were checked weekly. On 3/14/25 at 3:33 PM Staff 30 (CNA) stated Residents did not report concerns with hot water. On 3/14/24 at 3:09 PM with Staff 28 (Maintenance Director) Resident 2's bathroom water was observed to be 122 degrees F and the boiler was set at 114 degrees F. Staff 28 was not sure the reason the water was so hot with the boiler set at 114 degrees F. On 3/17/24 at 3:00 PM Staff 1 (Administrator), Staff 2 (DNS) Staff 24 (Regional Director of Care) were present for an…

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

Based on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-catheterize (sterile tube inserted into the bladder through the urethra [tube that goes from the bladder to the outside of the body] to drain the urine) for 1 of 1 sampled resident (#25) reviewed for UTI. This placed residents at risk for recurrent UTIs. Findings include: Resident 25 was admitted to the facility in 9/2024 with a diagnosis of incomplete quadriplegia (partial damage to the spinal cord resulting in varying degrees of weakness, paralysis, and loss of sensation in the legs and arms). A care plan initiated 1/20/22, from a former facility Resident 25 previously resided, revealed she/he had an ADL self care deficit due to quadriplegia, limited ROM, and weakness. Interventions included staff were to assist Resident 25 with hand washing. A 9/23/24 admission MDS revealed Resident 25 had impaired ROM, strength, and muscle coordination. Resident 25 was assessed to have more ability to use her/his arms and was able to straight catheterize her/himself…

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 it was determined the facility failed to ensure accurate communication occurred between the facility and the dialysis provider and daily weight were obtained per physician orders for 1 of 1 sample resident's (#224) reviewed for dialysis. This placed residents at risk for potential complications and dialysis care and treatment. Findings include: Resident 224 admitted to the facility on [DATE] with diagnoses including heart failure and ESRD (end stage kidney disease). a. The 2/26/25 admission MDS indicated Resident 224 was cognitively intact and had an active diagnosis of ESRD and received hemodialysis (treatment used to filter waste, excess fluids, and toxins from the blood when the kidneys are no longer able). A 3/3/25 physician order instructed staff to complete the Pre-Dialysis Assessment and Communication form and Post-Dialysis Assessment and Communication form. Staff were to ensure the form was sent to the dialysis center with the resident in the morning every Monday,…

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 it was determined the facility failed to ensure a resident who was a history of trauma received trauma-informed care for 1 of 1 sampled resident (#22) reviewed for mood and behavior These placed residents at risk for unmet trauma needs and a decrease in their quality of life. Findings include: Resident 22 was admitted to the facility in 10/2024 with diagnoses of psychotic disturbance, mood disturbance and vascular dementia. A 10/24/24 admission MDS and CAAs indicated Resident 22's BIMs was 10, signifying moderate cognitive impact. No behaviors were exhibited, and Resident 22 reported feeling down and depressed. A revised 11/4/24 care plan documented Resident 22 was cognitively impaired with altered thought process due to dementia and short-term memory loss. Interventions included addressing Resident 22 by name, facing Resident 22 when speaking, and make eye contact. The care plan did not address trauma. A 11/7/24 Social Services note revealed Resident 22 was suspected of experiencing financial, sexual, verbal, emotional and physical…

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 it was determined the facility failed to ensure a resident's use of bed rails was assessed for 1 of 1 sampled resident (#124) reviewed for side rails. Findings include: Resident 124 was admitted to the facility in 3/2025 with a diagnosis of cancer. A 3/5/25 nursing Admission/readmission Evaluation form revealed Resident 124 was admitted on hospice services, was cognitively intact, and required extensive assistance for bed mobility. On 3/10/25 at 12:16 PM Resident 124's bed was observed to have bilateral half rails. Resident 124 stated she/he did not use the rails to turn. Resident 124's clinical record did not have an assessment of the use of bed rails to ensure the rails did not place her/him at risk for entrapment. On 3/12/25 at 10:11 AM Staff 13 (CMA) stated Resident 124 did not turn on her/his own and did not have uncontrolled movements while in bed. On 3/12/25 11:01 AM at 3/12/25 Staff 1 (DNS) and Staff 19 (LPN Unit Manager) were present for an interview. Staff 1 stated prior to implementing bed rails staff were to do an…

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

Based on interview and record review it was determined the facility failed to ensure recommended mental health services were provided for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for unmet needs. Findings include: Resident 18 readmitted to the facility in 7/2021 with diagnoses including post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress, flashback and avoidance of similar situations), agoraphobia (a type of anxiety disorder characterized by fear of places or situations where a person might feel panicked, helpless, or trapped) and bipolar disorder (a mental health condition characterized by significant mood swings). Notes in the resident's 2/20/2025 Significant Change MDS assessment Cognitive loss/Dementia CAA described the resident as not liking to leave her/his room, yelling at staff and refusing care. A review of Physician Progress Note from 12/30/24 revealed the resident exhibited continued depressive…

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 it was determined the facility failed to provide timely pharmaceutical services for 1 of 1 sampled resident (#174) reviewed for insulin. This placed residents at risk for elevated blood sugars. Findings include: Resident 174 was admitted on [DATE] with diagnoses including diabetes and a surgical site infection. The 12/17/24 hospital Orders at Discharge revealed insulin orders for Resident 174 which were to be administered three times daily with meals. The 12/2024 Diabetic Administration Record for Resident 174 indicated a 9 (see progress notes) on 12/17/24 at noon and no meal time insulin was administered until 5:00 PM. A 12/17/24 at 12:14 PM Nursing Note indicated the facility's pharmacy received the request for Resident 174's prescriptions. On 12/26/24 a public complaint was received which indicated Resident 174 was admitted to the facility on [DATE] at 11:00 AM and did not receive her/his lunch time insulin as ordered. On 3/14/25 at 8:59 AM Staff 8 (LPN) stated there 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 interview and record review it was determined the facility failed to provide appropriate monitoring and dosing of medications for 3 of 5 sampled residents (#s 10, 18, and 20) reviewed for medications. This placed residents at risk for an adverse medication regimen. Findings include: 1. Resident 10 was admitted to the facility in 5/2024 with a diagnosis of a mental health disorder. A [DATE] Note to Attending Physician/Prescriber revealed a recommendation to decease Resident 10's divalproex (treats seizures and bipolar) from 500 mg two times a day to 250 mg in the morning and 500 mg at night. Resident 10's 12/2024 MAR and 1/2025 MAR revealed divalproex was not decreased per orders until [DATE]. On [DATE] at 11:20 AM Staff 45 (Physician) and Staff 2 (DNS) Staff 45 verified the facility did not implement the decreased dose as ordered for approximately a month. 2. Resident 18 admitted to the facility 5/2021 with diagnoses including Type II diabetes mellitus with neuropathy (a condition that occurs when 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 interview and record review it was determined the facility failed to complete a GDR (gradual dose reduction) and appropriately monitor a resident on psychotropic medications for 2 of 5 sampled residents (#s 10 and 20) reviewed for medications. This placed residents at risk for adverse medication regimen. Findings include: 1. Resident 10 was admitted to the facility in 5/2024 with a diagnosis of a mental health disorder. A 12/17/24 Consultant Pharmacist's Medication Regimen review form revealed Resident 10 was prescribed quetiapine (antipsychotic medication) 50 mg twice a day and a recommendation was made to decrease the dose. A 12/20/24 Pharmacist Communication Notice of Duplicate Therapy form revealed the resident was to be administered quetiapine 25 mg one and one half tablets in the morning and 50 mg daily. a physician verified this was intentional dosing. Review of the 12/2024 and 1/2025 MAR revealed quetiapine was not decreased as ordered until 1/23/25. On 3/14/25 at 11:20 AM with Staff 45 (Physician) and Staff 2 (DNS), Staff 45 verified after the order was clarified…

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 it was determined the facility failed to promptly notify the ordering physician of laboratory results for 1 of 1 sampled residents (#37) reviewed for antibiotics. This placed residents at risk for unmet needs. Findings include: Resident 37 admitted to the facility in 10/2024 with diagnosis including kidney failure. On 2/25/25 Labs were collected for a suspected UTI. A 2/27/25 at 4:51 PM Nursing Note indicated staff notified MD regarding Resident 37's urinalysis results. A 3/4/25 Nursing Note indicated staff notified the physician of the final culture. Staff indicated the resident was not on any antibiotic therapy and requested new orders. On 3/11/25 at 9:04 AM Staff 18 (LPN) 3/11/25 stated nursing was expected to follow up with the residents physician in a timely manor with lab results. Staff 18 confirmed resident 37 had a UTI, staff did not monitor the resident for complications and the doctor was not notified until six days later. On 3/14/25 at 12:46 PM Staff 21 (Infection Preventionist/LPN) stated staff should not wait six days 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 interview and record review it was determined the facility failed to ensure lab results were in the resident record for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for incomplete records. Findings include: 1. Resident 10 was admitted to the facility in 5/2024 with a diagnosis of a stroke. A 5/31/24 prescriber written Order Details revealed staff were to obtain blood samples from Resident 10 for testing including thyroid hormone levels. Resident 10's clinical record did not have results of the 5/31/24 thyroid hormone test results. A 2/15/25 Consultant Pharmacist's Medication Regimen Review revealed labs were sent to the lab on 6/4/24 but the results were not in the record. Please follow up. On 3/14/25 at 10:13 AM Staff 19 (LPN Unit Manager) stated the staff collected the blood and sent the blood to the lab but she was unsure the reason the labs were not in the resident's record. Staff 19 stated she was unable to provide the reason the facility did not follow up to ensure the results were in the resident's clinical record.

Based on observation, interview, and record review it was determined the facility failed to make reasonable efforts to deliver a menu based on resident requests and preferences for 2 of 2 residents (#s 7 and 61) during random observations. This placed residents at risk for unmet food preferences. Findings include: 1. Resident 7 was admitted to the facility in 2/2025 with diagnoses including anxiety and deficiency of specified B group vitamins. A 2/21/25 admission MDS indicated Resident 7's BIMs was 15, which indicated she/he was cognitively intact. A 2/21/25 care plan indicated Resident 7 had a nutritional problem due to increased physical demand for participation in therapy and protein-calorie malnutrition (a state of malnutrition in which there is a deficiency of calories and protein). Staff were to provide and serve diet as ordered, monitor intake, and record every meal. On 3/13/25, the following occurred: -1:17 PM, Staff 35 (Agency CNA) was observed writing on a paper at the kitchen door to request pizza for Resident 7 per her/his request. -1:41 PM, the facility intercom system…

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 it was determined the facility failed to follow infection control standards for contact and Enhanced Barrier Precautions for 3 of 7 sampled residents (#s 7, 20, and 274) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Finding include: 1. Resident 7 was admitted to the facility in 2/2025 with diagnoses including sepsis (a life-threatening condition caused by the body ' s overwhelming response to an infection) and a Foley catheter (a flexible tube inserted into the bladder to drain urine). A 2/19/25 physician order instructed staff to provide enhanced barrier precautions because of sepsis and Foley catheter. The 2/21/25 admission MDS revealed Resident 7's BIMs 15, which indicated the resident was cognitively intact. Resident 7 was dependent on staff for toileting hygiene, and had a urinary catheter. A 3/3/25 care plan indicated Resident 7 was on enhanced barrier precautions related to a Foley catheter. Staff were to follow guidelines posted next to the door. On 3/12/25…

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 it was determined the facility failed to provide antibiotic stewardship for 1 of 1 sampled resident (#25) reviewed for UTIs. This placed residents at risk for drug resistant organisms. Findings include: Resident 25 was admitted to the facility in 9/2024 with a diagnosis of incomplete quadriplegia (partial damage to the spinal cord resulting in varying degrees of weakness, paralysis, and loss of sensation in the legs and arms). A 9/23/24 admission MDS revealed Resident 25 had incomplete quadriplegia and self-catheterized (sterile tube inserted into the bladder through the urethra [tube that goes fro the bladder to the outside of the body] after staff set up the supplies. Resident 25 had a history of UTIs and was on trimethoprim (antibiotic) for prophylaxis (antibiotics taken daily to prevent infection in high risk residents). a. A 11/1/24 UA culture (test to determine which antibiotics eliminate the organism identified to have caused the UTI) result revealed Resident 25 had a UTI and the organism was resistant to trimethoprim. A 11/4/24 order…

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 it was determined the facility failed to maintain essential kitchen equipment for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk for food borne illnesses. Findings include: The 1/2023 Dietary Services Dishwashing using a Dish Machine instructions indicated a low temperature dish machine wash cycle was to remain at 120 to 140 degrees F with chemical sanitizer levels according to manufacturer's directions. A 11/14/2024 Sanitation Audit Report indicated Staff 3 (RD) provided low temperature dish washer education to dietary staff. The 12/2024 and 1/2025 Dish Machine Logs indicated the facility's low temperature dish machine wash cycle temperatures reached 120 degrees F on 12/13/24 and 12/14/24 through 1/7/25. A 12/19/24 Work Order was submitted by Staff 4 (Dietary Manager) and indicated the water in the kitchen was not hot enough and the priority was high. On 12/27/24 Staff 5 (Regional Director of Maintenance) updated the status to set to completed. On 1/3/25 at 9:25 AM Staff 4 acknowledged the water…

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 it was determined the facility failed to provide modified textured diets as ordered for 2 of 3 sampled residents (#s 1 and 2 ) reviewed for food. This placed residents at risk for medical complications and aspiration. Findings include: 1. Resident 1 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease and mood disturbance. A 10/4/24 Annual MDS indicated Resident 1 required a pureed (smooth textured) diet due to swallowing issues related to her/his Alzheimer's disease. A 10/22/24 care plan indicated staff were to assist Resident 1 with eating. A 1/2/25 public complaint indicated Resident 1's pureed food was observed with a chunk of meat. On 1/3/25 at 1:58 PM Staff 12 (Cook) stated he was aware Resident 1's food on 12/29/24 was not pureed completely. On 1/3/25 at 2:40 PM Staff 10 (CMA) stated on 12/29/24 she assisted Resident 1 with her/his evening meal and found a large piece of meat in her/his pureed food. Staff 10 stated she reported the concern to Staff 4 (Dietary Manager) and did not give Resident 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, interview and record review it was determined the facility failed to ensure sufficient nursing staff to maintain the highest practicable physical and psychosocial well-being for 3 of 3 Resident Halls reviewed for staffing. This placed residents at risk for unmet care needs and psychosocial harm. Findings include: An observation on 11/6/24 at 9:22 AM revealed Resident 7's call light on, the resident's door was open, and her/his bed linen was off which revealed the resident was wearing a soiled brief, leaking of the resident's bowel movement. The resident was visually anxious and distraught, called the surveyor into the room, stated she/he need immediate help because staff had not answered her/his call light and the brief was leaking all over my bed. This surveyor exited the room and immediately informed a staff member standing next to a medication cart across the hall from the resident's room. The staff member stated she was behind and could not assist the resident but would ask a CNA as soon as I see one. Four additional resident call lights were observed to 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 observation, interview and record review it was determined meals were not served at the proper temperature for 1 of 1 kitchens reviewed for meal service. This placed residents at risk for food not being served at the appropriate temperature. Findings include: The Food and Drug Administration instructed eggs to be served at 135 degrees F or above and milk at 40 degrees F or below. The August 2024 and September 2024 Resident Council Notes revealed residents' concerns of late meal service and cold food. On 11/6/24 at 8:33 AM, a breakfast test tray was completed with Staff 1 (Administrator) and Staff 17 (Dietary Manager). The meal consisted of a biscuit with gravy, hash browns, scrambled eggs and a cup of milk. All the food was cold when tasted. Staff 17 checked the temperature of the eggs to be 91 degrees F and the milk to be 45 degrees F. Staff 1 and Staff 17 verified the food was served cold. On 11/5/24 at 9:59 AM, Witness 1 (Complainant) stated Resident 1's meals were often served late and the food was cold. On 11/5/24 at 12:33 PM, Resident 4 stated the meals were cold 75%…

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 it was determined the facility failed to provide maintenance services to maintain a safe, comfortable and homelike environment for 2 of 3 resident rooms (Room #s 117 and 118) reviewed for environment. This placed residents at risk of outside air and odors entering the resident rooms. Findings include: An observation on 11/5/24 at 9:20 AM, revealed the wall underneath room [ROOM NUMBER]'s window was in disrepair and the baseboard coving was missing. An observation on 11/5/24 at 9:23 AM, revealed the resident smoking area to be in the outdoor area, in the line of sight from room [ROOM NUMBER]. An observation on 11/6/24 at 9:24 AM, revealed the wall underneath Resident 117's window was in disrepair and the baseboard coving was missing. On 11/5/24 at 9:59 AM, Witness 1 (Complainant) stated the wall underneath Resident 118's was in disrepair, had no baseboard coving and Resident 1 could feel the outside air and smell cigarette smoke. Witness 1 further stated staff placed towels…

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 it was determined the facility failed to ensure the resident's right to be free from neglect for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for unmet care needs. Findings include: Resident 1 was admitted to the facility in May 2024, with diagnoses including a left femur fracture. Review of a care plan revised on 5/18/24 revealed the resident was to be assisted with toileting every two hours. A revision on 6/11/24 revealed staff were to make sure the resident was wearing appropriate footwear prior to ambulation or transfers. Review of a progress note dated 6/26/24 at 3:27 PM, stated Staff 3 (LPN) was alerted Resident 1 needed assistance and found the resident on the floor in the resident's room. The note indicated the resident was not wearing socks or shoes and had a soiled brief. The note also indicated the resident was not able to explain how she/he fell and the resident told staff her/his arm was sore. The resident was toileted last at 10:10 AM according to Staff 4 (CNA) and the resident's call light was 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 interview and record review it was determined the facility failed to staff a RN for eight consecutive hours per day seven days per week for 22 out of 91 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the facility's Direct Care Staff Daily Reports and payroll documents identified the following 23 days without eight consecutive hours of RN coverage: January 2024: 1/3/24; 1/8/24; 1/9/24; 1/16/24; 1/17/24; 1/21/24; 1/22/24 and 1/23/24. February 2024: 2/2/24; 2/13/24; 2/14/24; 2/20/24; 2/21/24; 2/27/24 and 2/28/24. March 2024: 3/55/24; 3/11/24; 3/19/24; 3/20/24; 3/26/24 and 3/27/24. On 6/17/24 at 12:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged there was no RN coverage on the above identified days. Staff 1 stated she expected RN coverage eight hours per day.

Based on interview and record review it was determined the facility failed to obtain consent and review risks and benefits prior to administering a COVID-19 vaccination to 1 of 3 sampled residents (#9) reviewed for immunizations. This placed residents at risk for adverse side effects from the vaccine. Findings include: Resident 9 admitted to the facility in 10/2023, with diagnoses including COVID-19 and heart failure. Resident 9's Immunization Record revealed the COVID-19 Booster was administered on 11/17/24. Review of Resident 9's medical record revealed no evidence the risk versus benefits were discussed with the resident or the resident's representatives. On 6/18/24 at 9:51 AM, Witness 4 (Complainant) stated Resident 9 was administered the COVID-19 vaccine against both the resident and family wishes. Witness 4 further stated Resident 9's family informed the facility Resident 9 had a history of getting sick with previous COVID-19 vaccine administrations. On 6/20/24 at 9:24 AM, Staff 1 (Administrator) and Staff 2 (DNS) verified Resident 9 received the COVID-19 vaccine without…

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 it was determined Staff 5 (Agency RN) failed to follow standards of practice related to insulin administration and failed to be honest during an investigation for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at ongoing risk of jeopardized health status and blood borne pathogens. Findings include: Resident 2 admitted to the facility in 3/2022 with diagnoses including diabetes. Resident 3 admitted to the facility in 12/2021 with diagnoses including diabetes. On 12/21/23 a public complaint was received which alleged on 12/20/23 Staff 5 (Agency RN) administered the wrong insulin to the wrong resident when he administered insulin from Resident 3's insulin pen to Resident 2. The 1/5/12 CDC Clinical Reminder indicated insulin pens must never be used for more than one person. There was no evidence in Resident 2's or Resident 3's medical record or facility records a medication error occurred. On 12/27/23 at 9:05 AM Staff 2 (Regional RN/Interim DNS) stated she just interviewed Staff 5 and a medication error did not occur.…

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 it was determined the facility failed to ensure a resident was free from a significant medication error for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk of jeopardized health status and blood borne pathogens. Findings include: Resident 2 admitted to the facility in 3/2022 with diagnoses including diabetes. Resident 3 admitted to the facility in 12/2021 with diagnoses including diabetes. On 12/21/23 a public complaint was received which alleged Staff 5 (Agency RN) administered the wrong insulin to the wrong resident when he administered insulin from Resident 3's insulin pen to Resident 2. The 1/5/12 CDC Clinical Reminder indicated insulin pens must never be used for more than one person. There was no evidence in Resident 2's or Resident 3's medical record or facility records a medication error occurred. On 12/27/23 at 9:58 AM Staff 5 stated he used Resident 3's insulin pen (with a clean needle) and administered the insulin to Resident 2.

Based on interview and record review it was determined the facility failed to provide a response for Resident Council concerns for 1 of 1 Resident Council reviewed for grievances. This placed residents at risk for a decline in psychosocial well-being. Findings include: The 9/29/23, 11/10/23 and 11/23/23 Council Minutes indicated no old business was discussed which included grievance and resolutions. On 11/20/23 at 10:00 AM Resident 37, Resident 41 and Resident 49 all indicated they attended Resident Council meetings routinely and they were unaware how ongoing issues like staffing were addressed. On 11/30/23 at 12:21 PM Staff 1 (Administrator) stated he routinely met personally with the Resident Council President to share how Resident Council concerns were addressed by the facility. On 11/30/23 at 2:22 PM Staff 20 (Activities Director) indicated she coordinated Resident Council and acknowledged the resolution of grievances was not currently discussed during Resident Council.

Based on interview and record review it was determined the facility failed to assist or follow up with residents related to their desire to formulate an advance directive for 4 of 4 sampled residents (#s 14, 20, 41 and 56) reviewed for advance directives. This placed residents at risk for not having their healthcare decisions honored. Findings include: 1. Resident 41 was admitted to the facility in 2020 with diagnoses including end stage kidney disease. A review of Resident 41's medical record included no information related to advance directives. On 11/29/23 at 11:19 AM Resident 41 was asked about advance directives and stated she/he believed she/he was asked at the time of admission but did not recall discussing it again. On 11/28/23 at 3:10 PM Staff 4 (Regional Social Services and Activities) stated advance directives should be reviewed quarterly. Staff 4 indicated there was no information related to advance directives for Resident 41. 2. Resident 20 was admitted to the facility in 2022 with a diagnosis of depression. A review of Resident 20's clinical record revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 5 of 13 sampled residents (#s 4, 6, 21, 52, and 225) reviewed for accidents and ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 2023 with diagnoses including pain and end of life care. A review of the clinical records indicated Resident 4 was to be bathed on Tuesday and Friday evenings and was dependent on staff for bathing needs. The clinical records noted bathing omissions on 10/10/23, 10/13/23 and 10/24/23; three of the seven bathing tasks planned for Resident 4 in 10/2023. There was no indication Resident 4 refused bathing on the days noted. On 11/30/23 at 2:37 PM Witness 2 (Complainant) confirmed concerns related to lack of bathing for Resident 4. On 12/1/23 at 10:45 AM Staff 17 (RN Unit Manager) stated the facility had a bathing plan assigned to resident rooms and would make…

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 it was determined the facility failed to provide sufficient staffing to meet the needs of 1 of 8 sampled residents (#36) and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: The 9/29/23 Council Minutes indicated five residents felt rushed during care, nine residents waited more than 20 minutes for staff to answer call lights, five residents waited more than 30 minutes for staff to answer call lights, five residents waited more than 45 minutes for staff to answer call lights and wait times were worse at night. The 11/10/23 and 11/17/23 Council Minutes indicated call light wait times did not improve. On 11/20/23 at 10:00 AM Resident 37, Resident 41 and Resident 49 all indicated they attended Resident Council meetings routinely and they were unaware how the ongoing issues like staffing were addressed. 1. Resident 36 was admitted to the facility in 2021 with diagnosis of Parkinson's (a disease that affects the nervous system) like symptoms. An 10/31/23 Care Plan Detail indicated…

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 it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 8, 21, 22, 23, and 24) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of the facility's staff performance review records revealed the following: -Staff 8 (CNA), hired 9/25/19, did not have a performance review from 9/25/22 through 11/28/23. -Staff 21 (CNA), hired 11/20/09, did not have a performance review from 11/20/22 through 11/28/23. -Staff 22 (CNA), hired 6/7/18, did not have a performance review from 6/7/22 through 11/28/23. -Staff 23 (CNA), hired 11/5/22, did not have a performance review from 11/5/22 through 11/28/23. -Staff 24 (CNA), hired 9/20/21, did not have a performance review from 9/20/22 through 11/28/23. On 11/28/23 at 11:19 AM Staff 2 (Regional Director of Clinical) confirmed the above staff did not receive their yearly performance reviews.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 3 of 5 sampled residents (#s 41, 46, and 54) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 54 was admitted to the facility in 2022 with diagnoses including diabetes and dementia. A Psychotropic Medication Review meeting dated 8/23/23 recommended increasing Depakote (anticonvulsant, also used to treat mood disorders) with a goal to decrease Seroquel (antipsychotic) after one month. A Note to Attending Prescriber dated 8/28/23 listed current medications and a recommendation from the Psychotropic Drug Committee to increase Depakote and decrease the Seroquel as it was not effective in managing Resident 54's behaviors. A Psychotropic Medication Review meeting dated 9/22/23 repeated the recommendations to increase the Depakote and decrease the Seroquel. A Psychotropic Medication Review meeting dated 10/19/23 indicated to continue to follow up with the provider related to changes to Depakote 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.

Based on observation, interview, and record review it was determined the facility failed to ensure residents did not receive unnecessary medications for 6 of 6 sampled residents (#s 20, 23, 42, 46, 54, and 62) reviewed for hospice and medications. This placed residents at risk for adverse side effects of medications. Finding include: 1. Resident 42 was admitted to the facility in 2020 with diagnoses including anxiety and a broken hip. On 11/27/23 at 8:22 AM Resident 42 was sitting in bed with her/his breakfast tray on the overbed table positioned in front of the her/him. Resident 42 appeared comfortable without evidence of anxiety or pain. A pharmacy review dated 9/30/23 recommended a 14-day limit on PRN Haldol (antipsychotic) in accordance with regulation and the required direct provider assessment each 14 days for continued use. The provider responded by citing a guidance for medication use but added the guidance did not apply to hospice. A Physician Communication Sheet dated 10/30/23 indicated Haldol should be extended until 4/2024 to not cause undue suffering for Resident 42. 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, interview, and record review it was determined the facility failed to ensure proper flavor and appealing food textures for 1 of 1 kitchen and 1 of 13 sampled residents (#8) observed during dining observations. This placed residents at risk for meal dissatisfaction. Findings include: The 9/15/21 revised Pureed (PU4) diet instruction directed staff to puree all food to a smooth and extremely thick consistency and to always refer to the recipe and spreadsheet for directions. 1. On 11/26/23 at 1:08 PM during dining observations a slightly thick green food was observed on the plates of unidentified residents who were assisted with dining. The green food spread across the width of the plates. Staff 25 (CNA) stated the pureed food for residents was often thin. Residents were observed and able to eat the pureed food with assistance with the use of their spoons. On 11/29/23 the following occurred: -11:51 AM Staff 32 (Cook) stated she added water to puree foods if milk was not available. Staff 32 stated no recipes to puree foods were followed. -1:09 PM a sample pureed…

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 it was determined the facility failed to ensure resident records were accurate for 3 of 17 sampled residents (#s 8, 14, and 66) reviewed for ADLs, dialysis, nutrition and PU. This placed residents at risk for inaccurate and incomplete clinical records. Findings include: 1. Resident 8 was admitted to the facility in 2022 with diagnoses including end stage kidney disease and heart failure. A 6/3/23 physician order indicated Resident 8 was to receive one to five liters per minute of oxygen to maintain oxygen saturation greater than 90 percent. The order was discontinued on 8/3/23. The 11/2023 TAR indicated Resident 8's oxygen tubing, cannula (thin tubing inserted into the nose), tubing bag, concentrator bottled were changed every Sunday during the month and last completed on 11/26/23. On 11/26/23 at 10:47 AM Resident 8 was observed in her/his room without the use of oxygen. On 11/28/23 at 12:26 PM Staff 30 (CNA) confirmed Resident 8 did not use oxygen for months. On 11/29/23 at 12:16 PM Staff 2 (Regional Director of Clinical) observed Resident 8'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 observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. On 11/27/23 at 12:23 PM Staff 26 (SLP) was observed to enter and exit 10 minutes later from room [ROOM NUMBER] (COVID-19 positive room) wearing a facemask. Staff 26 acknowledged he should have worn full PPE (gown, N95 face mask, face shield and gloves). On 11/28/23 at 12:44 PM Staff 40 (LPN Unit Manager) stated all staff are to wear a gown, N95 face mask, face shield and gloves when entering a COVID-19 positive room. 2. On 11/27/23 at 12:32 PM Staff 41 (CNA) entered room [ROOM NUMBER] (COVID-19 positive room) without an N95 mask. Staff 41 acknowledged he should have worn an N95 face mask. On 11/28/23 at 12:44 PM Staff 40 (LPN Unit Manager) stated all staff are to wear a gown, N95 face mask, face shield and gloves when entering 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 interview, and record review it was determined the facility failed to have a system in place to track annual nurse aide training for the required 12 hours of in-service training annually for 5 of 5 sampled CNAs (#s 8, 21, 22, 23, and 24) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of competent staff. Findings include: On 10/20/23 a public complaint reported the administrator placed a clipboard for staff to sign regarding in-service training. No information was provided regarding the training, it was just a staff participation sign-in sheet. A review of the facility's staff training records revealed the following: -Staff 8 (CNA), hired 9/25/19, had two hours of documented training from 9/25/22 thought 9/25/23. -Staff 21 (CNA), hired 11/20/09, had no hours of documented training from 11/20/22 through 11/20/23. -Staff 22 (CNA), hired 6/7/18, had two hours of documented training 6/7/22 through 6/7/23. -Staff 23 (CNA), hired 11/5/22, had six hours of documented training 11/5/22 through 11/5/23. -Staff 24 (CNA), hired 9/20/21, had…

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

Based on observation, interview, and record review it was determined the facility failed to provide a comfortable shower chair for 1 of 9 sampled residents (#14) reviewed for ADLs. This placed residents at risk for unmet bathing needs. Findings include: Resident 14 was admitted to the facility in 2022 with diagnoses including stroke and heart failure. An 8/31/23 revised care plan indicated Resident 14 required the extensive assistance of one staff for showers and bathing. The 8/2023 and 11/2023 Follow Up Question Report indicated no showers were provided to Resident 14 on 8/26/23, 11/4/23, 11/11/23, 11/14/23, and 11/25/23 as scheduled. The 9/2023 and 10/2023 Documentation Survey Report indicated Resident 14 refused her/his shower on 9/16/23 and 10/21/23. On 11/27/23 at 10:05 AM Resident 14 stated she/he often refused showers because the shower chair scared her/him due to her/his size and it was uncomfortable. On 11/28/23 at 4:17 PM Staff 28 (LPN) stated she only heard in passing from staff that Resident 14 was uncomfortable with her/his shower chair and Resident 14's concern with…

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 it was determined the facility failed to provide a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for an unpleasant environment. Findings include: On 10/11/23 a public complaint was received which indicated the facility had odors because the staff did not have bags available to bag up items such as soiled linens and incontinent briefs. On 11/27/23 at 8:17 AM Resident 56 stated she/he kept a stash of plastic bags as the facility was short of bags at times. Resident 56 stated if a CNA ran out of bags, she/he would provide them one. Resident 56 stated her/his room did not have an odor since she/he provided the bags. On 11/27/23 at 10:22 AM Staff 7 (CNA) stated in 10/2023 there was a shortage of supplies in the building such as bags, wipes, and briefs. Staff 7 was informed when there were no bags in the trash can staff were instructed to bring the large trash can to the room and empty the room trash can into the larger one. Staff 7 stated there was an odor in the building 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 interview and record review it was determined the facility failed to ensure a resident grievance was resolved timely for 1 of 3 sampled residents (#375) reviewed for nutrition. This placed residents at risk for unresolved concerns. Findings include: Resident 375 was admitted to the facility in 2023 with a diagnosis of malnutrition. Resident 375 discharged on 10/5/23. A 9/26/23 Grievance Form revealed concerns related to kitchen services including poor food quality, lack of protein drinks, and unavailability of juice for residents. The form indicated there was no resolution to the grievance because the resident was discharged . On 10/30/23, over one month after the grievance was filed, it was determined the former dietary manager did not address grievances in a timely manner. On 11/28/23 at 9:42 AM Witness 1 (Complainant) stated a grievance was filed on behalf of Resident 375 and other residents related to food quality, lack of protein drinks and lack of juice between meals, and a response was never received. Witness 1 stated the grievance was given to Staff 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 interview and record review it was determined the facility failed to ensure a resident or resident representative was provided a bed hold policy for 1 of 1 sampled resident (#63) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to the right to return to the facility. Findings include: Resident 63 was admitted to the facility in 2023 with a diagnosis of heart disease. A 11/25/23 Progress Note revealed Resident 63 developed shortness of breath, a rapid heart rate and a new onset of chest pain. The resident was sent to the hospital for evaluation and treatment. Resident 63's clinical record revealed no indication the resident or resident's representative were provided a bed hold policy after she/he was admitted to the hospital for urgent care. On 12/4/23 at 8:12 AM Staff 2 (Regional Director of Clinical) stated Resident 63 was not provided a bed hold policy when she/he was admitted to the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to develop a baseline care plan to address residents' immediate care needs for 3 of 9 sampled residents (#s 4, 21, and 225) reviewed for ADLs. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 2023 for end of life care. A record review revealed the baseline care plan did not address Resident 4's bowel and bladder incontinence, risk for falls, lack of activity participation, end of life/hospice status or discharge plan. On 12/1/23 at 10:45 AM when Staff 17 (RN Unit Manager) was asked about the development of baseline care plans she stated they started with the initial resident assessment and were needed to inform staff of the resident's immediate care needs. Staff 17 added the baseline care plan should address basic ADL needs including bowel and bladder, falls and resident preferences. On 12/1/23 at 11:19 AM Staff 2 (Regional Director of Clinical) stated…

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 it was determined the facility failed to develop care plans for 2 of 7 sampled residents (#s 6 and 375) reviewed for pain and accidents. This placed residents at increased risk for unmet needs. Findings include: 1. Resident 6 was admitted to the facility in 2023 with a diagnosis including depression. A 11/23/23 Smoking Screen revealed Resident 6 was an independent smoker. A review of Resident 6's most recent comprehensive care plan revealed no information indicating she/he was a smoker. On 11/29/23 at 8:13 AM Resident 6 was observed in the outside smoking area smoking. On 12/1/23 at 10:29 AM Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) confirmed Resident 6's care plan did not include smoking information. 2. Resident 375 was admitted to the facility in 2023 with a diagnosis of cancer. A 9/21/23 admission MDS and associated CAAs revealed Resident 375 reported frequent moderate pain. The resident had chronic back and cancer pain which spread to the bone. Review of Resident 375's comprehensive care plan initiated…

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 it was determined the facility failed to ensure care plans were updated for 2 of 2 sampled residents (#s 8 and 11) reviewed for dialysis (process to purify blood) and care plans. This placed residents at risk for lack of appropriate care. Findings include: 1. Resident 8 was admitted to the facility in 2022 with diagnoses including end stage kidney disease and heart failure. The 6/20/23 Annual MDS and CAA indicated Resident 8 was new to dialysis and received dialysis three times weekly. An 10/25/23 revised care plan indicated not to draw blood or take blood pressures in Resident 8's arm with a graft (surgical access site for dialysis). The 11/14/23 and 11/25/23 Nursing Dialysis-Pre-Dialysis Assessment and Communication forms indicated Resident 8's access type was a central venous (location near the heart) catheter (medical tubing) at the left jugular (vein in the neck). On 11/29/23 at 11:34 AM Staff 28 (LPN) stated she recalled changes related to Resident 8's dialysis and was unaware where to locate the information. On 11/29/23 at…

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

Based on observation, interview and record review it was determined the facility failed to obtain eye care services for 1 of 1 sampled resident (#8) reviewed for vision. This placed residents at risk for lack of appropriate eye care services and devices. Finding include: Resident 8 was admitted to the facility in 2022 with a diagnosis of heart failure. The 6/20/23 Annual MDS and CAA indicated Resident 8 had severe vision impairment that increased her/his risk of falls. A 3/13/23 IDT (Interdisciplinary Team) Care Plan Conference and Welcome Meeting Form revealed Resident 8 wanted to have her/his vision checked. An 10/25/23 revised care plan indicated Resident 8 was to have eye care consultation as needed and to ensure her/his visual aids were available to participate in her/his activities. During multiple observations on 11/26/23 through 11/28/23 Resident 8 was observed with no glasses. On 11/26/23 at 10:57 AM Resident 8 stated she/he asked about glasses six months ago and there was no follow through. Resident 8 stated she/he could not see the television due to issues with her/his…

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 it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 4 sampled residents (#20) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 20 was admitted to the facility in 2022 with diagnosis of Parkinson's disease (A progressive disorder which affects the nervous system). A 11/18/22 revised care plan revealed Resident 20 had a swallowing problem because of dysphagia (difficulty in swallowing food or liquid). Interventions included 100 percent supervision for all meals. If solid foods were within reach of Resident 20 staff must be present for safety. An 4/26/23 Annual MDS indicated Resident 20 coughed and choked during meals. During a continuous observation on 11/29/23 the following was observed: -8:20 AM Resident 20 was in her/his room sitting in her/his wheelchair next to the bed. The bedside table was in front of Resident 20 with the breakfast food tray on top of the table. The lid was off the plate with visible food on the…

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

Based on observation, interview, and record review it was determined the facility failed to ensure resident's respiratory equipment was maintained for 2 of 3 sampled residents (#s 21 and 225) reviewed for respiratory needs. This placed residents at risk for respiratory complications. Findings include: 1. Resident 21 was admitted to the facility in 2023 with diagnosis of pneumonia. A 11/7/23 physician order revealed Resident 21 used oxygen. A review of the clinical record revealed no information about cleaning the oxygen filters or how often the oxygen tubing was changed. On 11/26/23 at 9:28 AM Resident 21 was in her/his bed with oxygen tubing in place and an oxygen machine next to the bed. On 11/30/23 at 3:07 PM Staff 40 (LPN Unit Manager) confirmed there was no system in place for the care of Resident 21's oxygen machine and tubing. 2. Resident 225 was admitted to the facility in 2023 with diagnosis of pneumonia. A 11/16/23 physician order indicated Resident 225 used oxygen as needed. A review of the clinical record revealed no information regarding cleaning the oxygen filters or…

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 it was determined the facility failed to ensure a resident was offered pain medication when assessed to have pain for 1 of 3 sampled residents (#375) reviewed for pain. This placed residents at risk for unaddressed pain. Findings include: Resident 375 was admitted to the facility in 2023 with a diagnosis of cancer. A 9/18/23 hospital Orders at Discharge form revealed Resident 375 was to be administered Dilaudid (a narcotic pain medication for moderate to severe pain) four times a day as needed. A 9/21/23 admission MDS and associated CAAs revealed Resident 375 reported frequent moderate pain. The resident had chronic back and cancer pain related to cancer which had spread to the bones. The resident reported pain medications were effective. A 9/26/23 SLUMS (St. Louis University Mental Status) score indicated Resident 375 had dementia. 9/2023 and 10/2023 MARs revealed staff were to ask the resident if she/he had pain every four hours. On the following dates the resident was documented to have moderate to severe pain but was not administered or…

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 it was determined the facility failed to comprehensively assess dementia needs for 1 of 2 sampled residents (#23) reviewed for dementia. This placed residents at risk for unmet needs. Findings include: Resident 23 was admitted to the facility in 2023 with diagnosis of Alzheimer's disease. A 9/12/23 admission MDS, Mood State, and Cognitive Loss Dementia CAAs indicated Resident 23 was unable to complete the interview and was moderately impaired. The Mood State CAA stated Resident 23 suffered from depression and to see diagnoses, orders, and care plan. The Cognitive Loss Dementia CAA indicated Resident 23 suffered from dementia and severe cognitive impairment with a history of dementia. The CAAs did not complete analysis of Resident 23, and her/his mood and cognitive loss challenges. The CAAs were not person-centered and did not capture Resident 23's mental health history and goals. An 10/23/23 Nursing Note revealed Resident 23 was alert and oriented to self, easily redirected and pleasantly confused. An 10/25/23 Nursing Note revealed Resident 23…

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

Based on interview and record review it was determined the facility failed to ensure a resident's physician was notified of abnormal laboratory results for 1 of 5 sampled residents (#375) reviewed for nutrition. This placed residents at risk for delayed care. Findings include: Resident 375 was admitted to the facility in 2023 with a diagnosis of cancer. Progress Notes revealed on 9/28/23 Resident 375 had increased confusion and did not appear to understand when staff spoke to her/him. Resident 375's physician was notified and an UA and blood work were ordered. There was no assessment of the resident documented on 9/29/23. On 9/30/23 Resident 375 was assessed to be alert, cooperative, and no concerns were identified. A 9/30/23 Lab Results Report form revealed the results were flagged for abnormal results. Abnormal results included a sodium level of 128 (the form lab reference sodium range 135 to 146). Resident 375's clinical record did not indicate the resident's physician was notified by staff of the low sodium level. On 11/29/23 at 12:41 PM Staff 43 (MDS RN) stated the labs 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.

Based on interview, and record review it was determined the facility failed to have an effective new staff orientation program for 2 of 3 staff members (#s 12 and 13) reviewed for staffing and orientation. This placed residents at risk for untrained staff. Findings include: On 10/20/23 a public complaint was received which indicated orientation was not provided to staff when hired at the facility. A review of the signed New Employee Orientation Agenda revealed no signed orientation documentation for Staff 12 (CNA) and Staff 13 (Medication Technician). On 11/29/23 at 10:47 AM Staff 9 (CNA) stated when she started at the facility no orientation was provided and she had to ask peers for assistance. On 12/1/23 at 7:32 AM Witness 3 (Complainant) stated when she worked as a new CNA in 2023 at the facility, she did not receive orientation. On 12/1/23 at 10:24 AM Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) stated they started a new process for orientation and Staff 13 was hired right before the process started. Staff 1 stated he was unsure what happened to Staff 12…

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.