Creswell Post Acute

Based on interview and record review it was determined the facility failed to provide a COVID-19 vaccine for 1 of 5 sampled residents (#13) reviewed for immunizations. This placed residents at risk for COVID-19. Findings include: Resident 13 admitted to the facility in 2018 with a diagnosis of respiratory failure.A 11/6/25 Informed Consent revealed Resident 13 consented to receive a COVID-19 vaccine.A review of Resident 13's immunization record revealed she/he did not receive a COVID-19 vaccine.On 1/30/26 at 1:59 PM Staff 2 (DNS) confirmed Resident 13 did not receive the COVID-19 vaccine during the facility's 11/2025 COVID-19 clinic.

Based on interview and record review, it was determined the facility failed to report timely to the State Survey Agency an allegation of injury of unknown source for 1 of 3 sampled residents (#18) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 18 was admitted to the facility in 6/2022 with diagnoses including behavioral disturbance and dementia. A facility incident report dated 1/15/25 indicated Resident 18 was found on 1/15/25 with a bruise to the left eye. Staff did not know how the injury occurred and the resident was unable to explain what happened. An Incident Investigation dated 1/15/25 indicated on 1/10/25, Staff 24 (CNA) observed a bruise to Resident 18's eye and reported the bruise to Staff 10 (LPN). On 12/11/25 at 9:45 AM, Staff 2 (DNS) confirmed the incident was not reported to the State Agency in a timely manner. The incident met the criteria for non-compliance as follows:1. The incident indicated non-compliance for F609 2. There was sufficient evidence the facility corrected the non-compliance and was in substantial compliance…

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 discharge plan for 1 of 3 residents (# 21) reviewed for discharged planning. This place residents at risk for not having a discharge plan. Findings include:A review of the resident 21's clinical record revealed no evidence of a discharge plan in the resident file. A notification on the Evaluations tab of the clinical record indicated the discharge plan was 16 days overdue. The resident's Care Plan dated 11/26/25 revealed the resident's discharge preferences were not addressed in the Care Plan. Care Conference Notes dated 12/3/25 revealed no documentation of the resident's discharge plan.On 12/11/25 at 1:58 PM, Staff 36 (Social Services Coordinator) stated she should have had the resident's discharge plan completed. On 12/11/25 at 2:00 PM, Staff 2 (DNS) stated she was not familiar with the discharge planning procedure, but it was the responsibility of Social Services to complete a discharge plan.

Based on interview and record review, it was determined the facility failed to complete timely MDS assessments for 2 of 7 sampled residents (#s 27 and 34) who were reviewed for catheter use and staffing. This placed residents at risk for unassessed needs. Findings include:1. Resident 27 was admitted to the facility in 11/2025 with diagnoses including fractured femur and osteoarthritis. On 12/8/25 a review of Resident 27's clinical record revealed the admission MDS assessment was marked in progress and overdue by 15 days. On 12/8/25 at 12:06 PM, Staff 11 (MDS Coordinator) confirmed she was behind on 11/2025's MDS reports. On 12/11/25 at 11:54 AM Staff 2 (DNS) confirmed MDS assessments should be completed timely. 2. Resident 34 was admitted to the facility in 11/2024 with diagnoses including pressure ulcer and chronic kidney disease. On 12/9/25 a review of Resident 34's clinical record revealed her/his annual MDS assessment was in progress and overdue by 15 days. On 12/11/25 at 11:54 AM Staff 2 (DNS) confirmed MDS assessments should be completed timely.

Based on interview and record review the facility failed to update the resident's care plan for 1 of 2 residents (#20) reviewed for abuse. This placed residents at risk for a lack of planned interventions. Findings include:Resident 20 was admitted to the facility 5/1/25 with diagnoses including dementia. A Facility Reported Incident (FRI) dated 5/22/25 revealed Resident 20's care plan was revised to keep the resident further than an arm's length away from other residents when she/he appeared agitated. A FRI dated 6/5/25 revealed Resident 20 was involved in physical aggression towards another resident. Resident 20's Care Plan revealed the intervention to keep the resident away from other residents when she/he appeared agitated was added to the Care Plan on 6/5/25. On 12/11/25 at 12:35 PM, Staff 2 (DNS) stated the resident's care plan should have been updated within five days of the 5/22/25 FRI and she had failed to update the resident's care plan timely.

Based on observation, interview, and record review, it was determined the facility failed to provide sufficient staffing to meet the needs of 2 of 4 residents (#17 and 33) during random observations. This placed residents at risk for unmet needs. Findings include:1. Resident 17 was admitted to the facility in 9/2025 with diagnoses including chronic kidney disease and epilepsy. An 8/20/25 admission MDS indicated Resident 17 had a BIMS score of 14 (cognitively intact). On 12/9/25 at 9:23 AM, the call light monitor was observed and revealed Resident 17's call light was activated at 8:47 AM and completed at 9:34 AM, a total wait time of 47 minutes. On 12/9/25 at 9:53 AM, Resident 17 stated call light wait times were sometimes long. On 12/9/25 at 1:12 PM, Staff 29 (CNA) stated during Resident 17's call light wait time, he was assisting another resident with incontinent care. Staff 29 stated the facility used to have devices to communicate with other staff, but they were no longer available. On 12/11/25 at 11:55 AM, Staff 2 (DNS) stated she expected resident's needs to be met 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 interview and record review it was determined the facility failed to complete a discharge summary which included a final summary of the resident's status for 3 of 4 sampled residents (#s 2, 4, and 5) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: 1. Resident 2 was admitted to the facility in July 2024, with diagnoses including diabetes. Review of a Discharge Summary/Plan of Care form dated 8/28/24, revealed the final summary of the resident's status did not include all items consistent with the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. 2. Resident 4 was admitted to the facility in July 2024, with diagnoses including heart failure. Review of a Discharge Summary/Plan of Care form dated 9/4/24, revealed the final summary of the resident's status did not include all items from the resident's most recent comprehensive assessment which included but not limited 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 observation, interview, and record review it was determined the facility failed to follow physician orders, provide bowel care, and administer medications timely for 9 of 12 sampled residents (#s 2, 4, 8, 13, 14, 41, 43, 47, 203) reviewed for change of condition, restraints, pain, bowel care, and medication pass. This placed residents at risk for ineffective interventions. Findings include: 1. Resident 2 admitted to the facility in 3/2010 with a diagnosis of cancer. A care plan initiated in 2020 revealed Resident 2's bed had bed rails to improve bed mobility. On 8/26/24 at 2:47 PM Witness 1 (Family Member) stated Resident 2 used mobility bars to assist with bed mobility, the facility removed the bars, and she was not informed the reason the mobility bars were removed. On 8/27/24 at 1:59 PM Resident 2 was observed in bed. The bed did not have bed rails. On 8/27/24 at 2:46 PM Staff 3 (RNCM) stated Resident 2's original bed was replaced with a new bed and the rails were not transferred to the new bed. 2. Resident 47 admitted to the facility in 7/2024 with a diagnosis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 treatment carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for reduced efficacy of medication, inaccurate tuberculosis testing, and decreased vaccine efficacy. Findings include: During an audit of the South Hall treatment cart with Staff 8 (RN) on [DATE] at 3:50 PM, an open vial of Insulin Glargine dated [DATE] was observed in the cart. Staff 8 examined the vial and confirmed the date on the vial was over 28 days and it should have been discarded. While conducting an audit of the medication and biologicals refrigerator on [DATE] at 11:14 AM with Staff 9 (LPN) an open and undated multi-dose vial of tuberculin solution (a solution used in testing for Tuberculosis), and multiple closed vials of Spikevax (COVID - 19 vaccine) with an expiration date of [DATE] 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 a resident was not spoken to in a dignified manner for 1 of 3 sampled residents (#47) reviewed for dignity. This placed residents at risk for lack of self-worth. Findings include: Resident 47 admitted to the facility in 7/2024 with a diagnosis of post-surgical procedure paraplegia. On 8/14/24 Witness 9 (Anonymous) reported to the State agency Staff 7 (CNA) would not change Resident 47's sheets and it caused Resident 47 to feel afraid and Resident 47 felt she/he had to argue to receive care. A 7/31/24 admission MDS revealed Resident 47 was cognitively intact. On 8/26/24 at 3:30 PM Resident 47 stated her/his sheets were wet from sweat and requested Staff 7 (CNA) to change the sheets. Staff 7 insisted the sheets were not wet. Resident 47 stated it was frustrating to have to always argue with staff to have care provided. Eventually the sheets were changed. On 8/28/24 at 10:31 AM Staff 2 (DNS) stated if a resident requested her/his sheets to be changed, staff should honor the request. Staff 2 stated Resident 47 reported 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 obtain consent for an influenza vaccination for 1 of 5 sampled residents (#16) reviewed for immunizations. This placed residents and responsible parties at risk for lack of informed consent. Findings include: Resident 16 admitted to the facility in 10/2023 with diagnoses including diabetes. An 8/25/24 Quarterly MDS indicated Resident 16 was cognitively intact. An 8/29/24 review of Resident 16's immunization record revealed she/he received the influenza vaccine in the facility on 12/13/23. An 8/29/24 review of Resident 16's medical record revealed no evidence of a signed consent for the influenza vaccine received in the facility on 12/13/23. On 8/29/24 at 3:35 PM Staff 2 (DNS) stated she was unable to locate a signed consent for Resident 16's influenza vaccine received in the facility on 12/13/23. Staff 2 stated consent needed to be obtained prior to a resident receiving vaccines.

Based on interview and record review it was determined the facility failed to notify a resident's emergency contact of a hospitalization and a resident's physician for a change of condition for 2 of 6 sampled residents (#s 18 and 47) reviewed for hospitalization and pressure ulcers. This placed residents at risk for lack of family involvement and delayed treatment. Findings include: 1. Resident 18 admitted to the facility in 2010 with a diagnosis of delayed stomach and bowel emptying. An undated admission Record revealed Witness 5 (Family Member), Witness 6 (Family Member), and Witness 7 (Family Member) were Resident 18's emergency contacts. An 10/26/23 Progress Note revealed Resident 18 was transported to the hospital for abdominal pain, nausea, vomiting, and uncontrolled diarrhea. There was no indication any of Resident 18's emergency contacts were notified. A 7/15/24 quarterly MDS indicated Resident 18 was cognitively intact. On 8/26/24 at 4:15 PM Resident 18 stated the facility did not call her/his emergency contacts when she/he was hospitalized . On 8/28/24 at 3:20 PM Staff 3…

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 respect the resident rights to deliver postal service mail unopened for 1 of 3 (#12) sampled resident reviewed for privacy. This placed residents at risk for lack of privacy and confidentiality. Findings include: Resident 12 admitted to the facility in 5/2023 with a diagnosis of diabetes. A 6/11/24 admission MDS revealed Resident 12 was cognitively intact. On 8/27/24 at 9:05 AM, Resident 12 stated she/he was upset because a staff member opened her/his mail a box, which was addressed to her/him. The resident stated the box had supplements and acknowledged she/he needed a doctor's approval before taking the supplements. However, staff did not honor her/his privacy or personal property. On 8/28/24 at 12:03 PM Staff 5 (CMA) stated on 6/3/24 she opened a package addressed to Resident 12's. After shaking the box, she heard a bottle which sounded like it contained supplements or medication. Staff 5 stated she should have let the resident open the box in front of her and acknowledged she violated Resident 12's…

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

Based on interview and record review it was determined the facility failed to initiate a grievance process for 1 of 2 sampled residents (#16) reviewed for personal property. This placed residents at risk for unaddressed concerns. Findings include: 1. Resident 16 admitted to the facility in 10/2023 with diagnoses including diabetes. An 8/25/24 Quarterly MDS indicated Resident 16 was cognitively intact. On 8/27/24 at 8:32 AM Resident 16 stated her/his cell phone was stolen a couple of months ago and she/he spent $300 to replace it. Resident 16 stated the facility did not reimburse her/him. On 8/28/24 at 11:39 AM Staff 4 (Social Services) stated she was informed by Resident 16 she/he bought a new phone because she/he lost her/his old phone. Staff 4 stated Resident 16 never filled out a grievance form and she did not complete a grievance form for Resident 16. Staff 4 stated this was a grievance and should have had a grievance form filled out and investigated.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure a resident received a bed hold policy for 1 of 2 sampled residents (#47) reviewed for hospitalization. This placed residents at risk for not being informed of their rights to return to the facility. Findings include: Resident 18 admitted to the facility in 2018 with a diagnosis of delayed emptying of the stomach and intestines. Progress Notes from 10/2023 through 8/2024 revealed Resident 18 was hospitalized on [DATE], 11/8/23, and 2/10/24. The notes did not indicate Resident 18 or her/his emergency contacts were provided a bed hold policy. On 8/29/24 at 9:23 AM Staff 4 (Social Services) stated if she was in the facility when a resident was discharged to the hospital, she ensured the resident or representative was provided a bed-hold policy. If it was after hours or on the weekend, nursing staff were to provide the policy. Staff 4 stated Resident 18 was not provided bed-hold policies at the time of the resident's hospitalizations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to develop a baseline care plan for 1 of 2 sampled residents (#47) reviewed for constipation. This placed residents at risk for unmet care needs. Findings include: Resident 18 admitted to the facility on [DATE] with a diagnosis of paralysis after spinal surgery. A baseline care plan was initiated on 7/26/24 and did not include Resident 47 was to be log-rolled (ensuring the spine did not twist). The care plan was updated on 8/5/24 to include log rolling and spinal precautions, and no leg movement. An untitled therapy document form revealed on 8/5/24 therapy indicated a care plan change was made. The change indicated two staff were to assist Resident 47 for all bed mobility for log rolls, use spinal precautions, and to ensure no leg movement. A 7/31/24 admission MDS revealed Resident 47 was cognitively intact. On 8/26/24 at 3:32 PM Resident 47 stated the staff did not follow therapy directions for turning. On 8/27/24 at 1:35 PM Staff 15…

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 safe discharge planning services for 1 of 5 sampled residents (#16) reviewed for unnecessary medications. This placed resident at risk for unsafe discharge. Findings include: Resident 16 admitted to the facility in 11/2023 with diagnoses including third degree burns to her/his left chest, abdomen and thigh. A review of a 11/10/23 facility discharge summary revealed Resident 16 was discharged from the facility to home on [DATE] with orders for home health, and Resident 16 had orders for daily wound care to her/his burn wounds. A review of a 11/15/23 hospital history and physical revealed Resident 16 went to the emergence room due to her/his concerns of a wound infection, inability to care for self at home and home health did not come to Resident 16's home since discharge from the facility on 11/10/23. The burn wounds on Resident 16's left chest, left abdomen and left thigh were described as having increased pain and purulent…

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 1 of 3 sampled residents (#41) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: Resident 41 admitted to the facility in 1/2024 with diagnoses including diabetes. A 7/13/24 Quarterly MDS indicated Resident 41 had severe cognitive deficits. On 8/27/24 at 9:26 AM Resident 41 was observed to have dirty hair and dirty, jagged fingernails. An 8/28/24 review of shower/bathing documentation revealed the following: - On 7/26/24 shower/bathing activity did not occur due to resident refusal. - On 8/2/24 shower/bathing activity did not occur. - On 8/19/24 Resident 41 received a shower. There was no shower/bathing documentation between 8/3/24 and 8/18/24. An 8/29/24 medical record review revealed no evidence Resident 41 refused shower/bath or nail care on 7/30/24 or between 8/3/24 and 8/18/24. On 8/29/24 at 11:31 AM an observation of Resident 41's fingernails was made with Staff 18 (CNA). Staff 18…

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 assist residents to obtain prescription glasses for 2 of 2 sampled residents (#s 3 and 18) reviewed for vision. This placed residents at risk for impaired vision. Findings include: 1. Resident 18 admitted to the facility in 10/2018 with bowel and stomach dysfunction. A 6/13/24 Eye Exam Summary revealed Resident 18 reported blurred distant vision and a new prescription was provided. A 7/15/24 quarterly MDS revealed Resident 18 was cognitively intact. On 8/26/24 at 4:12 PM Resident 18 stated she/he had a vision appointment, was to get new glasses, but never received her/his glasses. On 8/28/24 at 12:22 PM and 3:16 PM Staff 4 (Social Services) and Staff 20 (Social Services Coordinator) stated Resident 18 just had her/his eyes examined and they did not have the after visit summary. If Resident 18 required new glasses the facility would assist the resident to obtain new glasses. Staff 4 and Staff 20 stated they did not know a new prescription was written. 2. Resident 3 admitted to the facility in…

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

Based observation, interview, and record review it was determined the facility failed to prevent pressure ulcers for 1 of 4 sampled residents (#47) reviewed for pressure ulcers. This placed residents at risk for skin injury. Findings include: Resident 47 admitted to the facility in 7/2024 with a diagnosis of paralysis after spinal surgery. A 7/25/24 admission Nursing Datbase (sic.) revealed Resident 47 did not have a pressure ulcer. A care plan was initiated on 7/26/24 indicating Resident 47 was at risk for pressure ulcers. Interventions included staff were to educate the resident and family on the requirements for positioning. 7/2024 and 8/2024 Progress Notes revealed the following: -7/26/24 Resident 47 was assisted to turn from side to side. The note did not indicate the frequency of turns. -7/27/24 no education was provided. -7/28/24 Resident 47 was assisted with bed mobility. The note did not indicate the frequency of bed mobility. -7/29/24 Resident 47 reported back incision pain and did not want to move any more than necessary. No education was provided. -7/30/24 Resident 47…

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 splint for 1 of 2 sampled residents (#2) reviewed for mobility. This placed residents at risk for worsening contractures. Findings include: Resident 2 admitted to the facility in 3/2010 with a diagnosis of cancer. Occupational Therapy Treatment Encounter Note dated 5/9/24 revealed staff obtained measurements for Resident 2's right finger splint to treat a contracture. An Occupational Therapy Discharge Summary form dated 6/27/24 revealed Resident 2 tolerated the right finger splint for approximately one hour. A care plan last revised on 7/5/24 did not include Resident 2 required a right finger splint. A 7/24/24 physician appointment note revealed Resident 2 was seen for right finger swelling and redness. The note indicated Resident 2 had a right finger contracture and a hand therapy referral for a finger splint was made. On 8/26/24 at 2:46 PM Witness 1 (Family) stated Resident 2 was not able to straighten her/his finger, needed a splint, but did not have one. On 8/27/24 at 1:59 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 interview and record review it was determined the facility failed to provide supervision during an outing involving alcohol for 1 of 1 sampled resident (#43) reviewed for change of condition. This placed residents at risk for accidents. Findings include: Resident 43 admitted to the facility in 2/2024 with diagnoses including alcohol use. A 6/1/24 Quarterly MDS indicated Resident 43 had moderate cognitive impairment. A review of a 7/30/24 progress note written at 2:26 PM revealed Resident 43 returned from an outing fatigued with a decreased level of responsiveness, was diaphoretic, had abnormal vitals signs and EMTs were called. A review of a 7/30/24 progress note written at 2:43 PM revealed Resident 43 returned to baseline after the EMTs arrived to the facility and refused to go to the hospital. Resident 43 reported he consumed four beers while out of the facility on an outing. An 8/2/24 public complaint alleged the facility failed to ensure resident safety regarding alcohol consumption during an outing and the facility failed to notify the resident representative in a…

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

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than five percent. There were 2 errors in 39 opportunities resulting in a 5.13 percent error rate. This placed residents at risk for adverse medication side effects. Findings include: Resident 301 admitted to the facility in 8/2024 with diagnoses including chronic pancreatitis (difficulty with food digestion) and chronic obstructive pulmonary disease. Resident 310's 8/2024 Physician Orders included the following: - Creon Oral Capsule Delayed Release (releases food digesting enzymes) 6000-19000 unit, administer three times a day with meals at 8:00 AM, 12:00 PM, and 5:30 PM. - Advair Diskus Inhalation Aerosol Powder Breath Activated (prevents shortness of breath) 250-50mcg/act, administer twice a day at 8:00 AM and 5:00 PM. Resident 301 was to rinse mouth and spit after inhalation to prevent oral thrush. On 8/28/24 from 9:23 AM to 9:38 AM Staff 5 (CMA/CNA) administered Resident 301's medications after breakfast which included Creon and Advair Diskus…

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 understood an arbitration agreement for 1 of 3 sampled residents (#47) reviewed for arbitration. This placed residents at risk for loss of legal rights. Findings include: Resident 47 admitted to the facility in 7/2024 with a diagnosis of diabetes. A 7/31/24 admission MDS revealed Resident 47 was cognitively intact. A Patient and Facility Arbitration Agreement revealed Resident 47 signed the agreement on 7/25/24. On 8/28/24 at 3:29 PM Resident 47 stated she/he did not recall signing anything regarding an arbitration agreement. The resident stated she/he was so drugged up and no one followed up with her/him regarding an arbitration agreement. On 8/29/24 at 10:43 AM Staff 3 (Social Service Director) stated she was responsible for all admission paperwork, including arbitration agreements. Staff 3 stated she explained the arbitration agreement, it's meaning, and the option to sign the arbitration agreement or not. Staff 3 stated she did not follow up with residents after they signed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 3 sampled residents (#s 3, 5 and 6) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: 1. Resident 3 admitted to the facility on [DATE] with diagnoses including chronic pain. A 6/18/23 admission MDS indicated Resident 3's BIMS score was 13 indicating she/he was cognitively intact. Resident 3 required one-person physical assist with showers. A 6/2023 Documentation Survey Report indicated from 6/14/23 through 6/30/23 the following: -Page 12 ADL-Bathing Shower Sunday and Wednesday evenings: NA (Not applicable) was documented five times. 6/14/23, 6/18/23, 6/21/23, 6/25/23 and 6/28/23. -Page 16 ADL-Bathing Shower Sunday and Wednesday evenings; RR (resident refused) was documented on 6/18/23 and 6/21/23, no documentation on 6/25/23, and it was documented Resident 3 had a shower on 6/28/23 (18 days without bathing). A 6/19/23 Health…

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 provide sufficient staffing to meet the needs of residents for 3 of 4 sampled residents (#s 6, 8 and 9) and 1 of 3 halls (North) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 6 was admitted to the facility in 2023 with diagnoses including paraplegia and anxiety disorder. An 8/30/20 care plan indicated Resident 6 was at risk for falls with interventions which included to remind Resident 6 to use her/his call light for assistance and for staff to promptly respond to all requests for assistance. An 8/9/23 admission MDS indicated Resident 6's BIMS score was 15 which indicated she/he was cognitively intact. Resident 6 required extensive two-person assistance with bed mobility and transfers. A Page Report (call light time log) from 8/9/23 through 8/30/23 revealed the following call light wait times for Resident 6: -8/11/23: 6:58 AM, 38 minutes; 5:40 PM, 57 minutes -8/12/23:…

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 residents were free from verbal abuse for 2 of 3 sampled residents (#s 4 and 5) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 4 was admitted to the facility in 2020 with diagnoses including stroke. An 8/19/23 FRI indicated on 8/18/23 Resident 4 and Resident 5 were in the dining room having a conversation. Resident 5 suddenly started yelling at Resident 4, and called her/him and asshole and mother fucker. Staff 11 (CNA) and Staff 12 (CNA) witnessed the incident and attempted to redirect Resident 5 but had a difficult time calming her/him down. An 8/19/23 Incident Investigation revealed Resident 4 and Resident 5 were in the dining room for dinner on 8/18/23 and were having a conversation while waiting for dinner. Resident 5 started to yell at Resident 4 and called her/him an asshole and a mother fucker. The CNA attempted to redirect Resident 5 but had a difficult time calming her/him down. Neither resident wanted to leave the dining room table at which they…

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

Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#6) reviewed for catheter. This placed residents at risk for ineffective treatment of her/his infection. Findings include: When Vancomycin (an antibiotic medication used to treat several bacterial infections) was used in the treatment of infections, drug monitoring (a Vancomycin trough) is required to establish the concentration of medication in the blood just prior to administration of the next dose. This allows for adjustments to the prescribed dosage by the physician or pharmacist. If Vancomycin concentration in the blood is below therapeutic levels, the result is an ineffective treatment of infection with serious potential consequences. If the concentration is above therapeutic levels it can result in Vancomycin toxicity which can lead to serious consequences including acute renal (kidney) failure. Resident 6 was admitted to the facility in 2023 with diagnoses including methicillin resistant staphylococcus aureus (MRSA a bacterium which is…

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

Based on observation, interview and record review it was determined the facility failed to provide adequate catheter care for 2 of 3 residents reviewed for catheterization (#s 3 and 6) reviewed for catheter. This placed residents at risk for unmet catheter needs. Findings include: A revised facility In-dwelling Urinary Catheter Policy and Procedure indicated a care plan development would address the catheter use which may include management of the catheter, bag and tubing changes, prevention of drag on the catheter tubing, maintenance of the catheter bag below the level of the resident's pelvis, routine catheter care, fluid intake, preserving resident dignity and monitoring for signs of complications. Resident 3 was admitted to the facility in 2023 with diagnoses including obstructive and reflux uropathy (a blockage of the normal flow of contents of the urinary tract). A 6/13/23 care plan indicated Resident 3 had a urinary catheter and would remain free of catheter related trauma with interventions including position bag and tubing below level of bladder, ensure tubing was free of…

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

Based on interview and record review it was determined the facility failed to monitor behaviors related to dementia for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk for unmet dementia care needs. Findings include: Resident 5 admitted to the facility in 2022 with delusional disorders and dementia. An 4/5/23 Annual MDS and Psychotropic CAA revealed Resident 5 had behaviors which included impulsiveness, yelling, swinging at staff, refusal of care, and arguing with other residents. Resident 5 also made disturbing sexual comments and stated she/he wanted to commit rape. Resident 5 was scheduled to visit with psychiatry and her/his mood was better. Staff were to administer medication as ordered, ensure pharmacist review per protocol, and engage psychiatry as needed. An 4/9/22 care plan indicated Resident 5 had a history of resident-to-resident incidents with interventions including monitor for changes in behavior and the effectiveness of interventions, and attempt to redirect and monitor for signs and symptoms of psychological distress. If Resident 5…

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 administer medications as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#2) reviewed for safe medication system. This placed residents at risk for adverse medication consequences. Findings include: Resident 2 admitted to the facility in 2022 with diagnoses including malnutrition, cirrhosis (degenerative disease of the liver resulting in scarring and liver failure) of the liver. A 11/9/22 care plan indicated Resident 2 was on Hospice services. A 11/17/22 Alert Note indicated family was contacted by phone and notified Resident 2 was declining and if family wanted to visit they should come. The Chaplin was with Resident 2 in her/his room. A 11/18/22 Incident Note indicated Staff 3 (RN) administered sorbitol (to treat constipation), senna (to treat constipation), and Pepsi (to break up obstructions in tubing) through Resident 2's PICC (peripherally inserted central catheter, a long line inserted in a vein to be passed through to larger vein near heart) instead of the…

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

Based on interview and record review it was determined the facility failed ensure physician orders were followed for 3 of 6 sampled residents (#s 33, 42 and 54) reviewed for ADLs, nutrition and dialysis. This placed residents at risk for unmet needs. Findings include: 1. Resident 33 was admitted to the facility in 2022 with diagnoses including diabetes. An 8/29/22 care plan revealed Resident 33 attended dialysis three days a week on Tuesday, Thursday and Saturday. The care plan also indicated Resident 33 had diabetes with interventions including providing diabetes medication as ordered by the physician. An 4/2023 TAR instructed staff to inject Lispro insulin before meals on a sliding scale if blood sugar levels were between 90 and 180 and to administer eight units of insulin. If blood sugar levels were over 161 to inject 10 units of insulin. Staff were to hold insulin if blood sugar levels were below 90 or if Resident 33 was not eating. A review during the lunch time insulin administration revealed the following: -4/4/23 indicated Resident 33 was out of facility without 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.

1. Based on interview and record review it was determined the facility failed to ensure fall investigations were thorough for 3 of 5 sampled residents (#s 15, 41 and 42) reviewed for accidents and care planning. This placed residents at risk for continued falls and neglect of care. Findings include: a. Resident 15 was admitted to the facility in 2022 with diagnoses including an unspecified brain disorder. A 2/3/23 Annual MDS and associated CAAs indicated Resident 15 required extensive assistance with ADLs, had falls in the facility and was at risk for continued falls. A care plan was to be developed to provide interventions to minimize the risk of falls. Resident 15's care plan initiated 1/27/22 revealed the resident was at risk for falls related to impaired balance. The care plan had multiple interventions and revisions including the resident was to have frequent checks to ensure the resident was safe and her/his needs were met. An 4/9/23 Fall investigation indicated Resident 15 fell on 4/9/23 at 1:45 PM. The investigation did not indicate the last time the resident was last…

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 residents for 7 of 9 sampled residents (#s 6, 13, 15, 18, 25, 58 and 202) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 6 was admitted to the facility in 3/2023 with diagnoses including femur fracture. An 4/4/23 admission MDS revealed Resident 6 had a BIMS of 14 indicating she/he was cognitively intact. On 5/3/23 at 8:34 AM Resident 6 stated she/he had to wait for the call light to be answered at times and it resulted in incontinence. The 3/30/23 through 4/5/23 call light response log for Resident 6's room revealed the following call light wait times over 20 minutes: - 3/30/23 at 10:09 AM: 42 minutes - 3/30/23 at 4:16 PM: 40 minutes - 3/30/23 at 8:42 PM: 40 minutes - 3/31/23 at 12:32 PM: 38 minutes - 4/1/23 at 6:18 AM: 29 minutes - 4/1/23 at 12:07 PM: 21 minutes - 4/2/23 at 8:07 AM: 22 minutes - 4/2/23 at 8:45 AM: 24 minutes - 4/3/23 at 7:43 AM: 46 minutes - 4/3/23 at 9:24 AM: 25 minutes -…

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 treat residents with respect and dignity for 2 of 9 sampled residents (#s 13 and 55) reviewed for abuse and hospice. This placed residents at risk for lack of dignity. Findings include: 1. Resident 55 was admitted to the facility in 7/2020 with diagnoses including depression. Review of an undated incident investigation revealed on 3/30/23 Resident 55 turned on her/his call light for assistance while getting ready for a resident outing. When the resident did not receive assistance, after some time, the resident started to ring a silver desk bell to get the staff's attention. Resident 55 was worried she/he would miss the outing. Staff 6 (CMA) entered the resident's room and told the resident to stop ringing the silver desk bell. The investigation indicated Staff 6 said she was going to take away her/his silver desk bell and attempted to take it from the resident. Resident 55 moved the desk bell away from Staff 6 and Staff 6 walked out of the room and closed the resident's door. The investigation concluded…

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 a comprehensive care plan for 1 of 1 sampled resident (#202) reviewed for unnecessary medication. This placed residents at risk for unmet needs. Findings include: Resident 202 was admitted to the facility in 2023 with diagnoses including atrial fibrillation (abnormal heart rhythm), COPD (chronic obstructive pulmonary disease) and high blood pressure. Resident 202's 4/2023 MAR indicated the resident received an anticoagulant for atrial fibrillation, multiple inhalers for COPD and multiple blood pressure medications. Resident 202's care plan dated 3/7/23 did not include safety interventions and monitoring for bruising or bleeding related to anticoagulant use, or safety interventions and monitoring for multiple medications for COPD and high blood pressure placing the resident at risk for adverse side effects. On 5/4/23 at 9:36 AM Staff 3 (LPN Resident Care Manager) acknowledged Resident 202 received an anticoagulant medication which placed the resident at risk for bruising and bleeding,…

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 routine medication was obtained timely for 2 of 6 sampled residents (#s 11 and 41) reviewed for pain and medications. This placed residents at risk for medication withdrawal symptoms. Findings include: 1. Resident 11 was admitted to the facility in 9/2022 with diagnoses including ankylosing spondylitis (inflammatory arthritis). Resident 11's 9/22/22 MDS and associated CAAs indicated she/he was alert and oriented. A 1/2023 MAR revealed Resident 11 was to be administered Methadone (narcotic pain medication) four times a day at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. On 1/14/23, a Saturday, Resident 11 did not receive her/his 5:00 PM and 9:00 PM doses. The resident also did not receive the 1/15/23 9:00 AM dose. The 1/14/23 at 4:53 PM Progress Notes indicated the Methadone was on order and the 8:29 PM note indicated the pharmacy was called and the prescription was not authorized to be filled until 1/15/23. There were no additional notes in the resident's record to indicate the physician was called 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 pharmacy review recommendations were addressed by the physician for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for subtherapeutic medication levels. Findings include: Resident 15 was admitted to the facility in 2022 with diagnoses including depression. Resident 15's current medications last reviewed 4/25/23 revealed the resident was to be administered sertraline (treats depression) 25 mg daily. A Recommendation Summary for Medical Director and DON (Director of Nursing) form dated 2/20/23 indicated Resident 15's current dose of sertraline was 25 mg daily. The dose was noted to be very low and the pharmacist indicated the resident could benefit from a dose of 50 mg or higher. On 5/3/23 at 9:16 AM Staff 4 (RNCM) stated she did not find a response from the 2/20/23 pharmacy recommendation for Resident 15.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from a medication error rate less than 5 percent. There were 3 errors in 31 opportunities resulting in a medication error rate of 9.7 percent. This placed residents at risk for adverse medication consequences. Findings include: Resident 18 was admitted to the facility in 2020 with diagnoses including diabetes. On 5/2/23 at 4:15 PM Staff 25 (CMA) was observed to prepare and deliver, lactulose (treats constipation), bupropione (treats depression), metformin (treats diabetes), diclofenac (decreases inflammation) and Tylenol (treats pain) to Resident 18. Staff 25 left the medications at the bedside and stated Resident 18 was assessed and staff were allowed to leave medications at the bedside. Review of the resident's record revealed there was a Self Administration of Medication Evaluation form dated 9/3/21 for staff to leave medications at the bedside. The assessment indicated the medication to be left at the bedside included bupropione and Tylenol. The form did not…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents received coordination for end-of-life care for 1 of 1 sampled resident (#13) reviewed for hospice. This placed residents at risk for a lack of coordination of care. Findings include: Resident 13 was admitted to the facility in 2023 with diagnoses including dysphagia (difficulty in swallowing food or liquid) following a stroke. The facility's 1/30/23 signed Hospice Contract with the facility agreed to observe, and record on a regular basis, the resident's response to treatment and the facility agreed to notify hospice immediately of any change in condition of the hospice resident. A hospice care plan with a certification period of 1/18/23 through 3/18/23 revealed safety measures of Resident 13 included aspiration precautions with a regular diet. On 5/1/23 at 10:34 AM and at 1:01 PM Resident 13 stated she/he had difficulty eating as she/he could not chew the food. Resident 13 revealed the inside of her/his mouth; no teeth were visible. Resident 13 stated she/he did not like 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.