South Hills Rehabilitation Center

Based on interview and record review, the facility failed to report an allegation of abuse for 3 of 3 sampled residents reviewed for abuse resident (#s 43, 49 and 69). This placed residents at risk for uninvestigated abuse. Findings include: The Abuse Policy revised 5/14/23 states abuse included verbal abuse. The policy applies to any who is an owner, operator, employee, manager, agent or contractor of the facility. It further states it is not necessary for the reporter to categorize the event as abuse for the facility to consider the potential for abuse and act accordingly and it remains the responsibility of the covered individual to verify the report (to appropriate entity) timely.1. Resident 43 was admitted in 6/2025 with diagnoses including respiratory failure.Resident 43's admission MDS completed in 6/2025 revealed a BIMS score of 14, indicating the resident was cognitively intact.1. Resident 43 was admitted in 6/2025 with diagnoses including respiratory failure.Resident 43's admission MDS completed in 6/2025 revealed a BIMS score of 14, indicating the resident was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to inform the resident of the Bed Hold Policy for 2 of 2 sampled residents (#40 and 72) reviewed for hospitalization. This placed residents at risk for being uninformed of their rights. Findings include: Resident 40 was admitted to the facility in 1/2023 with diagnoses including Type 2 diabetes mellitus. Resident 40 has a BIMS of 15 (cognitively intact). The undated Bed Hold Policy stated before the facility transferred a resident to a hospital the facility shall provide the resident a copy of the Bed Hold Policy and document in the resident's record whether the resident or resident's representative declined or agreed to pay to hold the bed. According to the policy, if a resident was unable to make a decision due to physical or mental incapacity and there was no legal representative to make a decision, the information would be documented in the resident's clinical record. A 3/4/25 Progress Note indicated Resident 40's roommate informed staff Resident 40…

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 follow physician orders related to labs for 1 of 1 sampled residents (#62) reviewed for mood and behavior. This placed residents as risk for unmet needs. Findings include:Resident 62 was admitted to the facility on [DATE] with diagnoses including a stroke with fluency disorder (disrupts the natural flow of speech) and depression. The 7/28/25 psychiatric admission progress note indicated a new order for CBC (Complete Blood Count) lab.A review of Resident 62's medical record revealed no indication a CBC lab draw was obtained.On 8/11/25 at 2:22 PM Staff 2 (DNS) stated she was not aware of the laboratory order for Resident 62, and it was not completed.

Based on observations, interviews, and record reviews it was determined the facility failed to monitor a resident after a fall for 1 of 3 sampled residents (# 10) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 10 was admitted to the facility in 7/2025 with diagnoses including stroke.A Fall Investigation Report indicated that on 6/12/25 at 4:10 AM, Staff 24 (Former LPN) responded to Resident 10's call light and found her/him on the floor next to her/his bed. It was determined Resident 10 fell out of bed and her/his roommate activated the call light. Resident 10 was unable to recall how she/he ended up on the floor and did not know if she/he struck her/his head.On 6/12/25 at 4:10 AM, neurological checks were initiated. The Neurological Check Assessment form directed staff to complete neurological checks every 15 minutes for one hour, every 30 minutes for one hour, and every hour for four hours. Resident 10's clinical record contained documentation of only one neurological assessment.On 8/11/25 at 11:00 AM, Staff 23 (LPN) stated that when 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 and interview the facility failed to ensure refuse containers were covered for 1 of 1 exterior refuse containers. This placed residents at risk for pest infestations. Findings include:On 8/4/25 at 9:45 AM, the outdoor refuse container for the facility was observed during a walk through with Staff 9 (Dietary Manager) of the outdoor trash and recycling area for the facility. The lid to the dumpster was open with a gap of about twelve to fifteen inches between the lid and body of the dumpster at the front of the unit. Staff 9 stated the staff did not always close the dumpster because it was difficult to close. When Staff 9 attempted to close the lid of the dumpster, he was unable to do so and stated the cranking mechanism used to close the dumpster appeared to be broken.

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 5 sampled residents (#14, 17, and 22) and 2 of 2 floors (1st floor and 2nd floor) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 17 admitted to the facility in 4/2024 with diagnoses including paraplegia and pressure ulcer. A review of Resident 17's care plan dated 4/16/24 indicated Resident 17 was at risk for falls and to ensure the resident's call light was in reach, to encourage the resident to use it for assistance, and she/he needed prompt response to all requests for assistance. A review of Resident 17's admission MDS dated [DATE] revealed Resident 17's BIMS score was 15 which indicated she/he was cognitively intact. On 10/8/24 at 10:10 AM Resident 17 stated the facility was short-staffed in 8/2024 and 9/2024 and there were times when here/his call light was activated for multiple hours 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 observation, interview, and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: A review of the Direct Care Staff Daily Reports (DCSDR) from 7/1/24 through 7/30/24, and 8/1/24 through 8/31/24 revealed the following: -7/3/24 no census documented on evening and night shift. -7/7/24 no census documented on night shift. -7/8/24 no DCSDR completed. -7/17/24 no hours worked documented for CNAs on day shift. -7/18/24 no DCSDR completed. -7/21/24 no census documented on night shift -8/10/24 no census documented on night shift -8/23/24 day shift census documented as 27, evening shift documented as 29 and night shift documented as 74. (8/22/24 census was 74 on day shift and 73 on evening and night shift.) A review of Daily Punches (staff time sheet) dated 8/15/24 and 8/28/24 revealed the following: -8/15/24 evening shift: four CNA staff worked a total of 32.5 hours, plus one CNA worked two…

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 protect residents' right to be free from verbal abuse by staff for 1 of 3 residents (#10) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include: Resident 10 admitted to the facility in 9/2024 with diagnoses including chronic ulcer to left lower leg, and fracture to the sacrum. An Investigation Report, with an investigation date from 10/3/24 through 10/8/24, revealed on 10/3/24 at approximately 11:00 AM Resident 10 asked Staff 17 (Admissions Coordinator) to assist with filling out a grievance form. Resident 10 stated she/he was asleep and Staff 4 (CNA) came into the room and, with a loud voice, stated I need your vitals. Staff 4 was loud enough to wake Resident 10 from a deep sleep. Resident 10 stated she/he did not know why Staff 4 was yelling. Staff 4 continued to yell and his voice got louder. Resident 10 stated she/he raised her/his voice to match Staff 4's voice. Staff 4 informed Resident 10 he was at the facility for three years and stated he was going to do what 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 report investigations timely to the State Survey Agency for 3 of 6 sampled residents (#s 12, 19, and 20) reviewed for medications, abuse, and neglect. This placed residents at risk for abuse and neglect. Findings include: 1. Resident 12 admitted to the facility in 9/2024 with diagnoses including anxiety and a leg fracture. A FRI form dated 9/22/24 indicated an incident was reported to the State Agency on 9/22/24 for an unknown incident date. A related Investigation Report with an investigation date of 9/22/24 through 9/27/24 was received by the State Agency on 10/2/24. On 10/16/24 at 10:49 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated Staff 2 thought she emailed the investigation timely, but she did not, and confirmed the investigation was sent late to State Agency. 2. Resident 19 admitted to the facility in 5/2024 with diagnoses including pain and surgical aftercare. A FRI form dated 6/24/24 indicated an incident was reported to the State Agency on 6/24/24 for 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 conduct timely or thorough investigations for 3 of 6 sampled residents (#s 11, 19, and 20) reviewed for medications and accidents. This placed residents at risk for falls, uncontrolled pain, and overdose. Findings include: 1. Resident 11 admitted to the facility in 3/2023 with diagnoses including arthritis. Review of a Progress Note dated 6/3/24 revealed Resident 11 was found on the floor next to her/his bed laying on her/his left side. A review of an Un-witnessed Fall investigation dated 6/3/24 revealed Resident 11 was found on the floor next to her/his bed laying on her/his left side. The investigation was completed on 6/26/24. On 10/16/24 at 10:39 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed Resident 11's fall investigation for her/his 6/3/24 fall was completed late. 2. Resident 19 admitted to the facility in 5/2024 with diagnoses including pain and surgical aftercare. A review of the TAR dated 6/2024 instructed staff to change Resident 19's right lower…

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 facility staff failed to follow professional standards of practice during care and services for 1 of 3 (#12) sampled residents reviewed for abuse and neglect. This placed residents at risk for abuse and neglect. Findings include: Resident 12 admitted to the facility in 9/2024 with diagnoses including a leg fracture. A FRI was received on 9/23/24 which indicated Staff 7 (CNA) was a little too personal with her. Staff 7 spent too much time with Resident 12, rubbed cream on her/his buttocks and massaged her/his right hip in a way which felt inappropriate, and unlike any other staff. Staff 7 also gave Resident 12 a big hug. Staff 7 provided his personal phone number to Resident 12 and reported to her/him that he could be her/his personal caregiver at her/his home when she/he discharged from the facility. Staff 7 also spent way too much time with Resident 12 and came into her/his room and visited with her/him. On 10/8/24 at 12:58 PM Resident 12 stated Staff 7 massaged her/his leg, and no other CNAs were massaging her/him. Staff 7…

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 2 of 3 sampled residents (#s 21 and 22) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 21 admitted to the facility in 8/2024 with diagnoses including dementia and anxiety. A review of Resident 21's care plan dated 8/20/24 indicated Resident 21 had an ADL self-care performance deficit and required substantial to maximal assistance from staff with bathing. The admission MDS dated [DATE] revealed Resident 21's BIMS score was four, which indicated severe cognitive impairment. A review of the Documentation Survey Report (DSR) for 8/20/24 through 8/31/24 revealed Resident 21's bathing days were Monday and Thursday, and she/he required substantial to maximal assistance from staff for bathing on 8/22/24. On 8/26/24 there was no documentation Resident 21 received bathing. On 8/29/24 documentation indicated Resident 21 refused…

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 related to controlled medications were complete and accurate for 1 of 3 sampled residents (#20) reviewed for medications. This placed residents at risk for medication errors. Findings include: Resident 20 admitted to the facility in 5/2024 with diagnoses including a leg fracture. Review of the 9/2024 Narcotic Logbook (NLB) revealed the following regarding oxycodone (narcotic pain medication) related to Resident 20: Oxycodone five mg one tablet twice daily PRN start date 9/18/24: -9/20/24 4:30 AM one tablet, 8:13 AM two tablets, and 8:45 PM two tablets. -9/21/24 2:15 AM two tablets, 7:07 AM one two tablets, 1:30 PM two tablets, 4:19 PM one tablet, 8:45 PM two tablets. -9/22/24 7:05 AM two tablets 9/27 (under 9/22/24) 8:30 PM two tablets. -9/23/24 7:19 AM one tablet, 1:04 PM one tablet, and 8:35 PM two tablets. -9/24/24 9:34 AM one tablet, 1:19 PM two tablets, and 7:30 PM one tablet. Resident 20 was administered two tablets instead of one on nine occurrences and was administered over…

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 address resident choice for 5 of 22 sampled residents (#s 2, 18, 30, 35, and 38) reviewed for dining. This placed residents at risk for lack of choice and meal satisfaction. Findings include: On 3/18/24 at 10:45 AM and 11:51 AM posted daily menus were observed in the facility on the first and second floors and no weekly menus were found. On 3/18/24 at 11:41 AM Resident 35 stated she/he normally ate in her/his room and she/he no longer had choices available regarding her/his meal selections because the option was taken away. On 3/18/24 at 12:23 PM Resident 30 stated both snack and meal choices were changed, were inadequate, and she/he planned to discuss these concerns with Staff 1 (Administrator). On 3/18/24 at 12:48 PM Resident 2 stated the facility implemented a new system and the daily choice to receive one of two meal options was no longer available. Resident 2 stated she/he was aware the kitchen required a three hour notice for menu changes but the only available menu was posted 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 interview and record review it was determined the facility failed to respond timely to resident concerns related to dining for 1 of 1 Resident Council reviewed for dining. This placed residents at risk for unresolved dining issues. Finding include: The 11/2023 Council Minutes indicated: -Residents had concerns that the always available menus were not current in residents' rooms on the first floor. The facility responded that the menus would be updated. -Residents asked what day the weekly menu would be available each week. The facility responded on Wednesday for the next week. The 1/2024 Council Minutes indicated no old business was reviewed. The 2/2024 Council Minutes indicated residents with dietary concerns were to attend the Dining Committee and no old business was reviewed. The 3/13/24 Council Minutes indicated residents requested weekly menus so residents could make menu choices. The facility responded they could send out a week at a glance menu to residents. On 3/21/24 at 2:35 PM Staff 31 (Dietary Manager) and Staff 16 (RD) acknowledged printed menus for residents…

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 it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for lack of timely written communications. Findings include: On 3/19/24 at 3:05 PM during a Resident Council meeting Resident 23 stated for a long time residents did not receive mail on Saturdays. On 3/21/24 at 12:04 PM, Staff 40 (Activity Director) stated when the facility had an activity assistant mail was delivered on Saturdays. The facility currently did not have anyone in that position. For approximately the last month mail was not delivered on Saturdays.

Based on observation and interview it was determined the facility failed to ensure past survey results were readily available for 1 of 1 facility reviewed for survey results. This placed residents and visitors at risk for not being informed of the facility's survey results. Findings include: On 3/19/24 at 3:05 PM during the resident council interview residents stated they did not know where the past survey results were kept and they thought it was at the nurses' station. On 3/21/24 at 10:23 AM the past survey results were observed in a clear wall mounted bin that was labeled Requests, concerns, and suggestions. In the front of the survey binder, obscuring it from view, was information regarding following rules for visits, grievance forms, and other unrelated facility forms. On 3/21/24 at 10:25 AM Staff 1 (Administrator) confirmed the above noted location was where the facility normally kept the survey results.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide care and treatment to prevent accidents for 4 of 10 sampled residents (#s 4, 22, 35, and 220) reviewed for accidents, hospice, ADLs and medications. This placed residents at risk for injury. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including dysphagia (a condition with difficulty in swallowing food or liquid). The most recent comprehensive care plan for Resident 4 revealed the following: -Interventions for nutrition: supervision and set up assistance for eating, needs to be UP in wheelchair for all meals, cue to take small sips between bites, mug with handle, lid and straw as needed. -Swallowing problem with coughing or choking during meals, order for thickened liquids. Interventions: small bites and sips, use teaspoon for eating, Do not use straws. Eat in upright position, eat slowly, chew each bite thoroughly, Supervision/frequent checks with meals. Resident 4 ate in the dining room.…

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

Based on interview, and record review it was determined the facility failed to have adequate staff available to meet the needs of residents in a timely manner for 1 of 14 sampled residents (#10) and 1 of 2 floors (2nd floor) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 10 admitted in 2020 with diagnoses including difficulty in walking and a stroke. A 11/1/23 care plan indicated Resident 10 required supervision and touching assistance with transferring on and off the bedside commode and was dependent on staff for toileting hygiene, and adjusting of clothing before and after toileting. A 2/12/24 annual MDS indicated Resident 10 was continent of bowel and bladder and was cognitively intact with a BIMs of 15. On 3/19/24 at 6:40 AM Resident 10 stated call light wait times were over 15 minutes and about once a month over 30 minutes. Resident 10 stated she/he had incontinent episodes multiple times because she/he had to wait for assistance. A 3/2024 Documentation Survey Report indicated Resident 10 was incontinent on the evening shift…

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 registered nurse for 8 consecutive hours per day 7 days per week for 15 out of 123 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: Review of the Direct Care Staff Daily Reports from 5/1/23 through 5/31/23, 6/1/23 through 6/31/23, 8/1/23 through 8/31/23 and 2/17/24 through 3/17/24 revealed the facility did not have RN coverage on all three shifts on the following days: 5/18/23, 5/24/23, 5/30/23, 5/31/23, 6/6/23, 8/1/23, 8/2/23, 8/9/23, 8/15/23 2/18/24, 2/27/24, 3/3/24, 3/5/24, 3/10/24, and 3/12/24. On 3/22/24 at 10:10 AM in an interview with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) it was stated the facility continued actively hiring staff.

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 18, 19, 20, 21, and 22) reviewed for staffing. This placed residents at risk for lack of competent staff. Findings include: On 3/21/24 at 9:50 AM Staff 1 (Administrator) provided the most recent performance reviews for Staff 18 (CNA), Staff 19 (CNA), Staff 20 (CNA), Staff 21 (CNA), and Staff 22 (CNA). - Staff 18 was hired on 12/14/13 and the facility was unable to provide a performance review. - Staff 19 was hired on 1/9/19 and the facility was unable to provide a performance review. - Staff 20 was hired on 10/7/21 and the facility was unable to provide a performance review. - Staff 21 was hired on 12/18/15 and the facility was unable to provide a performance review. - Staff 22 was hired on 12/14/21 and the facility was unable to provide a performance review. On 3/21/24 at 10:43 AM Staff 1 (Administrator) confirmed there were no performance reviews for Staff 18, Staff 19, Staff 20, Staff 21, and Staff 22.

Based on interview and record review it was determined the facility failed to adequately monitor psychotropic medications for 1 of 5 sampled residents (#19) reviewed for medications. This placed residents at risk for lack of effective medication management. Findings include: Resident 19 was admitted to the facility in 1/2020 with diagnoses including bipolar disorder with depression, personality disorder and agoraphobia (fear of entering crowded places) with panic disorder. A review of Resident 19's Physician Orders dated 2/2024 revealed the following medications: -Duloxetine (for depression) 120 mg, two tablets for mood disorder with depression. -Rexuliti (an antipsychotic) 1 mg at bedtime for bipolar disorder. A review of Resident 19's 2/2024 and 3/2024 MARs revealed facility staff were to monitor for adverse reactions to the antidepressant and antipsychotic medications each shift. Review of the monitoring documentation revealed the following: -2/2024: out of 87 opportunities facility staff did not monitor Resident 19 for adverse reactions to her/his antidepressant or antipsychotic…

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

Based on observation and interview it was determined the facility failed to ensure waste was properly contained in the garbage storage area for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for exposure to pathogens related to pests. Findings include: On 3/21/24 at 12:36 PM the outside garbage area was observed with a garbage container lid open and on the ground of the surrounding area was observed broken doors, unused resident commodes, dirty disposable gloves, miscellaneous wood pieces, and outdoor debris accumulated in the corner of the building. On 3/21/24 at 12:40 PM Staff 42 (Maintenance Director) acknowledged the garbage area was dirty, not organized, and Staff 42 lacked the time since 2/2024 to clean it. On 3/21/24 at 12:44 PM Staff 41 (CNA) stated she came outside routinely and the garbage area frequently had debris around it including dirty disposable gloves on the ground. On 3/22/24 at 9:11 AM the outside garbage area was observed with Staff 31 (Dietary Manager). The lid on the garbage container was open and multiple dirty gloves 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 submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information. Findings include: Review of the Payroll Based Journal Staffing Data for fiscal year, quarter two, 2023 (4/1/23 through 6/30/24) indicated the facility failed to submit required data for the quarter. On 3/22/24 at 10:10 AM in an interview with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) it was stated the corporate office handled submitting data and they were unaware it was not submitted.

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 4 sampled residents (#4) and 1 of 2 floors (1st floor) reviewed for accidents and infection control. This placed residents at risk for cross contamination. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including prostate cancer. An 8/14/23 care plan indicated Resident 4 had a catheter due to a history of prostate cancer and urinary retention. On 3/19/24 at 8:25 AM Resident 4 was observed with her/his catheter bag attached to small garbage can next to the bed. On 3/20/24 at 8:58 AM and 9:33 AM Resident 4 was observed in the dining room with her/his catheter bag attached to her/his wheelchair with approximately one fourth of the catheter bag in contact with the floor and falling out of the privacy bag. On 3/20/24 at 11:27 AM Staff 12 (Agency CNA) stated she attached Resident 4's catheter bag to the garbage can as the bed was in a low position…

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 were assessed to self-administer medications for 2 of 2 sampled residents (#s 13 and 47) reviewed for pain and dialysis (process to remove fluids and waste from the blood when kidney function fails). This placed residents at risk for an ineffective medication regimen. Findings include: 1. Resident 13 was admitted to the facility in 2022 with a diagnosis of kidney disease. A 2/16/24 Progress Note by Staff 16 (RD) revealed she spoke to the RD at the dialysis center for Resident 13. The note indicated Staff 16 would communicate with the resident's unit manager and see if the resident was appropriate to self-administer a phosphorous binder (medication to lower the mineral phosphate in the blood). Staff 16 also communicated with the unit manager on ensuring staff administered Resident 13's phosphorous binder with meals and not before or after meals. A 3/3/24 quarterly MDS revealed Resident 13 was cognitively intact. On 3/21/24 at 2:35 PM Resident 13 stated she/he was capable 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 notify residents' representatives regarding changes in status or condition for 3 of 9 sampled residents (#s 19, 41, and 220) reviewed for notification failure and medications. This placed residents and responsible parties at risk for delayed notification. Findings include: 1. Resident 41 was admitted to the facility in 2022 with a diagnosis including respiratory failure. A 9/14/23 at 4:10 PM Nursing Note indicated Witness 3 (Family Member-emergency contact) called to check status of Resident 41 and no one informed her Resident 41 had COVID-19. A 9/14/23 at 6:24 PM Nursing Note indicated Staff 14 (Former DNS) called Witness 3 regarding communication complaints. Staff 14 apologized for poor communication and provided an update on Resident 41's status. On 3/21/24 at 12:13 PM Staff 13 (Social Services) stated the nurse was to notify the family member when a resident obtained COVID-19. Staff 13 stated she only sent out general notifications of COVID-19 in the building. On 3/19/24 at 8:59 AM Witness 3 stated she…

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

Based on observation and interview it was determined the facility failed to ensure rooms were homelike and in good repair for 2 of 10 sampled residents (#s 2 and 7) reviewed for environment. This placed residents at risk for lack of a homelike environment and disrepair. Findings include: Random observations from 3/18/24 through 3/21/24 revealed the following: -The footboard of Resident 7's bed was damaged. It was mended with electrical tape encircling its entire vertical width. Additionally, the fractured segment was angled away from the mattress, failing to align seamlessly with the bed. -A wall in Resident 2's room had multiple large gouges that exposed the underlying drywall, along with numerous black vertical streaks extending approximately four feet in width and four feet in length. On 3/18/24 at 12:57 PM Resident 2 stated the black marks and exposed drywall were present for approximately six to seven months back to when she/he moved rooms. On 3/21/24 at 11:43 AM Staff 42 (Maintenance Director) stated he was aware Resident 7's footboard was broken for roughly two weeks, but did…

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 missing items were addressed timely for 1 of 2 sampled residents (#22) reviewed for personal property. This placed residents at risk for loss of meaningful items. Findings include: Resident 22 admitted to the facility in 2024 with a diagnosis of heart disease. On 3/18/24 at 12:38 PM Witness 8 (Family Member) stated approximately one month prior, in 2/2024, he reported to the laundry staff Resident 22's favorite shirt was missing and approximately two weeks ago the resident's new blanket went missing. Witness 8 indicated the staff stated they would look for the items but after he reported the missing items no resolution was provided. On 3/19/24 at 13:35 PM Staff 38 (Regional Director of Clinical) stated there were no missing item forms filled out for Resident 22. On 3/20/24 at 9:32 AM Staff 3 (Laundry Manager) stated a hand-written note was provided to the laundry staff indicating the resident lost a blanket. Staff looked for the item, but did not yet find it. The item did not have 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 monitor and assess the continued use of a physical restraint for 1 of 4 sampled residents (#4) reviewed for accidents. This placed residents at risk for potential abuse or neglect. Findings include: Resident 4 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy (shrinkage of muscles or nerve tissues). An 8/14/23 revised care plan indicated Resident 4 was an elopement risk due to dementia and wandering behavior. Interventions included distract Resident 4 from wandering and ensure a Wander Guard placed to the right wrist was working by testing the device every Thursday. A 3/2024 Documentation Survey Report indicated to verify placement of the Wander Guard on the right wrist every shift for elopement prevention. From 3/1/24 through 3/5/24 out of 15 opportunities there was no documentation the device was verified for placement four times. No documentation was found to indicate the device placement was verified from 3/13/24 through 3/22/24. A 3/2024 TAR…

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 an elopement event to the State Survey Agency within 24 hours of the incident for 1 of 4 sampled residents (#220) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 220 was admitted to the facility in 2023 with diagnosis including brain damage. A 5/16/23 Investigation Report revealed on the evening of 5/16/23 Resident 220 had two episodes of wandering on facility property. A FRI form dated 5/18/23 indicated on 5/16/23 Resident 220 walked outside to the facility smoking area without informing staff of her/his intended whereabouts. The FRI was received at the State agency via email on 5/19/23 at 12:24 AM. In an interview on 3/22/24 at 10:20 AM with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations), Staff 1 confirmed the incident was not reported to the State Agency in a timely manner.

Based on interview and record review it was determined the facility failed conduct a Significant Change MDS assessment within the required timeframe for 1 of 1 sampled resident (#22) reviewed for hospice. This placed residents at risk for unassessed needs. Findings include: Resident 22 was admitted to the facility 2024 with a diagnosis including heart disease. A 2/3/24 signed hospice narrative revealed the resident was approved and certified for hospice services by the physician on 2/3/24. Review of Resident 22's clinical record revealed a significant change MDS was not completed within 14 days after the resident was admitted to hospice. On 3/20/24 at 12:54 PM Staff 11 (MDS Coordinator) acknowledged she did not do the significant change MDS after the resident was admitted to hospice. Refer to F849.

Based on interview and record review it was determined the facility failed to ensure a care plan was revised for 3 of 3 sampled residents (#s 13, 22, and 47) reviewed for dialysis, hospice and pain. This placed residents at risk for increased injury and pain. Findings include: 1. Resident 13 admitted to the facility in 2022 with a diagnosis including kidney failure. A Progress note dated 1/12/24 revealed Resident 13's dialysis (process to remove fluids and wastes from the blood when the kidneys stop functioning) start times were to change on 1/29/24. On Mondays, Wednesdays, and Fridays Resident 13 was to be at the dialysis center at 7:40 AM and dialysis was to start at 8:00 AM. A Care Plan revised on 9/12/23 revealed Resident 13 had dialysis on Monday, Wednesday, and Friday and she/he was picked up between 8:00 AM and 8:10 AM. A 3/3/24 quarterly MDS revealed Resident 13 was cognitively intact. On 3/18/24 at 2:52 PM Resident 13 stated on dialysis days she/he needed to leave the facility by 7:00 AM. On 3/21/24 at 2:50 PM Staff 15 (LPN Unit Manager) acknowledged the care plan 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.

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 3 of 9 sampled residents (#s 4, 35, and 41) reviewed for ADLs and accidents. This placed resident at risk for unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy (shrinkage of muscles or nerve tissues.) A 2/23/23 care plan indicated Resident 4 required extensive assist of one staff with bathing. A 3/2024 Documentation Survey Report (DSR) revealed no documentation Resident 4 received any type of bathing from 3/1/24 through 3/6/24. Resident 41 was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. The DSR revealed no documentation Resident 4 received any type of bathing from 3/13/24 through 3/20/24. On 3/20/24 at 11:27 AM Staff 12 (CNA) stated she did not always have time to complete all assigned cares for residents and at times had to prioritize…

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 care and treatment as care planned, follow physician orders for blood sugar parameters, and provide bowel care for 3 of 9 residents (#s 4, 35 and 41) reviewed for accidents, and medications. This placed residents at risk for delayed treatment, constipation, and risk for adverse side effects. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy (shrinkage of muscles or nerve tissues). A 7/10/23 revised care plan indicated Resident 4 had an ADL self-care performance deficit due to weakness and she/he used a soft pad call light to call for assistance. On 3/19/24 at 8:25 AM and 3/21/24 at 7:55 AM Resident 4 was in bed with a regular call light button next to him/her in bed. On 3/20/24 at 10:35 AM Staff 11 (MDS Coordinator) stated she did not know why Resident 4's call light was a regular call light and not a soft pad call light. Staff 11 stated she/he was care planned for a soft pad call light. On 3/20/24 at 11:27 AM Staff 12 (Agency…

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 splints to reduce contractures (a permanent tightening of muscles, and tendons) for 1 of 1 sampled resident (#18) reviewed for position and mobility. This placed residents at risk for compromised mobility and pain. Findings include: Resident 18 was admitted to the facility in 2019 with diagnoses including contractures of the left and right elbows. An 8/1/23 revised care plan indicated Resident 18 was to receive elbow braces to her/his right and left elbows during the day for six hours. A 2/28/24 quarterly MDS revealed no splint or brace was provided to Resident 18 during a seven-day review period. The [NAME] (care plan for CNAs) reviewed on 3/20/24 had no reference to Resident 18's elbow braces. On 3/19/24 at 9:44 AM Resident 18 was observed in her/his bed with no braces applied to her/his right and left elbows. Resident 18 stated her/his elbow braces were offered inconsistently and last applied three days prior.…

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 catheter care for 1 of 3 sampled residents (#6) reviewed for catheter care. This placed residents at risk for increased infections. Findings include: Resident 6 admitted to the facility in 7/2022 with diagnoses including quadriplegia (paralysis of all four limbs) and dysfunction of the bladder. Review of Resident 6's care plan revised on 12/23/23 revealed the resident had a history of UTIs related to a chronic indwelling catheter. A suprapubic (situated above the pubis) catheter was placed on 11/1/23 due to a dysfunction of the bladder. Resident 6 had an 18 FR [French Foley], 8 cc [cubic centimeter] balloon. A 1/3/24 urology clinic note revealed Resident 6 had her/his suprapubic tube replaced with an 18 French Foley catheter and placed 8cc in the balloon. There was no concern with the suprapubic replacement. Resident 6 was to have a follow-up appointment in one week to exchange the suprapubic tube. A review of Resident 6's medical record from 1/4/24 through 3/17/24 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.

Based on observation, interview, and record review the facility failed to maintain healthy parameters of nutritional status for 1 of 3 sampled residents (#4) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 4 admitted to the facility in 2022 with diagnosis including dysphagia (a condition with difficulty in swallowing food or liquid). The most recent comprehensive care plan for Resident 4 revealed the following: -Interventions for nutrition: supervision and set up assistance for eating, needs to be UP in wheelchair for all meals, cue to take small sips between bites, mug with handle, lid and straw as needed. -Swallowing problem with coughing or choking during meals, order for thickened liquids. Interventions: small bites and sips, use teaspoon for eating, Do not use straws. Eat in upright position, eat slowly, chew each bite thoroughly, Supervision/frequent checks with meals. -Nutritional problem physician order for unavoidable weigh loss was requested on 1/16/24 because of high supplementation and meal fortification. The RD was 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 ensure pain interventions were implemented to ensure a resident's pain was managed for 1 of 1 sampled resident (#47) reviewed for pain. This placed residents at risk for decreased activity. Findings include: Resident 47 admitted to the facility in 2023 with diagnoses including diabetes. A 12/19/23 quarterly MDS revealed Resident 47 was cognitively intact. Progress notes revealed the following: -12/24/23 Resident 47 reported increased pain due to hemorrhoids. -1/5/24 refused cream for hemorrhoid pain due to burning. -1/31/24 Resident 47 reported rectal pain, she/he was assessed, and cream was applied. -2/1/24 a new order regarding hemorrhoids was obtained. -2/2/24 an acute provider visit occurred due to the resident's report of increased pain from hemorrhoids. -3/1/24 NP progress note revealed the resident continued with hemorrhoid pain and the plan was for a roho cushion. Resident 47's care plan last revised on 2/29/24 was not revised to include pain related to hemorrhoids. On 3/20/24 at 1:05…

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 address pharmacy recommendations for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for medication complications. Findings include: Resident 43 was admitted to the facility in 2023 with diagnoses including arthritis and anxiety. A pharmacy review dated 12/25/23 recommended labs be obtained to evaluate several medications the resident received. There was no evidence in the clinical record the labs were obtained. On 3/21/24 at 2:54 PM Staff 26 (Staff Development Coordinator) confirmed the labs were not obtained timely.

Based on interview and record review it was determined the facility failed to obtain routine labs to monitor medication effectiveness for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for ineffective medication management and unnecessary medications. Findings include: A pharmacy review dated 12/25/23 identified the need for routine labs to evaluate Resident 43's medications used to treat high cholesterol, diabetes, vitamin D, B12 deficiencies, sodium, and potassium levels. A pharmacy review dated 2/27/24 noted the labs were ordered by the physician on 2/19/24 and requested the facility obtain a copy of the results to be included into Resident 43's clinical record. There was no evidence in Resident 43's clinical record the labs were obtained until 3/1/24. On 3/21/24 at 2:54 PM Staff 26 (Staff Development Coordinator) confirmed the labs were not obtained as recommended until 3/1/24.

Based on interview and record review it was determined the facility failed to ensure a resident colonoscopy (scope passed through the rectum to visualize the large intestine and part of the small intestine) was rescheduled for 1 of 3 sampled residents (#35) reviewed for nutrition. This placed residents at risk for delayed treatment. Findings include: Resident 35 admitted to the facility in 2021 with a diagnosis of a stroke. A provider Progress Note dated 2/7/24 revealed Resident 35 had abnormal weight loss. A colonoscopy was scheduled for 2/15/24. After the colonoscopy additional tests would be completed to assist in diagnosing possible causes of the resident's weight loss. The resident verbalized the desire to complete the colonoscopy. Resident 35's clinical record did not indicate if the 2/15/24 colonoscopy was completed. In interview on 3/20/24 at 11:48 AM with Staff 26 (Staff Development Coordinator) and Staff 15 (LPN Unit Manager) Staff 26 stated the resident was to have the colonoscopy on 2/15/24. The preparation for the test came from the pharmacy on 2/14/24 and the 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 interview and record review it was determined the facility failed to obtain dental services for 1 of 1 sampled resident (#18) reviewed for dental. This placed residents at risk for dental pain and difficulty eating. Findings include: Resident 18 was admitted to the facility with diagnoses including malnutrition and quadriplegia (a form of paralysis that affects all four limbs). The 2/28/24 quarterly MDS indicated Resident 18 did not have dentures. A 3/1/24 revised care plan indicated Resident 18 had her/his teeth extracted in 5/2023 and arrangements for dental care and transportation should be coordinated. On 3/19/24 at 9:34 AM Resident 18 stated she/he continued to ask for dentures and there remained no update regarding her/his request. On 3/20/24 at 9:44 AM Staff 23 (Social Worker) stated she worked to get a denture appointment for Resident 18 and waited for Staff 2 (DNS) to speak with Resident 18 about the risks and benefit of sitting in a dental chair for an extended period of time. On 3/21/24 at 9:21 AM Staff 2 stated she was first approached in 2/2024 about 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 snack requests were honored and provided for 1 of 5 sampled residents (#2) and 1 of 1 Resident Council reviewed for dining. This placed residents at risk for lack of response to dietary requests and snack preferences. Findings include: 1. Resident 2 was admitted to the facility in 2023 with diagnoses including kidney disease and diabetes. Resident 2 resided on the second floor. The 1/30/24 through 2/1/24 Snack List indicated the residents' snack refrigerator on the second floor did not have string cheese or yogurts in stock at the time the snack inventory was taken. No additional Snack List inventory sheets during the last three months were provided. A 2/8/24 revised care plan indicated to provide Resident 2 additional protein intake for wound healing. A 2/20/24 Dietary Profile indicated Resident 2 requested yogurt and sandwiches as snacks. On 3/20/24 at 8:00 AM the second floor resident snack refrigerator was observed with no yogurt. On 3/21/24 at 2:00 PM Staff 30 (Cook) stated she…

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 coordinate care with hospice for 1 of 1 sampled resident (#22) reviewed for hospice. This placed residents at risk for unmet needs. Findings include: Resident 22 was admitted to the facility in 2024 with a diagnosis of heart disease. A 2/3/24 signed hospice narrative revealed the resident was approved and certified for hospice services by the physician on 2/3/24. Resident 22's clinical record did not have a significant change MDS completed with an assessment of the resident's end of life care needs with coordination from hospice, resident, family, and facility. Resident 22's care plan last updated on 2/12/24 revealed the following: -Resident 22 was independent to eat. -Hospice would address the resident's advance directive status. -There was no revision of the care plan related to admission to hospice including the name of the agency. -The discharge plan was to be determined. A 2/22/24 Care Plan Conference form revealed hospice attended the conference. It was determined hospice was to review the resident's…

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

Based on interview and record review it was determined the facility failed to ensure an antibiotic was indicated for use for 1 of 3 sampled residents (#60) reviewed for beneficiary. This placed residents at risk for antibiotic resistant organisms. Findings include: Resident 60 admitted to the facility in 2023 with a diagnosis of dementia with behaviors. 2/2024 through 3/2024 Vital Signs records revealed Resident 60's highest temperature was 99 F which was on 2/23/24. Progress notes revealed the following: -2/27/24 Resident 60's urinary catheter was removed on 2/26/24. -2/28/24 a NP progress note indicated the resident wanted her/his urinary catheter replaced because she/he had urgency and frequency and could not sleep. Staff monitored the resident and the staff reported the resident did not have urinary retention (urine remains in the bladder after attempting to urinate). The resident's symptoms were possibly a response from the catheter removal or a UTI. The resident did not have a fever or bloody urine. The resident's recent blood test showed a slightly elevated white count 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 treat residents with dignity and respect during dining for 1 of 3 sampled residents (#5) reviewed for dignity. This placed residents at risk for an undignified dining experience. Findings include: Resident 5 was admitted to the facility in 2018 with diagnoses including Parkinson's disease. Resident 5's Annual MDS dated [DATE] indicated the resident was not cognitively intact and was completely dependent on staff for all ADL needs. On 4/2/19 at 9:09 AM Resident 5 was in the dining room at a table with a meal and beverage in front of her/him. Staff 26 (CNA) was standing over the resident assisting him to eat and drink. When Staff 26 was asked why she was not sitting down to assist Resident 5 to eat she stated she was assisting other residents at other tables at the same time. She acknowledged the proper procedure was to sit when assisting a resident to eat but she did not get a chair and sit down. On 4/2/19 at 5:04 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 investigate an incident related to medications for 2 of 2 sampled residents (#s 70 and 275) reviewed for discharge and dignity. This placed residents at risk for drug diversion. Findings include: Resident 275 admitted to the facility in 3/2019 with diagnoses including PTSD (post traumatic stress disorder). A 3/25/19 nursing assessment indicated the resident was alert, oriented and able to state her/his needs. A physician's order dated 3/25/19 directed staff to administer Oxycodone (a narcotic pain medication) every three hours as needed for pain, one to three tablets given as needed and document the dose. Review of the March 2019 MAR indicated Resident 275 was administered her/his Oxycodone as requested on 3/26/19. In an interview on 4/2/19 at 9:40 AM Resident 275 stated on 3/26/19 Staff 30 (LPN) brought in some medication, handed her/him the pills and left the room. The resident said the pills she/he received were not Oxycodone and she/he reported this to Staff 25 (LPN). In an interview on 4/4/19 at 10:15…

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.

Based on observation, interview and record review it was determined the facility failed to develop and implement a compressive person centered care plan for 1 of 1 sampled residents (#26) reviewed for dental needs. This placed residents at risk for unmet dental needs. Findings include: Resident 26 was admitted to the facility in 2016 with a diagnoses of dysphasia (difficulty with swallowing). Review of the 5/17/18 Dental CAA indicated Resident 26 had obvious or likely cavity or broken natural teeth. Resident 26 had only six teeth in poor condition and the resident was looking forward to a set of dentures. The care plan revised on 2/26/19 for Resident 26 revealed no comprehensive care plan for Resident 26's dental care needs included measurable objectives and timeframes to meet the resident's needs, goals, outcome and preferences. On 04/01/19 at 11:12 AM Resident 26 was observed eating breakfast in the dining room and she/he had a difficult time chewing food. On 4/2/19 at 9:35 AM Resident 26 stated she/he had very few teeth and chewing food was difficult. On 4/3/19 at 3:10 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 review and revise the in-room care plan for 1 of 1 sampled resident (#26) reviewed for dental needs. This placed resident at risk for unmet dental needs. Findings include: Resident 26 was admitted to the facility in 2016 with a diagnoses of dysphasia (difficulty with swallowing). Resident 26's diet order updated on 2/14/18 indicated the resident was to receive a controlled carbohydrate (CCHO) diet, regular texture, and thin consistency. On 4/5/19 at 10:09 AM review of Resident 26's in room care plan indicated two different diet orders. Diet texture mechanical soft, CCHO, mechanical soft bread products (must be moistened with butter/jelly etc). Diet texture regular, CCHO, thin liquids using flow control cup (cup used to control liquid flow) only no straws. On 4/5/19 at 10:58 AM Staff 2 (DNS) acknowledged that Resident 26's in room care plan had two different dietary orders.

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 adequate nail care was provided for 1 of 2 residents (#35) reviewed for ADLs. This placed residents at risk for poor grooming and bleeding related to anticoagulant use. Findings include: Resident 35 was admitted to the facility in 2018 with diagnoses including diabetes and dementia. Resident 35's 30-day Medicare MDS dated [DATE] indicated the resident was cognitively impaired and needed assistance with ADLs. Resident 35's care plan dated 11/30/18 indicated a nurse was to provide nail care due to the resident's diagnoses of diabetes and use of a blood thinner. A review of Resident 35's clinical record 3/28/19 revealed no documentation on how often the resident's nails were to be trimmed and when the resident's nails were last trimmed. On 4/1/19 at 3:30 PM and on 4/3/19 at 9:15 AM Resident 35 was observed to have long fingernails with debris underneath them. On 4/3/19 at 11:05 AM Staff 3 (Unit Manager LPN) stated 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 observation, interview and record review it was determined the facility failed to follow or obtain physician orders for 3 of 7 sampled residents (#s 50, 73 and 126) reviewed for respiratory care, discharge and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 126 was readmitted to the facility on [DATE] with diagnoses including dementia. Review of physician orders dated 3/28/19 revealed no documentation the resident was to receive oxygen therapy. On 4/1/19 through 4/3/19 periodic observations of Resident 126 revealed the resident used oxygen per nasal cannula at 2 liters per minute. On 4/3/19 at 10:38 AM Staff 7 (LPN/Unit Manager) and Staff 11 (MDS Coordinator) both acknowledged the resident did not have a physician's order for the use of oxygen after the resident was readmitted to the facility on [DATE]. 2. Resident 50 was admitted to the facility in 7/2017 with diagnoses including quadriplegia (paralysis of all four limbs). A 3/29/19 physician order directed 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 observation, interview and record review it was determined the facility failed to provide routine dental services for 1 of 1 sampled resident (#26) reviewed for routine dental care. This placed residents at risk for unmet dental needs. Findings include: Resident 26 was admitted to the facility in 2016 with a diagnoses of dysphasia (difficulty with swallowing). A 5/17/18 Annual MDS assessment indicated Resident 26 was cognitatively intact, able to express ideas wants and understood others. A 5/17/18 Dental CAA indicated Resident 26 had obvious or likely cavity or broken natural teeth. Resident 26 had only six teeth on lower jaw and the teeth appeared to be in very poor condition. Resident 26 was scheduled for an appointment to address tooth extraction and dentures. On 5/22/18 Resident 26 was pre-authorized for dentures. On 4/1/19 at 11:12 AM Resident 26 was observed eating breakfast in the dining room and having a difficult time chewing food. On 4/2/19 at 9:35 AM Resident 26 stated she/he had very few teeth and chewing food was difficult. Resident 26 further stated 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 observation, interview and record review it was determined the facility failed to ensure resident equipment was kept sanitary and failed to ensure proper hand hygiene was completed during meals for 2 of 5 sampled residents (#s 50 and 60) reviewed for environment, positioning and mobility. This placed residents at risk for cross contamination. Findings include: 1. Resident 50 was admitted to the facility in 7/2017 with diagnoses including quadriplegia (paralysis of all four limbs). The 4/3/19 revised care plan indicated Resident 50 was totally dependent on staff and required extensive assistance with eating. An observation on 4/2/19 at 5:24 PM Staff 14 (CNA) revealed assisting Resident 50 with eating dinner. She removed the lid from the plate and then applied her gloves. The resident stated she/he needed to spit and Staff 14 grabbed a tissue and allowed the resident to spit into the tissue. She removed her gloves and placed a new pair on and proceeded to feed the resident. In an interview on 4/5/19 at 10:16 AM Staff 2 (DNS) stated she expected staff to wash their hands after…

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.