Royale Gardens Health & Rehabilitation Center

Based on interview and record review, it was determined the facility failed to inform the resident prior to the initiation of a psychotropic medication for 1 of 3 sampled residents (#3). This placed residents at risk for not being informed of the side effects of a medication and not participating in their treatment. Findings include:Resident 3 admitted to the facility in 2/2025 with a diagnosis of seizures. Resident 3's Physician Order Details revealed she/he was administered the following psychotropic medications between 2/12/25 and 6/16/25:- Asenapine (prescribed to treat bipolar disorder)- Buspirone (prescribed to treat anxiety).- Lamotrigine (prescribed for seizures (can also be used for bipolar)). - Abilify (prescribed to treat bipolar). There was no documented evidence to show the resident was informed of the side effects of these medications prior to being administered.On 7/21/25 at 11:48 AM, Staff 14 (SSD) confirmed Resident 3 was not informed for the listed medications prior to the medication being administered. 7/23/25 at 10:45 AM, Staff 16 (Administrator), Staff 15 (DNS),…

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 protect the resident's right to be free from sexual abuse by another resident for 1 of 3 sampled residents (# 6) reviewed for abuse. This placed residents at risk for mental anguish and abuse. Findings include:Resident 6 admitted to the facility in 2024, with diagnoses including diabetes and below the knee amputation.Resident 6's 6/25/25 Quarterly MDS revealed Resident 6 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident 7 admitted to the facility in 2023, with diagnosis including cognitive communication deficit. Resident 7's 6/10/25 Quarterly MDS revealed Resident 7 had a BIMS score of 15, which indicated the resident was cognitively intact.On 6/16/25 a public complaint was filed which alleged Resident 7 made sexual contact with Resident 6 with a food item. On 7/16/25 at 9:47 AM, Resident 7 stated she/he gestured toward Resident 6 with a doughnut. Resident 7 did not recall saying anything afterward. Resident 7 stated Resident 6 had avoided her/him since 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 ensure sufficient nursing staff to ensure timely incontinent care and resident showers were completed for 6 of 6 sampled residents (#s 5, 8, 12, 14, 15, and 16) reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's 1/2025 Resident Council Notes revealed concerns related to short staffing and having care needs met. The facility's 3/2025 Resident Council Notes revealed resident showers were not completed as scheduled. Review of the assigned showers on 4/20/25 revealed Resident 5, Resident 12, Resident 14, Resident 15, and Resident 16 did not receive their showers. The CNA staff documented, not attempted due to environmental limitations, refused, or NA. Resident 8's 4/2025 Shower Record revealed she/he did not receive a shower on 4/23/25 and 4/25/25. On 4/30/25 at 5:40 PM, Resident 8 stated the facility was often short staffed, call lights were not answered timely and she/he did not always get her/his scheduled showers. On 4/30/25 at 6:00 PM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined the facility failed to treat, assess, and monitor wounds for 3 of 3 sampled residents (#s 101, 102, and 103) reviewed for wound care. This placed residents at risk for worsening wounds and infections. Findings include: 1. Resident 101 admitted to the facility on 2/2025, with diagnoses including mononeuropathy of the bilateral lower limbs (damage or dysfunction of two or more peripheral nerves in both legs), second degree burns of the right foot (2nd and 3rd toes) and second degree burns to the left foot and toes. Resident 101's 2/13/25 Hospital Discharge Orders indicated to continue local dressing changes daily with Xeroform and a dry sterile dressing. Resident 101's 2/13/25 Nursing Admission/readmission Evaluation included the following skin observation: -Right toe(s): burns, blisters -Left toe(s): burns, blisters No additional information related to the wounds was found such as: description, measurements, which toes were involved, or the condition 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 assess the effectiveness of interventions and provide adequate resident supervision to prevent falls for 1 of 3 sampled residents (#s 102) reviewed for accidents. This placed residents at risk for recurring falls. Findings include: Resident 102 was admitted to the facility in 2024 with diagnoses including dementia, and repeated falls. Resident 102 had a BIMS score of 5 which indicated severe cognitive impairment. The resident had a total of 27 falls during the two months she/he was at the facility. Resident 102's care plan dated 9/30/2024 indicated the resident was a two person extensive assist with bathing/showering, transferring, and locomotion. Resident 102's 10/7/24 Fall Risk Care Plan instructed staff to anticipate and meet the resident's needs, keep the call light within reach, encourage use of the call light, educate the resident about safety reminders, ensure commonly used items were within reach, wear appropriate footwear, keep the bed in a low position,and a PT consult for strength and mobility.…

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 sanitary kitchen environment for 1 of 1 facility kitchen. This placed residents at risk for food-borne illness. Findings include: An 10/2024 Sanitizer Bucket Log indicated the facility's Multi-Quat Sanitizer had a broad efficacy range of 150-400 PPM (parts per million), staff were to complete testing of the sanitizer levels a minimum of every four hours and more often as needed, and to keep the water clean to keep the sanitizer in use effective. On 10/25/24 at 9:23 AM Staff 47 (Dietary Aide) was observed to sanitize a soiled dish cart with a rag that was removed from a red bucket and contained sanitizing solution. The rag and sanitizing solution was observed to contain black flecks. Staff 47 was asked to test the concentration of the sanitizer in the bucket and confirmed the sanitizer solution used to sanitize the soiled dish cart was ineffective at 100 PPM. Staff 47 indicated the sanitizer in the bucket was changed every four hours. On 10/25/24 at approximately 9:30 AM Staff 37…

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 3. Resident 52 admitted to the facility in 9/2023 with a diagnosis of diabetes. A 9/10/23 admission MDS revealed Resident 52 was cognitively intact but was not assessed for activity preferences. Resident 52 was identified to be at risk for social isolation, depression, and had blindness to both eyes. The assessment also indicated Resident 52 preferred to visit with her/his significant other. Activities/Recreation reviews revealed the following: -12/23/23 Resident 52 participated in 1:1 activities and her/his favorite activity was smoking outside with others. There was no identified activity goal or focus. -3/13/24 Resident 52 participated in 1:1 activities and enjoyed to smoke with others. There was no identified goals or focus. -6/23/24 Resident 52 reported she/he felt staff did not allow visits with her/his significant other and reported she/he could not do anything because she/he was going blind. The form indicated the resident used to like audio books. New interventions included to offer audio books.…

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 administer bowel care and follow therapy recommendations for 3 of 5 sampled residents (#s 30, 70 and 191) reviewed for pressure ulcers, and unnecessary medications. This placed residents at risk for unmet care needs. Findings include: 1. Resident 8 admitted to the facility in 9/2024 with diagnoses including stroke and heart disease. A 9/26/24 admission MDS indicated Resident 8 required setup assistance for eating. An 10/15/24 revised care plan indicated Resident 8 required extensive assistance of one staff for eating, and to encourage the resident to sit upright after meals. An 10/18/24 Occupational Therapy Treatment Encounter Note indicated therapy staff spoke to nursing to ensure Resident 8 was in her/his wheelchair for all meals and communication would be provided to CNAs. On 10/21/24 at 1:35 PM Resident 8 was observed sitting in her/his bed with her/his head in a slouched position. A meal was on a bedside table in front of the resident. Witness 8 (Family Member) stated she spoke with…

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

Based on interview and record review it was determined the facility failed to ensure a plan of care was reviewed and signed by a physician for 4 of 4 sampled residents (#s 2, 29, 31, and 35) reviewed for physician orders. This placed residents at risk for unassessed medical needs and adverse side effects of medication. Findings Include: 1. Resident 2 admitted to the facility in 9/2021 with diagnoses including arthritis and heart disease. During a review of Resident 2's clinical record on 10/28/24, a physician signed plan of care was not found for 1/2023 through 12/2023, 1/2024 through 3/2024, 5/2024, and 6/2024. On 10/28/24 at 4:00 PM Staff 1 (Administrator) and Staff 52 (Regional Director of Clinical Services) stated no further physician signed plans of care were available, and acknowledged the months without physician signed plans of care in Resident 2's clinical record. 2. Resident 29 admitted to the facility in 1/2024 with diagnoses including breast cancer and diabetes. During a review of Resident 29's clinical record on 10/28/24, a physician signed plan of care was not found…

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 seen by a physician every 60 days for 4 of 4 sampled residents (#s 2, 29, 31, and 35) reviewed for physician visits. This placed residents at risk for unmet medical needs. Findings include: 1. Resident 2 admitted to the facility in 9/2021 with diagnoses including arthritis and heart disease. During a review of Resident 2's clinical record on 10/28/24, no physician visit notes were found for 1/2024 through 3/2024, 5/2024, 6/2024, and 8/2024. On 10/28/24 at 4:00 PM Staff 1 (Administrator) and Staff 52 (Regional Director of Clinical Services) stated no further physician visit notes were available, and acknowledged there was no evidence to indicate Resident 2 had a physician visit every 60 days relative to the above timeframes. 2. Resident 29 admitted to the facility in 1/2024 with diagnoses including breast cancer and diabetes. During a review of Resident 29's clinical record on 10/28/24, no physician visit notes were found after 4/2023. On 10/28/24 at 4:00 PM Staff 1 (Administrator) and…

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

Based on observation, interview, and record review it was determined the facility failed to ensure a medication error rate of less than 5 percent. There were five errors out of 44 medication administration opportunities resulting in a 11.36 percent error rate. This placed residents at risk for an ineffective medication regimen. Findings include: 1. Resident 21 admitted to the facility in 9/2024 with a diagnoses including respiratory failure. An 10/7/24 physician order indicated staff were to administer Advair powder inhaler, inhale one puff and then rinse her/his mouth after each administration. On 10/23/24 at 8:37 AM Staff 36 (CMA) handed Resident 21 her/his inhaler and the resident inhaled twice, but she/he did not rinse her/his mouth after the medication administration. On 10/23/24 at 8:40 AM Resident 21 stated she/he inhaled the medication twice but did not rinse her/his mouth after the medication administration. On 10/23/24 at 8:45 AM Staff 36 stated the resident should inhale the medication one time then rinse her/his mouth after inhaling the medication. On 10/24/24 at 2:50 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to accommodate resident needs for 1 of 6 sampled residents ( #49) reviewed for environment and speech. This placed residents at risk for unmet needs. Findings include: Resident 49 admitted to the facility on [DATE] with diagnoses including Aphasia (a disorder in speaking and understanding language). On 10/21/24 at 11:32 AM, an interview with Resident 49 revealed her/his verbal communication was severely impaired (nonverbal with the use of pointing and gestures). At that time Staff 5 (CNA) reported Resident 49 often confused no for yes which decreased staff's understanding of how to meet Resident 49's communication and care needs. Staff 5 confirmed there was no picture communication board for Resident 49 to point to for more specific requests and communication. On 10/22/24 at 12:41 PM, Staff 3 (speech therapist and clinical supervisor) confirmed three separate speech therapy evaluations, dated 6/30/23, 12/30/23, and 6/27/24, were conducted…

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

Based on interview and record review it was determined the facility failed to ensure residents' grievances were addressed for 2 of 2 sampled residents (#s 52 and 70) reviewed for personal property. This placed residents at risk for unresolved grievances. Findings include: 1. Resident 52 admitted to the facility in 9/2023 with a diagnosis of diabetes. A 9/10/24 annual MDS revealed Resident 52 was cognitively intact. A 7/3/24 Grievance Report revealed Resident 52 reported a missing or misplaced heavy jacket. The grievance indicated staff looked in laundry but the jacket was not found. There was no resolution to the missing jacket. On 10/21/24 12:58 PM Resident 52 stated she/he was missing a heavy jacket and there was no follow-up. On 10/22/24 at 12:23 PM Staff 53 (CNA) stated Resident 52 reported a missing jacket and it was sentimental to her/him because a friend gifted it to her/him. On 10/24/24 at 11:54 AM Staff 2 (DNS) acknowledged there was no resolution for the missing jacket. On 10/25/24 at 10:32 AM Staff 27 (Social Services Director) stated if a resident was missing clothing,…

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 report of misappropriation was reported to the State Survey Agency for 1 of 2 sampled residents (#52) reviewed for personal property. This placed residents at risk for abuse. Findings include: Resident 52 admitted to the facility in 9/2023 with a diagnosis of diabetes. Resident 52's 9/10/24 annual MDS revealed Resident 52 was cognitively intact. A 7/3/24 Grievance Report revealed Resident 52 was missing or misplaced a wallet. The investigation revealed Resident 52 reported money was missing from her/his bank account. A police report was filed. On 10/24/24 at 11:54 AM Staff 2 (DNS) stated an allegation of a missing wallet and money could be misappropriation. Staff 2 stated social services filed a police report on behalf of Resident 52 but a FRI was not submitted.

Based on interview and record review it was determined the facility failed to ensure a resident was referred to the state agency authority for Level II PASARR (preadmission screening and resident review: assessment to ensure individuals with serious mental illness) evaluation for 1 of 1 sampled resident (#52) reviewed for PASARR. This placed residents at risk for lack of mental health services. Findings include: Resident 52 admitted to the facility from another facility on 9/2023 with a diagnosis of mental illness. A 9/10/23 admission MDS revealed Resident 52 was not administered antidepressants or mood stabilizing medications and she/he was at risk for ongoing social isolation and depression. A plan was to refer Resident 52 to behavioral health services. 9/2023, 10/2023 and 11/2023 MARs and DARs (Diabetic Administration Records) revealed Resident 52 accepted medications and allowed CBG testing. 12/2023, 1/2024 and 2/2024 MARs and DARs revealed Resident 52 refused to take certain medications, cooperate by providing pain levels, and allow staff to obtain CBGs. Progress Notes revealed…

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 baseline care plans were developed for 2 of 9 sampled residents (#s 24 and 243) reviewed for accidents and discharge. This placed residents at risk for unmet needs. Findings include: 1. Resident 24 re-admitted to the facility on [DATE] with a diagnosis of type 1 diabetes with complications including high blood sugar levels. 9/24/24 hospital Discharge orders revealed Resident 24 was admitted for diabetic ketoacidosis (a complication of diabetes in which acids build up in the blood to levels that can be life threatening) and was discharged to the facility with insulin orders. Resident 24's baseline care plan initiated 9/24/24 did not include Resident 24 was diabetic with history of high blood sugar levels, symptoms to monitor, and interventions to provide if needed. On 10/24/24 at 12:52 PM Staff 2 (DNS) stated when a resident was discharged to the hospital her/his care plan was discontinued and a new care plan was initiated upon…

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 involve residents and/or representatives in the care planning process for 1 of 2 sampled residents (#8) reviewed for care plans. This placed residents at risk for lack of care plan interventions. Findings include: Resident 8 admitted to the facility in 9/2024 with diagnoses including stroke. A 9/25/24 through 10/22/24 (CNA) Task: Shower/Bathe Self Saturday and Wednesday document indicated Resident 8 refused or did not receive bathing for six of nine opportunities. A 9/26/24 admission MDS indicated Resident 8 was moderately cognitively impaired. The 10/4/24 IDT (Interdisciplinary Team) Care Plan Conference/Welcome Meeting Form indicate Resident 8 was present but Witness 8 (Family Member) was not present during a discussion of Resident 8's care needs. The 10/22/24 contact list for Resident 8 indicated Witness 8 was her/his first emergency contact and POA (Power of Attorney) for care. On 10/21/24 at 3:44 PM Witness 8 stated because of Resident 8's memory issues, the resident wanted her involved…

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 dependent residents received required assistance with ADLs for 2 of 5 sampled residents (#s 31 and 240) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: 1. Resident 31 admitted to the facility in 8/2018 with diagnoses including stroke and dementia. An 8/23/24 MDS revealed Resident 31's BIMS score was seven which indicated severe cognitive impairment. Resident 31 required substantial to maximal assistance with toilet transfers and was dependent on staff for assistance with toileting hygiene. Resident 31 was frequently incontinent of bladder and bowel. The urinary incontinence CAA indicated Resident 31 required significant assistance with most ADLs. Resident 31 was at risk for complications resulting from bowel and bladder incontinence. Staff were to provide assistance with toileting and incontinence, frequent checks and assistance with incontinent care, and to encourage toileting independence as safely able. A review of Resident 31's care plan revised 2/23/23…

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 accurately assess, care plan, implement, follow and maintain pressure ulcer treatments and care plans for 1 of 1 sampled resident (#191) reviewed for pressure ulcers. Resident 191 developing an avoidable unstageable (obscured full-thickness skin and tissue loss) pressure ulcer. Findings include: Resident 191 admitted to the facility in 6/2024 with diagnoses including kidney failure. The 6/17/24 admission MDS indicated Resident 191 had pressure ulcer and was at risk for pressure ulcers due to incontinence and decreased mobility. Resident 191 admitted with a Stage 2 (shallow open wound) pressure ulcer to the coccyx. A public compliant was received on 6/25/24 which indicated Resident 191 discharged from the hospital on 6/12/24 with a Stage 2 (shallow open wound with red or pink base) pressure ulcer on her/his coccyx (tailbone) measuring 2 cm by 0.1 cm. Resident 191 returned to the hospital on 6/19/24 with worsening wounds to her/his coccyx. The 6/27/24 care plan indicated Resident 191 had potential for skin…

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 a resident received trauma informed care for 1 of 1 sampled resident (52) reviewed for behavioral-emotional care. This placed residents at risk for re-traumatization. Findings include: Resident 52 was admitted to the facility 9/2023 with a diagnosis of a mental health illness. A [DATE] Psychosocial History revealed Resident 52 had trauma related to a child's death and had nightmares about the incident. A [DATE] annual MDS revealed Resident 52 was cognitively intact. A [DATE] Grievance Summary Report revealed staff assisted Resident 52 with a shower. Resident 52 agreed to have her/his beard shaved. The CNA started to shave Resident 52's mustache. Resident 52 stated the CNA was in a hurry to leave the room after the shower and shave. A [DATE] Statement form revealed Staff 51(CNA) offered to shower Resident 52, shave her/his beard, and trim her/his hair. Resident 52 agreed and Staff started to shave her/his mustache. Halfway…

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

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 1 of 5 sampled CNA staff (#35) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: During a review of the most recent performance reviews for CNA staff no documentation was provided for Staff 35 (CNA) who was hired on 5/22/22. On 10/29/24 Staff 1 (Administrator) confirmed there was no performance review for Staff 35.

Based on interview and record review it was determined the facility failed to provide timely pharmaceutical services for 3 of 7 sampled residents (#s 198, 21, and 78) reviewed for medication administration, and failed to ensure narcotic medication management systems were in place to account for and reconcile narcotics for 2 of 5 narcotic books reviewed for medication administration. This placed residents at risk for untimely medications and diversion. Findings include: 1. Resident 198 admitted to the facility in 10/11/24 with a history of seizures. The 10/2024 MAR instructed staff to administer lacosamide (antiseizure medication) two times a day for seizures, with a start date of 10/11/24. From 10/11/24 through 10/21/24 the MAR referred the reader to progress notes. Administration Notes revealed the following for lacosamide administrations: -10/11/24 waiting for delivery. -10/12/24 at 7:37 AM waiting for medication delivery. -10/12/24 at 7:17 PM the medication was unavailable. -10/13/24 at 8:44 AM the medication was unavailable. -10/14/24 at 10:01 AM an Administration Note revealed…

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 a resident on a psychotropic medication for 1 of 5 sampled residents (#85) reviewed for medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: Resident 85 admitted to the facility in 9/2024 with diagnoses including dementia and depression. The 9/30/24 admission MDS and CAA indicated Resident 85 was severely cognitively impaired and had multiple falls prior to admission and within the facility. An 10/7/24 physician order indicated to administer trazodone (antidepressant medication) to Resident 85 at bedtime for insomnia. An 10/16/24 Psychotropic Medication Review indicated Resident 85 was a new admission and her/his trazodone would be monitored to establish baseline. There was no indication for the use of trazodone for Resident 85. An 10/22/24 revised care plan revealed no indication Resident 85 had insomnia or received medication to address her/his sleep. On 10/24/24 at 8:57 PM Staff 54 (LPN) stated Resident 85 was difficult to arouse in the…

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

Based on observation, interview and record review it was determined the facility failed to ensure a resident was provided dental services for 1 of 4 sampled residents (#30) reviewed for dental. This placed residents at risk for dental pain. Findings include: Resident 30 admitted to the facility with a diagnosis of diabetes. A 9/5/24 quarterly MDS revealed Resident 30 was cognitively intact. On 10/23/24 at 11:28 AM Resident 30 was observed to have a missing left upper tooth. Resident 30 stated Witness 6 (Family Member) visited about one month prior and noticed her/his tooth was broken. Resident 30 stated the tooth fragment remained in her/his gums. On 10/23/24 12:19 PM Witness 6 stated in 9/2024 she visited Resident 30 and asked her/him What's up with your tooth? Witness 6 stated she notified one of the CNAs who was in Resident 30's room about the newly identified broken tooth. Shortly after she visited Resident 30 a dental office called her to set up an appointment for Resident 30's tooth. Witness 6 stated she informed the dental office to call the facility to set up the appointment…

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 determine the facility failed to follow modified textured diets as ordered for 1 of 6 sampled residents (#8) reviewed for food. This place residents at risk for medical complications and aspiration. Findings include: Resident 8 admitted to the facility in 9/2024 with diagnoses including stroke and intestinal obstruction. A 9/26/24 admission MDS indicated Resident 8 required set-up assistance for eating. A 9/29/24 Order Details revealed Resident 8's diet texture was an Easy to Chew texture. An 10/21/24 Lunch Day 23 Diet Guide instructed staff to serve minced dijon pork loin with brown gravy for Easy to Chew and Soft and Bite Size diet textures. Staff were also instructed to serve bite-sized moistened citrus glazed angel food cake for Soft and Bite Size diet textures. On 10/21/24 at 1:36 PM Resident 8 stated she/he often did not receive the modified textured diet as ordered. Resident 8's partially eaten plate of food was observed which included one-inch cubed pieces of cooked pork with no gravy as part of her/his meal. On…

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

Based on observation, interview and record review it was determined the facility failed to provide assistive devices for 1 of 3 sampled residents (#15) reviewed for nutrition. This placed residents at risk for unmet dining needs. Findings include: Resident 242 admitted to the facility in 3/2024 with diagnoses including anxiety and catatonic schizophrenia (subtype of schizophrenia characterized by extreme changes in motor activity). A revised care plan dated 8/26/24 indicated Resident 15 had a nutritional problem and need for assistance with food and fluids. Interventions included Resident 15 was to be provided a non-weighted built-up spoon with each meal. On 10/22/24 at 8:09 AM Resident 15 was in the dining room and was eating her/his breakfast with her/his hands. On 10/23/24 at 11:54 AM Resident 15 was in the dining room and was provided a spoon which was not a non-weighted built-up spoon. At 12:01 PM Staff 11 (CNA) stated CNAs did not have access to the resident's specialized equipment and confirmed the kitchen did not provide Resident 15 the non-weighted built-up spoon for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to maintain adequate room temperatures and a home like environment for 1 of 1 facility reviewed for comfortable and homelike environment. This placed residents at risk for an uncomfortable and un-homelike environment. Findings include: 1. OAR §483.10(i)(6) Comfortable and Safe Temperature Levels: indicated facilities must maintain a temperature range of 71 to 81°F; and the ambient temperature should be in a relatively narrow range to minimize residents' susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, and comfortable for the residents. Resident 13 was admitted to the facility in 2021 with diagnoses including diabetes and bi-polar disorder (disorder with episodes of mood swings ranging from depressive lows to manic highs). On 11/27/23 Resident 13 reported to hospital staff her/his room at the facility was cold and did not get any heat. On 1/8/24 at 1:45 PM Staff 6 (Maintenance Manager) indicated…

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

Based on interview and record review it was determined the facility failed to follow physician orders, and failed to identify and address a resident's change of condition for 3 of 6 sampled residents (#s 2, 10 and 11) reviewed for physician orders and change of condition. This placed residents at risk for lack of care and treatment and negative medical outcomes related to delayed treatment. Findings include: 1. Resident 10 admitted to the facility in 7/2023 with diagnoses including paralysis due to stroke. Resident 10's care plan indicated she/he was admitted to the facility with a Stage 4 pressure ulcer on the sacrum (the area between the right and left hip bones) and another Stage 4 ulcer on the lower right buttock due to immobility, poor food and fluid intake. Resident 10 also had wounds on her/his left and right lower legs. Interventions ordered were to cleanse the large coccyx (the small bone located below the sacrum) which forms the wound with wound cleanser/saline, pat dry, apply calcium alginate to the wound bed and apply sacral foam dressing daily and PRN. Orders for 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 resident care equipment for 4 of 4 halls (A, B, F and G Halls) and failed to maintain kitchen equipment in a safe and functional condition for 1 of 1 kitchen reviewed for environment. This placed residents at risk for unmet needs, accidents, injury and food-borne illnesses. Findings include: 1. A public complaint was received on 11/16/23 which alleged the facility's crash cart (cabinet containing supplies for medical emergencies), located on A Hall, was not monitored by staff twice a week. On 1/8/24 at 12:27 PM Witness 8 (Complainant) stated the crash cart contained vital medical equipment such as oxygen, a suction machine and other supplies. Witness 8 stated the last time she/he checked the cart it had been months since the log showed the cart had been checked. On 1/9/24 at 4:47 PM, the crash cart was observed in Hallway A. A log book was on top of the cart with Crash Cart Inventory/Audit Instructions attached to the log book. The instructions stated nursing staff were to check 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 a fall resulting in a serious bodily injury was reported to the State Agency for 1 of 3 sampled residents (#4) reviewed for falls. This placed residents at risk for abuse/neglect. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses including a right hip fracture and atrial fibrillation (irregular heartbeat that can lead to blood clots). A 9/13/23 Incident Report revealed Resident 4 was found on the floor next to the bed in her/his room. The resident stated she/he was sitting on the bedside commode and tried to get up on her/his own and fell. The report revealed the resident reported intense left hip pain and was transferred to the hospital for evaluation. A 9/13/23 ED (Emergency Department) visit note indicated X-rays confirmed the resident had a left hip fracture and the previous right hip fracture repair was intact. 9/16/23 hospital discharge orders revealed Resident 4 had left hip repair surgery…

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 complete a thorough investigation regarding an injury of unknown origin for 4 of 4 sampled residents (#s 1, 2, 4 and 14) reviewed for safe environment and falls. This placed residents at risk for potential abuse. Findings include: 1. Resident 1 was admitted to the facility in 9/2023 with diagnoses including a stroke. Review of a progress note dated 8/19/23 at 8:25 AM revealed the resident told staff that a night shift CNA had grabbed her/his arm during a transfer causing a bruise. The note indicated the CNA had not transferred the resident during the night shift. Review of an incident investigation dated 8/19/23 revealed Resident 1 told staff a night shift staff person had grabbed her/his arm during a transfer causing a bruise to the right inside arm. The investigation indicated the resident's care plan was followed, the incident was unavoidable and abuse and neglect was ruled out. The investigation did not include a comprehensive…

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 implement the care plan for 1 of 3 sampled residents (# 12) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 12 was admitted to the facility in 2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), contractures of the right and left hand, right elbow, and lower extremities (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the body part) and a history of traumatic brain injury. Resident 12 was dependent on a power wheelchair for her/his mobility. Resident 12's care plan dated 11/17/2020 indicated the resident had an ADL self-care deficit related to quadriplegia and contractures in both upper and lower extremities. The resident was dependent on two staff for assistance with bed mobility, toilet use and transferring. The resident was totally dependent on one staff for eating, filling a water cup and drinking fluids. Resident 12's care plan also included: -The resident had the…

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

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 3 sampled residents (#3) reviewed for facility discharge. This placed residents at risk for an unsafe discharge. Findings include: Resident 3 was admitted to the facility in 5/2023 with diagnoses including diabetes. Review of a fax dated 10/24/23 revealed the facility requested physician orders for physical therapy, occupational therapy and home health for the resident's anticipated discharge to an Assisted Living Facility (ALF) on 10/25/23. Review of a Discharge Instructions/Orders form dated 10/24/23 revealed Resident 3 had diabetic medication training by the facility nursing staff. Review of a progress note dated 10/25/23 at 3:35 PM revealed the resident was discharged from the facility to the Assisted Living Facility (ALF) with instructions and medications. No discharge summary was created to include Resident 3 recapitulation of stay, functional status on discharge or the resident's discharge plan of care. In an interview on 1/9/24 at 2:24 PM Staff 1 (DNS)…

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 (#12) reviewed for catheter care. This placed residents at risk for unmet catheter needs. Findings include: Resident 12 was admitted to the facility in 2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso) and neurogenic bladder (lacking bladder control due to brain, spinal cord, or nerve problem.) Resident 12 was alert and oriented and able to direct her/his own care. On 1/8/24 Resident 12 said she/he woke up with her/his catheter plugged. For at least an hour she/he asked the CNAs to get the nurse but the nurse would not come. The resident felt she/he could not wait because she/he thought her/his body would go into shock since it had happened before. Resident 12 said Staff 22 (CNA) came in, saw she/he had been waiting over 40 minutes, she/he was not looking good, was in pain, so she went to get a nurse. The nurse finally came in but said she needed to assess the resident first, wanted…

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.

2. Resident 166 was admitted to the facility in 2023 with diagnoses including respiratory problems and pain. Resident 166's care plan dated 6/9/23 indicated she/he used smoking materials and the interventions were to instruct the resident on the facility policy for smoking, locations, times and safety. Resident 166's progress notes documented several incidents when the resident did not follow the smoking policy or left the facility to obtain beer. The care plan was not revised to indicate whether Resident 166 was an independent or supervised smoker, failed to comply with the facility's smoking policy or brought beer into the facility without a physician's order. On 7/14/23 at 12:01 PM Resident 166 was discussed with Staff 1 (Administrator) and Staff 2 (DNS). Staff 2 stated Resident 166 did not follow the smoking rules and was bringing beer into the facility without a physician's order. No additional information was provided. 3. Resident 1 was admitted to the facility in 2023 with diagnoses including weakness. On 5/24/23 Resident 1 had a fall, broke her/his leg and required a brace.…

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 3 of 4 Halls (A, G & F Halls) and 1 of 1 dining room reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. On 5/22/23 a public complaint was received which indicated Resident 18 reported the facility was short staffed and there was not enough staff to provide care for all of the residents. Resident 18's call light was on all night when she/he needed assistance and no staff responded until the day shift. A 6/7/23 Call light Audit Tool revealed the following call light wait times: -Room A-14 call light was activated at 8:07 AM and answered and 8:23 AM (16 minutes), and 8:32 AM and was answered at 8:53 AM. (21 minutes) -Room A-5 call light activated 8:09 AM and answered at 8:27 AM (18 minutes). On 6/28/23 a public complaint was received which indicated the facility was understaffed and residents did not receive the care they needed. Day shift had only two CNAs for 19 residents and all 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 to have a qualified and trained IP in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control. Findings include: A Staff List provided on 7/10/23 indicated the facility had an IP. On 7/10/23 at 3:15 PM Staff 2 (DNS) stated the facility did not have a qualified IP working in the facility at least part time. Staff 2 stated she did not have specialized training for infection control. On 7/12/23 at 10:00 AM Staff 3 (Regional IP) stated she was not in the facility for the past year and would not be in the facility until 7/24/23. Staff 3 acknowledged the facility did not have an IP that worked at the facility at least part time.

Based on interview and record review it was determined the facility failed to ensure a dignified dining experience for 1 of 2 sampled residents (#46) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 46 was admitted to the facility in 4/2023 with diagnoses including heart disease and a neurological disorder. An 4/17/23 care plan indicated Resident 46 required one staff to assist with locomotion. An 4/23/23 admission MDS indicated Resident 46 was cognitively intact and set-up assistance was required for dining. On 7/10/23 at 7:57 PM Witness 4 (Family Member) stated Resident 46 was left in the dining room after a meal and was later heard yelling after she/he became stuck in a corner of the dining room in her/his wheelchair when attemping to return to her/his room. On 7/11/23 at 9:46 AM Resident 46 recalled when she/he was left in the dining room and it made her/him feel small and insignificant but not abused. On 7/11/23 at 4:57 PM the details of the 7/11/23 interview with Resident 46 was shared with Staff 10 (Social Service Director).…

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 included in care planning for 1 of 3 sampled residents (#18) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 18 was admitted to the facility in 2020 with diagnoses including anxiety disorder and muscle weakness. A review of Resident 18's clinical record revealed Resident 18 did not receive a care conference from 10/18/22 through 5/14/23. A review of Resident 18's care plan revealed on 2/22/23 and 3/3/23 Resident 18's care plan was updated. On 7/10/23 at 1:35 PM and 7/13/23 at 8:40 AM Resident 18 stated with dissatisfaction she/he and the facility met at care conferences about once a year but did not discuss her/his care planning in detail. Resident 18 stated she/he did not receive a copy of her/his care plan. Resident 18 stated with dissatisfaction she/he did not remember a representative from dietary services attending her/his care conferences. On 7/14/23 at 10:00 AM Staff 10 (Social Services…

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

Based on observation, interview and record review it was determined the facility failed to assess or assess timely for self-administration of medication for 2 of 6 sampled residents (#s 31 and 214) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 31 was admitted to the facility in 2021 with diagnoses including diabetes. A 7/6/23 Nursing Note indicated Resident 31 woke up and checked her/his own blood sugar. A 7/6/23 Alert Note indicated Resident 31 was given cream for her/his groin area and was able to administer it by herself/himself. A 7/9/23 Alert Note indicated staff handed Resident 31 an insulin pen and dialed the insulin to 12 units for her/him to administer, as [she/he] usually does and Resident 31 changed the insulin pen to 18 units and administered the insulin. There was no assessment in the clinical record to indicate Resident 31 was evaluated to self-administer her/his medications. On 7/11/23 at 9:12 AM Resident 31 stated she/he always checked her/his own blood sugars. On 7/14/23 at 10:40 AM Staff 1…

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

Based on interview and record review it was determined the facility failed to ensure residents' personal belongings were not searched without permission for 1 of 1 sampled resident (#166) reviewed for respect and dignity. This place residents at risk for lack of respect. Findings include: Resident 166 was admitted to the facility in 2023 with diagnoses including respiratory problems and pain. A nurses' note dated 6/23/23 indicated Staff 33 (former agency LPN) visualized a bag in Resident 166's room, opened the bag and saw a tall can of beer. Staff 33 informed Resident 166 of the need for an order to consume alcohol and removed the beer from the resident's room. On 7/13/23 at 2:12 PM Staff 33 stated she was informed in the morning meeting Resident 166 left the facility and when the resident returned, Staff 33 accompanied her/him to her/his room. Staff 33 indicated she was concerned the resident brought beer into the facility again without a physician's order. Staff 33 noticed a bag behind the trash can and picked it up, looked inside and discovered a tall can of beer. Staff 33 stated…

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

Based on observation, interview and record review it was determined the facility failed to accommodate resident needs for 1 of 6 sampled residents (#21) reviewed for environment. This placed residents at risk for unmet needs. Findings include: Resident 21 was admitted to the facility in 2021 with diagnoses including difficulty walking and obesity. A 3/10/23 Social Services Note indicated Staff 10 (Social Services Director) spoke with Resident 21 about her/his previous request for a wheelchair and Resident 21 stated she/he did not wish to move forward at this time. A review of the clinical record revealed no additional information about Resident 21's wheelchair status after 3/10/23. A 5/18/23 Quarterly MDS indicated Resident 21's BIMS score was 15 which indicated she/he was cognitively intact. The 6/10/23 care plan did not have any information about Resident 21's wheelchair. On 7/11/23 at 7:45 AM Resident 21 stated she/he did not have a wheelchair and she/he was not able to get out of bed except to shower. Resident 21 stated she/he wanted a larger wheelchair but it would not fit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide bed hold information for 1 of 1 sampled resident (#61) reviewed for hospitalization. This placed residents at risk for lack of information related to the right to hold their bed placement while in the hospital. Findings include: Resident 61 was admitted to the facility on [DATE] with diagnoses including spinal fractures. Progress notes dated 6/13/23 and 6/14/23 revealed the resident called emergency transportation and went to the hospital because she/he reported lack of pain control. The resident's clinical record did not include documentation to indicate the resident was provided the bed hold policy. On 7/11/23 at 2:41 PM Staff 10 (Social Services) stated the resident was admitted on [DATE] and the resident was assessed to be cognitively intact. The bed hold policy was usually provided with admission paperwork. Staff 10 indicated she was not sure if Resident 61 received the bed hold policy. On 7/11/23 at 2:49 PM Staff 35…

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 implement a care plan for catheters, anticoagulant medication and accidents for 1 of 9 sampled residents (#313) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 313 was admitted to the facility in 2023 with diagnoses including mood disorder and acute deep vein thrombosis (the formation of a blood clot within a blood vessel). The 6/2023 and 7/2023 MARs revealed Resident 313 received Eliquis (blood thinner medication) daily from 6/27/23 through 7/1/23 and 7/5/23 through 7/11/23. A 6/28/23 care plan revealed no reference to Resident 313's use of Eliquis. On 7/13/23 at 4:49 PM Staff 12 (LPN-Unit Manager) stated because Resident 313 had a recent bleed it was important for all staff to be aware of her/his use of Eliquis and acknowledged there was no reference to the use of blood thinner medication with the initial care plan.

Based on observation, interview and record review it was determined the facility failed to implement fall interventions and reevaluate a resident's smoking status for 2 of 4 sampled residents (#s 13 and 166) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 166 was admitted to the facility in 2023 with diagnoses including respiratory problems and pain. A 6/9/23 Smoking Policy review and evaluation indicated residents were not allowed to maintain their smoking materials, could not share their smoking materials with others and smoking materials must be secured by nursing staff. The evaluation indicated Resident 166 wore oxygen and demonstrated safe smoking behavior. An alert note dated 6/11/23 indicated Resident 166 was observed out in the smoking area with a cigarette and lighter. Resident 166 indicated the lighter was provided by another resident. Resident 166 relinquished the lighter and was educated on the need to turn in smoking materials. A 6/16/23 nursing note by the Staff 36 (Unit Manager) indicated Resident 166 was smoking while…

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 respiratory care and services for 1 of 2 sampled residents (#49) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: Resident 49 was admitted to the facility in 2023 with diagnoses including systemic inflammatory response syndrome (a condition where the body reacts to an infection with inflammation which affects the whole body.) A 3/11/23 care plan indicated Resident 49 had oxygen therapy with the goal not to have signs or symptoms of poor oxygen absorption with oxygenation saturation greater than (SPECIFY) (no specified amount was documented) through the review date. Interventions included Resident 49 was on oxygen. A 6/2023 TAR instructed staff to provide Resident 49 oxygen per nasal cannula zero to four liters to keep oxygen saturations greater than 90 percent as needed. There was no documentation Resident 49 was administered oxygen in 6/2023. The TAR also instructed staff to change the humidifier bottle every 28 days. It…

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 food preferences were honored for 1 of 2 sampled residents (#314) reviewed for food. This placed residents at risk for lack of meal satisfaction and weight loss. Findings include: Resident 314 was admitted to the facility in 2023 with diagnoses including depression and high blood pressure. A 7/2/23 admission MDS indicated Resident 314 was cognitively intact. A 7/6/23 care plan indicated interventions for Resident 314's depression included involvement in her/his own decision making as much as possible. An undated Dietary Profile Form indicated Resident 314 received a regular texture diet and liked good vegetables. An undated Always Available Menu indicated Chef Salad, Tossed Salad and Grilled Cheese along with cold sandwiches were available. On 7/10/23 at 3:53 PM Resident 314 stated the general menu was limited and there was no discussion or detailed information regarding alternative food options since she/he admitted . Resident 314 stated she/he saw other residents with grilled…

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

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 2 of 4 sampled residents (#s 49 & 214) reviewed for respiratory and urinary catheter. This placed residents at risk for exposure to and contraction of infectious diseases. Findings include: 1. Resident 49 was admitted to the facility in 2023 with diagnoses including acute kidney failure. A 5/16/23 revised care plan indicated Resident 49 had a catheter. Resident 49 required a mechanical lift with two-person assistance for transfers and one to two persons for bed mobility. On 7/12/23 at 7:32 AM Resident 49 was laying on her/his side in bed and her/his catheter bag was on the floor about two feet away from the bed with the privacy bag halfway off. On 7/13/23 at 7:34 AM Staff 25 (CNA) stated Resident 49 did not pull or move her/his own catheter bag and she/he did not get up on her/his own. On 7/14/23 at 12:45 Staff 2 (DNS) confirmed Resident 49's catheter bag should not be on the floor. 2. Resident 214 was admitted to the facility in 2023 with diagnoses…

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

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 27 and 29) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff. Findings include: On 7/14/23 at 3:00 PM Staff 2 (DNS) provided documentation of all completed training and in-services for Staff 27 (CNA) and Staff 29 (CNA): -Staff 27 completed Essentials of HIPAA on 5/16/22 with no abuse or dementia training in the last 18 months. -Staff 29 did not have training documented since 2019. On 12/6/22 at 11:32 AM Staff 1 (Administrator) acknowledged the required 12 hours of annual in-service training was not completed for Staff 27 and Staff 29.