Village Health Care

Based on interview and record review it was determined the facility failed to ensure residents were notified their of rights both orally and in writing on an ongoing basis for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for not being informed of their rights. Findings include: On 1/30/25 at 11:00 AM the Resident Council members stated they were not informed of resident rights on an ongoing basis, were unsure if any were posted in the facility, or where to obtain the resident rights. Record review of Resident Council Meeting minutes for 11/12/24, 12/10/24 and 1/17/25 revealed no evidence resident rights were provided to, or reviewed with, residents during the meetings or by any other method. On 1/30/25 at 12:27 PM Staff 1 (Administrator) stated he believed resident rights were reviewed through Resident Council and was not aware of any other method used to relay resident rights. Staff 1 acknowledged this finding and no additional information was provided.

Based on interview and record review it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 Resident Council reviewed. This placed residents at risk for lack of timely written communications. Findings include: On 1/30/25 at 11:00 AM during the Resident Council group interview, residents stated their mail was not delivered on Saturdays. Review of 11/20024 through 1/2025 resident activity participation charts revealed no evidence mail was delivered to residents on Saturdays. On 1/30/25 at 1:10 PM, Staff 1 (Administrator) confirmed there was no system in place to deliver mail to residents on Saturdays.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to comprehensively assess 3 of 7 sampled residents (#s 15, 18 and 33) reviewed for medications, ROM and behaviors. This placed residents at risk for unassessed needs and a lack of a person-centered care plan. Findings include: 1. Resident 15 was admitted to the facility in 2019 with diagnoses including major depression, schizophrenia, post traumatic stress disorder and anxiety disorder. An annual MDS assessment dated [DATE] indicated the resident had mild cognitive impairment with a BIMS of 13. According to the MDS the resident was prescribed daily psychotropic medication including antianxiety, antipsychotic, and antidepressant medication. Under the CAA for psychotropics, the analysis of findings was limited to a list of psychiatric diagnoses, a list of the prescribed psychotropic medications, and a statement that psychotropic meds have been included in [the resident's] Care Plan as a preventative measure. Care Plan will be updated if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 17 was admitted to the facility in 2021 with diagnoses including stroke and Aphasia (language disorder that affects a person's ability to communicate). Resident 17's 10/13/24 Annual MDS revealed the resident experienced severely impaired cognition. Resident 17 liked listening to music, doing things in groups of people, pets, participating in favorite activities and participating in religious activities or practices. On 1/27/25 at 1:11 PM Witness 4 (Family) stated Resident 17 enjoyed watching television, listening to music, especially jazz, classical and the oldies. Witness 4 stated Resident 17 had a radio in her/his room but they had not seen the radio since last spring. A review of Resident 17's current care plan directed staff to complete the following: - Assist patient to/from activity area. -Coordinate with nursing/therapy staff to get patient up for activities of choice. -Arrange for resident to attend group activities. -Encourage resident to eat in common dining area. -Seat resident near others…

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 evidence a designated licensed nurse (LN) served as a charge nurse to provide the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for staffing. This placed the residents at risk for unmet needs. Findings include: The facility's Direct Care Staff Daily Reports revealed from 1/1/25 through 1/27/25, 36 out of 81 shifts were without LN coverage to serve as a charge nurse as follows: -1/1/25; day shift. -1/2/25; day, evening and night shifts. -1/3/25 day shift. -1/6/25; day, evening and night shifts. -1/8/25; night shift. -1/9/25; day and night shifts. -1/10/25; night shift. -1/14/25; day, evening and night shifts. -1/15/25; night shift. -1/17/25; evening and night shift. -1/20/25; day, evening and night shifts -1/21/25; day, evening and night shifts. -1/22/25; day, evening and night shifts. -1/23/25; evening…

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 RN was available for at least eight consecutive hours per day seven days per week for 9 of 27 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 1/3/25 through 1/27/25 revealed no RN coverage was available for at least eight consecutive hours per day on the following days: -1/2/25. -1/6/25. -1/13/25. -1/14/25. -1/17/25. -1/20/25. -1/21/25. -1/22/25. -1/24/25. On 1/30/25 at 9:42 AM Staff 17 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days on the Direct Care Staff Daily Reports. No additional information was provided. On 1/30/25 at 9:56 AM Staff 1 (Administrator) acknowledged the facility's failure to meet RN coverage for eight consecutive hours per day on the dates provided. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (# 3) and 1 of 1 facility reviewed for dignity and dining. This placed residents at risk for lack of dignity. Findings include: 1. Resident 3 was admitted to the facility in 10/2014 with diagnoses including adult failure to thrive, abnormal weight loss and anxiety. Resident 3's 12/20/24 Annual MDS revealed the resident had no cognitive impairments and had impairments of both upper extremities. Observations of Resident 3 during breakfast and lunch meals from 1/28/25 through 1/30/25 revealed the following: -1/28/25 at 8:52 AM: Resident 3 received two glasses of juice served in plastic medication glasses and cereal served in a medium sized paper bowl. -1/28/25 at 12:48 PM: Resident 3 received two glasses of juice served in plastic medication glasses. -1/29/25 at 8:23 AM: Resident 3 received two glasses of juice served in plastic medication glasses. -1/30/25 at 8:37 AM: Resident 3 received two glasses of juice served in…

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

Based on interview and record review it was determined the facility failed to inform residents and/or the residents' responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 1 of 5 sampled residents (# 220) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent. Findings include: The facility's Informed Consent for Psychotropic Drugs, dated 9/2017, revealed the licensed nurse was to: -Discuss the rationale/benefits for the orders as directed by the physician. -Discuss the potential risk factors (side effects/symptoms) of taking the prescribed drug. -Review the content with the resident and obtain their signature if they agreed to take the prescribed drug. Resident 220 was admitted to the facility in 1/2025 with diagnoses including generalized anxiety disorder. Resident 220's 1/2025 MAR revealed the resident received the following psychotropic medications as ordered by her/his physician: -Citralopram Hydrobromide (a medication to treat depression and panic attacks) one time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure residents were included in care planning for 1 of 4 sampled residents (#28) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 28 was admitted to the facility in 1/8/25 with diagnoses including myocardial infarction (heart attack) and a fractured leg. A review of Resident 28's clinical record revealed she/he was her/his own responsible party. Resident 28's Functional Abilities and Goals assessment dated [DATE] indicated she/he was cognitively independent. No evidence was found in Resident 28's clinical record to indicate she/he was involved in the development of her/his care plan. On 1/27/25 at 10:54 AM Resident 28 stated the facility staff did not speak with her/him to develop her/his care plan and added she/he did not know what was included in her/his care plan. On 1/28/25 at 3:55 PM Staff 3 (RNCM) stated she did not find any evidence…

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 determine the appropriateness for the self-administration of medication for 2 of 2 sampled residents (#s 18 and 60) reviewed for self-administering medication. This placed residents at risk for unsafe medication administration. Findings include: Review of the facility's Self-Administration of Medications policy, dated 9/2017, revealed if a resident desires to self-administer medications, the Self-Medication Evaluation was completed. This evaluation was completed before the resident was able to self-administer medication. 1. Resident 18 was admitted to the facility in 2023 with diagnoses including a stroke. On 1/30/25 at 12:16 PM Resident 18 was observed to lie in her/his bed with the overbed table placed over her/his lap. On the table was a brown bottle, spray of Fluticasone Propionate Nasal spray, 50mg, within her/his reach. Review of the resident's health record revealed no self-administer medication assessment was completed to determine Resident 18's ability to safely self-administer 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 the call light was within reach for 1 of 1 sampled resident (#17) reviewed for call lights. This placed residents at risk for accidents and the inability to call for assistance. Findings include: Resident 17 was admitted to the facility in 2021 with diagnoses including Aphasia (language disorder which affects a person's ability to communicate). Resident 17's 1/29/25 in room care plan directed staff to ensure the resident's call light was in reach. On 1/29/25 at 9:31 AM and 10:47 AM, Resident 17 was observed to lie in her/his bed. The resident's call light was not within reach and was wrapped around the base of the head of the frame. During a 1/30/25 at 11:00 AM Resident Council meeting the residents stated their call lights were often not within reach and were tied to the back of their beds which did not allow them to call for assistance. On 1/30/25 at 12:59 PM Staff 8 (CNA) confirmed Resident 17's call light was not within reach and was tied to the back of her/his bed. On 2/3/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 1 of 3 sampled residents (#34) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for unknown financial liabilities. Findings include: Resident 34 was admitted to the facility on [DATE] with Medicare A benefits. A 10/11/24 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 34's Medicare Part A benefits ended on 10/14/24. Review of Resident 34's health record indicated the resident remained in the facility and was financially responsible for her/his care from 10/15/24 until 12/1/24. There was no documentation indicating the SNF ABN notification was provided to Resident 34 or their representative to inform them of the resident's daily out-of-pocket costs. On 1/29/25 at 12:54 PM Staff 2 (DNS) reported the facility was not providing SNF ABN notifications to residents or their…

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 accurate assessments for 2 of 5 sampled residents (#s 25 and 45) reviewed for medications. This placed residents at risk for unmet care needs. Findings include: 1. Resident 25 was admitted to the facility in 2018 with diagnoses including diabetes. On 1/28/25 at 12:54 PM Resident 25 was observed to be alert, oriented and was able to effectually express her/his current and past needs and history. Resident 25's 12/21/24 Quarterly MDS indicated the resident's BIMS score was not assessed as she/he was rarely/never understood and no diagnosis was provided to indicate the use of opioid medication. Resident 25's 3/20/24 Annual MDS revealed the resident's BIMS score of 15 (cognitively intact) and a diagnosis of chronic pain. On 2/3/25 at 8:08 AM Staff 2 (DNS) was informed of the findings and stated Resident 25's 12/21/24 Quarterly MDS was not accurate and she expected resident assessment to be accurate. 2. Resident 45 was admitted to the facility in 4/2024 with diagnoses including anxiety…

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 the facility failed to conduct a new/accurate Level I PASARR (Pre-admission Screening and Resident Review) when the facility became aware of indicators of a serious mental illness diagnosis and failed to complete a referral for a Level ll PASARR for 1 of 2 sampled residents (# 24) reviewed for PASARR coordination of care. This placed residents with a mental health disorder at risk for delayed care, emotional distress related to mental illness and lack of services to attain their highest practicable well-being. Findings include: Resident 24 admitted to the facility in 6/2022 with diagnoses including Bi-Polar Disorder (episodes of mood swings), Major Depressive Disorder and anxiety. Resident 24's heath record revealed a PASARR l coded for no indication of a serious mental illness was completed by the hospital upon admission on [DATE]. Resident 24's in room care plan directed staff with interventions for the following safety and behavioral concerns: -To give…

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 comprehensively develop a resident-centered baseline care plan within 48 hours of a resident's admission for 2 of 3 sampled residents (#s 41 and 220) reviewed for choices and accidents. This placed residents at risk for unmet care needs. Findings include: The facility's Baseline Plan of Care policy, last updated 4/2024, indicated the following: -The baseline plan of care included information regarding care and services sufficient to promote safe delivery of care. -Once triggered, the baseline care plan must be addressed and all customizations must be completed on the day of admission. 1. Resident 220 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia (a condition of inadequate supply of oxygen to the the body), oxygen dependence, dysphagia (difficulty swallowing), moderate protein-calorie malnutrition (a condition in which reduced nutrients lead to changes in body…

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 develop a plan of care to address resident centered medication management or need for PASARR (Pre-admission Screening and Resident Review) for 2 of 3 residents (#s 24 and 118) reviewed for implementation of physician orders or PASSAR. This placed the residents at risk for emotional distress related to lack of services to attain their highest practicable well-being. Finding include: 1. Resident 118 was admitted in 8/2024 with diagnoses including epilepsy, surgical repair of fractured hip, anxiety disorder and depression. admission orders dated 8/16/24 included clobazam 15 mg twice a day for seizure disorder and diazepam 10 mg gel rectally twice daily as needed for aura (physical, emotional or sensory changes that may proceed seizure activity in some individuals). The admission MDS dated [DATE] indicated the resident had mild cognitive impairment with a BIMS of 13, no mood concerns or behaviors, frequent pain, and received opioid 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.

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 care and treatment as care planned for 1 of 3 sampled residents (# 25) reviewed for skin conditions and failed to ensure person-centered medication management for 1 of 1 sampled resident (# 118) reviewed for implementation of physician orders. This placed residents at risk for delayed treatment and unmet needs. Findings include: 1. Resident 118 was admitted to the facility in 8/2024 with diagnoses including surgical repair of a fractured hip, epilepsy, depression and anxiety disorder. admission orders for Resident 118 dated 8/16/24 included clobazam 15 mg twice a day for seizure disorder, diazepam 10 mg gel, rectally, twice daily as needed for aura (physical, emotional or sensory changes that may proceed seizure activity in some individuals) or seizures and buspirone (an anti-anxiety medication). An admission MDS dated [DATE] indicated the resident had mild cognitive impairment with a BIMS of 13, no mood concerns…

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 glasses repair assistance for 1 of 1 sampled resident (# 45) reviewed for vision. This placed residents at risk for decreased visual abilities. Findings include: Resident 45 was admitted to the facility in 4/2024 with diagnoses including anxiety disorder. An 8/28/24 MDS Assessment stated Resident 45 used corrective lenses to assist with her/his vision. On 1/29/25 at 9:29 AM Resident 45 was observed wearing glasses. A scratch the size of a quarter was observed on the right lens of Resident 45's glasses. Resident 45 stated this scratch had been on her/his glasses for a long time and it makes her/his vision hazy. On 1/29/25 at 9:41 AM Staff 9 (Activity Director/SSD) stated Resident 45's glasses were damaged as result of a fall which occurred at the facility. On 1/29/25 at 10:46 AM Staff 2 (DNS) confirmed Resident 45's glasses should have been repaired or replaced as result of the damage having occurred at the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to regularly provide restorative nursing services to ensure residents maintained or improved their current level of ROM or mobility for 2 of 2 residents (#s 18 and 33) reviewed for mobility. This placed residents at risk for decline in physical functioning. Findings include: 1. Resident 33 was admitted to the facility in 11/2021 with diagnoses including stroke with hemiparesis (partial paralysis on one side of the body). According the resident's Annual MDS dated [DATE] Resident 33 was cognitively intact, It was important to the resident to make choices and to be active. The resident had ROM impairment on one side and used a walker and wheelchair for mobility. Under Restorative Nursing Programs the MDS indicated the resident received no RA services during the seven-day look back period. Resident 33's Comprehensive Care Plan last revised 12/8/24 included a restorative nursing program related to impaired mobility to be provided…

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 update pain medication instructions to include resident centered dosing for 1 of 3 residents (#26) reviewed for pain. This placed the resident at risk for increased pain and anxiety related to inconsistent interpretation of PRN orders. Findings include: Resident 26 was admitted to the facility in 10/2022 with diagnoses including anxiety, cancer and a more recent diagnosis of an abscess of the lower limb. Resident 26's Annual MDS dated [DATE] identified she/he had mild cognitive impairment with a BIMS of 13, experienced pain daily and received scheduled and PRN pain medication. The Pain CAA indicated house providers and licensed nurses monitored and managed the resident's pain control. Review of the resident's physician orders revealed a 11/6/24 order for oxycodone HCl 5 MG, 1 tablet by mouth as needed for Pain three times a day as needed. Resident 26's Comprehensive Care Plan last revised 11/12/24 included a problem statement related…

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 dialysis services were in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (# 22) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment. Findings include: The facility's Dialysis policy, last updated 3/2015, indicated the following: -The facility communicated with the dialysis center by completing the dialysis transfer form and sending new labs obtained. -The facility required the dialysis center to provide information, including pre-dialysis and post-dialysis weights, labs and results obtained at dialysis, medications given at the dialysis center and follow-up care or procedures needing to be done at the facility. -If the facility nurse did not receive the requested information from the dialysis center, a call was to be placed to request the information. -If the dialysis center did not provide the needed information, the nurse should notify the DNS and the DNS would contact the dialysis…

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 to pharmacy recommendations for limiting use of PRN antipsychotic to 14 days for 1 of 5 residents (#15) reviewed for medication regimen. Findings include: Resident 15 was admitted to the facility in 5/2019 with diagnoses including major depression, schizophrenia, and anxiety disorder. Review of the December 2024 and January 2025 MARs revealed an order for Seroquel (an antipsychotic medication) 25 mg every six hours PRN agitation/anxiety in addition to scheduled doses. The Seroquel had a start date of 12/2/24 and an end date of 1/28/25 when the order changed to a 14 day duration. On 1/30/25 at 11:15 AM Staff 13 (Corporate Nurse Consultant) stated there was no evidence the December pharmacy review was completed or acted upon. On 1/31/25 at 10:01 AM in a telephone interview Staff 20 (Consultant Pharmacist) stated he sent a review and note to the prescriber on 12/20/24 and 1/27/25 regarding the need for the 14 day limit and to ensure evidence of in-person physician visits.

Based on Interview and record review it was determined the facility failed ensure PRN use of an antipsychotic was limited to 14 days for 1 of 5 residents (#15) for whom medications were reviewed. This placed the resident at increased risk for unnecessary use of psychotropic medications. Findings include: Resident 15 was admitted to the facility in 2019 with diagnoses including major depression, schizophrenia, and anxiety disorder. Review of the December 2024 and January 2025 MARs revealed an order for Seroquel (an antipsychotic medication) 25 mg every six hours PRN for agitation/anxiety in addition to scheduled doses. The Seroquel had a start date of 12/2/24 and an end date of 1/28/25 when the order changed to a 14 day duration. Review of the MAR for December 2024 revealed the PRN dose was used 15 times. January 2025 revealed the PRN Seroquel was used eight times. On 1/30/25 at 11:15 AM Staff 13 (Corporate Nurse Consultant) confirmed the PRN Seroquel should have been limited to 14 days.

Based on observation, interview and record review it was determined the facility failed to accurately document physician orders for 2 of 4 sampled residents (#s 220 and 269 ) reviewed for choices and pain. This placed residents at risk for inaccurate medical records and risk for injury and/or decreased ability for recovery. Findings include: 1. Resident 220 was admitted to the facility in 1/2025 with diagnoses including dysphagia (difficulty swallowing), moderate protein-calorie malnutrition (a condition in which reduced nutrients lead to changes in body functioning), stroke and anxiety disorder. Resident 220's 1/20/25 post-discharge hospital orders indicated the resident was discharged to the facility with physician orders for mechanical soft diet textures (a modified diet consisting of soft, easy to chew foods). Resident 220's 1/20/25 Admission-readmission Nursing Evaluation indicated the resident was admitted to the facility with physician orders for mechanical soft diet textures. Resident 220's 1/20/25 facility's physician orders indicated the resident received minced and moist…

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 periodic review regarding advance directives was completed for 4 of 4 sampled residents (#s 1, 2, 29 and 32) reviewed for advance directives. This placed residents at risk for not having their health care wishes honored. Findings include: 1. Resident 1 was admitted to the facility in 6/2022 with diagnoses including femur fracture and schizophrenia. Resident 1's 6/2022 admission MDS indicated moderate cognitive impairment. Resident 1's face sheet revealed the Power of Attorney was her/his daughter. Review of Resident 1's health care record indicated there was no follow-up completed regarding the resident's advance directive information. On 6/8/23 at 12:21 PM Staff 1 (Administrator) acknowledged there was no system in place to periodically review residents' advance directive information. 2. Resident 2 was readmitted to the facility in 6/2022. Resident 2's 7/2023 Quarterly MDS indicated she/he was cognitively intact. Review of Resident 2's health care record indicated there was no follow-up completed…

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

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 17 of 36 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 8/1/23 through 9/5/23 DCSDRs indicated the following days when the number of CNA staff and CNA hours worked were inaccurate on the daily postings: -8/1, 8/2, 8/4, 8/5, 8/6, 8/7, 8/8, 8/9, 8/11, 8/13, 8/17, 8/22, 8/23, 8/24, 8/31, 9/2 and 9/5. On 9/7/23 at 2:53 PM Staff 8 (Human Resource Director) confirmed the facility's failure to accurately complete required information on the DCSDRs.

Based on interview and record review it was determined the facility failed to ensure a resident's missing personal property was addressed for 1 of 1 sampled resident (#34) reviewed for personal property. This placed residents at risk for loss of personal items. Findings include: Resident 34 was admitted to the facility in 4/2023 with diagnoses including a fractured hip and stroke with right sided paralysis. On 9/5/23 at 11:24 AM Resident 34 stated she/he had an heirloom back scratcher given to her/him as a gift and had a lot of sentimental value. Resident 34 stated several months ago, a staff member took the back scratcher away from her/him. The resident reported she/he spoke with several staff and asked to have the back scratcher returned but she/he had not heard anything further. Resident 34 stated she/he just wants it back because it was a gift from my step-dad and means a lot to me. On 9/6/23 at 1:25 PM and 1:48 PM Staff 4 (Social Service Director) and Staff 5 (Social Service Assistant) stated they were not aware Resident 34 was missing a back scratcher. Staff 4 stated 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 interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 5 sampled residents (#20) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 20 was admitted to the facility in 7/2023 with diagnoses including chronic headache and long term use of anticoagulant medication. 1. A 7/21/23 physician order indicated Resident 20 was prescribed cetirizine (an allergy medication) two times a day for allergies. A review of Resident 20's 8/1/23 through 8/31/23 MAR indicated the resident's cetirizine was not administered according to the physician orders on the following days: -8/21 evening dosage and -8/29 evening dosage. On 9/7/23 at 12:17 PM and 9/8/23 at 10:51 AM Staff 3 (LPN-Care Manager) and Staff 2 (DNS) reviewed Resident 20's cetirizine MAR and confirmed the resident's cetirizine should have been given on the dates identified. 2. A 7/21/23 physician order indicated Resident 20 was prescribed cyanocobalamin (a form of Vitamin B 12) two times a day…

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

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#20) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 20 was admitted to the facility in 7/2023 with diagnoses including bladder infection. Review of Resident 20's 8/24/23 through 9/6/23 MAR indicated an 8/24/23 physician order for MiraLAX (a laxative) which was to be administered one time a day for bowel care. The order indicated to hold the medication if Resident 20 had loose stools. The MAR indicated Resident 20 was administered MiraLAX daily and there were no instances when the medication was held. Review of Resident 20's Bowel Elimination Flow Record from 8/24/23 through 9/6/23 indicated Resident 20 had loose stools on the following dates: -8/28, 9/1, 9/2, 9/5 and 9/6. On 9/7/23 at 12:17 PM Staff 3 (LPN-Care Manager) reviewed Resident 20's MiraLAX MAR and Bowel Elimination Flow Record. Staff 3 stated the staff members responsible 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 ensure a medication pass error rate of less than five percent. There were three errors in 26 opportunities resulting in a 11.54% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: According to the [NAME] Drug Guide 2023, thyroid medications should be taken on an empty stomach and eating and drinking should be avoided for 30-60 minutes afterwards. Resident 28 was admitted to the facility in 5/2022 with diagnoses including hypothyroidism and diabetes. Resident 28's 9/2023 physician orders included the following: -levothyroxine sodium, (treats low thyroid) 25mcg, give one tablet by mouth one time a day. -Advair Diskus Inhalation Aerosol Powder, (asthma medication) 100-50 mcg/ACT, one puff inhale orally every 12 hours, rinse mouth with water after use. -ziprasidone (antipsychotic) 60mg, give one tablet by mouth twice a day, give with food. On 9/7/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to store drugs and biologicals in locked compartments for 2 of 3 treatment carts observed during this survey. This placed residents at risk for medication diversion and accidents. Findings include: The facility's Storage of Medications Policy and Procedure dated 8/2018 stated: Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 9/6/23 at 8:36 AM a treatment cart was observed to be unlocked outside room [ROOM NUMBER]. The nurse was not in view of the cart. Staff 7 (LPN-Care Manager) verified the cart was unlocked. On 9/7/23 at 3:17 PM a treatment cart was observed to be unlocked near room [ROOM NUMBER]. The nurse was not in view of the cart. Staff 8 (Human Resources Manager) walked by and locked the cart. Staff 10 (RN) acknowledged she left the cart unlocked. On 9/8/23 at 9:43 AM Staff 2 (DNS) stated it was her expectation the carts remained locked when not in use.