Avamere Rehabilitation Of Lebanon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to comprehensively assess 1 of 3 resident (#11) reviewed for positioning and hospitalization. This placed resident at risk for unassessed needs. Findings include:Resident 11 was admitted to facility in 8/2023 with diagnoses including chronic kidney disease.On 9/2/25 at 2:19 PM, Resident 11 stated she/he was not certain of what her/his care needs consisted of, as she/he had recently experienced multiple hospitalizations.A review of Resident 11's clinical record revealed her/his Annual MDS completion deadline date was 8/2/25 and was incomplete as of 9/7/25. A review of Resident's clinical record revealed she/he was hospitalized on [DATE], 7/29/25, 8/13/25 and 8/18/25 and her/his most recent entry back to facility was on 8/22/25. No evidence was found in the clinical record to indicate a significant change assessment, or an admissions assessment was completed as of 9/7/25.On 9/8/25 at 8:58 AM, Staff 15 (Regional Reimbursement Analyst)…

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 coordinate the appropriate services to address communication needs for 1 of 1 sampled resident (#6) reviewed for communication. This placed residents at risk for ineffective communication and unmet needs. Findings include: Resident 6 was admitted to the facility in 4/2025 with diagnoses including persistent vegetative state (awake with no environmental awareness) and traumatic brain injury.The 4/24/25 admission MDS indicated Resident 6's ability to understand others was not assessed.A 5/26/25 physician order indicated PT, OT, SLP per family request. A 7/21/25 facility Care Conference Information form indicated Witness 2 (Family Member) requested Staff 6 (Resident Care Manager-LPN) coordinate referrals for OT. PT, SLP and a neurologist (brain disorder specialist).A 7/23/25 revised care plan indicated Resident 6 was not able to make her/his needs known and used non-verbal techniques to supplement her/his communication.On 9/2/25 at 12:59 PM, Witness 2 stated Resident 6 previously communicated…

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 bathing and shower care for 1 of 3 sampled residents (#16) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 16 was admitted to facility on 7/5/25 with diagnoses including chronic obstructive pulmonary disease and metabolic encephalopathy (temporary or permanent brain dysfunction caused by a problem with the body's metabolism).Resident 16's 7/5/25 Care Plan indicated she/he required two staff to assist with bathing.Resident 7/13/25 admission MDS indicated the resident was dependent on assistance with bathing/showering.Resident 16's 7/2025 Bath/Shower task logs indicated the resident received showers on 7/8/25, 7/15/25 and 7/22/25. There was no documentation for 7/11/25, 7/18/25, and 7/29/25, which were Resident 16's scheduled shower days, as those entries were left blank.A review of Resident 16's Progress Notes from 7/5/25 through 7/30/25 revealed no evidence the resident was offered additional a showering opportunity when a shower was refused or not…

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

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 4 sampled residents (# 49) reviewed for infection control. This placed residents at risk for wound infections. Findings include:Resident 49 was admitted to the facility in 8/2025 with diagnoses including a leg fracture.An 8/8/25 Orthopedic Physician Order directed staff to remove Resident 49's dressing one week after 8/8/25. Staff were instructed to gently cleanse the incision using warm water and soap, pat dry, apply a nonadhesive pad or gauze dressing secured with tape, and change the dressing every one to two days until the follow-up appointment. Staff were to contact Trauma/Orthopedics if signs or symptoms of redness, drainage, onset of pain, chills, fever, sweats, or infection were observed.The 8/25 TAR did not contain the Orthopedic Physician's order for wound care. There was no evidence the wound care was completed.On 8/25/25, a Progress Note indicated Resident 49's middle incision on her/his left thigh was red, swollen, and warm to the touch. Resident…

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

Based on observation, interview and record review it was determined the facility failed to implement care plan interventions related to smoking safety for 1 of 2 sampled residents (#37) reviewed for accidents. This placed residents at risk for increased smoking hazards and avoidable accidents. Findings include: The facility provided the following schedule for smoking:3:00 AM9:30 AM1:30 PM4:00 PM7:45 PM11:00 PMResident 37 was admitted to the facility in 9/2019 with diagnoses including inhalant dependence with inhalant-induced dementia (a condition where an individual has developed a physical or psychological reliance on substances which are inhaled to induce psychoactive effects).Resident 37's 8/8/25 Annual MDS assessment indicated she/he was cognitively intact.Resident 37's comprehensive Care Plan related to smoking safety last revised 8/26/25 indicated although she/he was assessed to be independent with smoking, she/he was to smoke in the smoking areas and to follow the smoking schedule. The care plan also indicated Resident 37's clothing and hands were to be checked for burns and…

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

Based on interview and record review, it was determined the facility failed to ensure annual performance reviews for CNA staff were completed for 2 of 5 sampled CNA staff (#s 24 and 25) reviewed for staffing. This placed residents at risk due to lack of competent staff. Findings include:A review of personnel profile records revealed the following.-Staff 24 (hired on 5/14/20): The last performance review was dated 6/12/24.-Staff 25 (hired on 8/1/18): The last performance review was dated 8/15/24.On 9/8/25 at 11:36 AM, Staff 1 (Administrator) stated he expected the timely completion of annual staff evaluations.

Based on observation, interview, and record review it was determined the facility failed to timely address a new identified behavior for 1 of 2 sampled residents (#2) reviewed for mood and behavior. This placed residents at risk for lack of emotional and behavioral health needs. Findings include:Resident 2 was admitted to the facility in 7/2025 with diagnoses including anxiety and heart failure. The 2/2025 Facility Assessment revealed behavior health staffing was insufficient. The 7/23/25 admission MDS revealed Resident 2 had a BIMS score of 15 which revealed she/he was cognitively intact, was depressed two to six days during the previous two weeks and received no antidepressant medications. The 8/2025 Behavior Monitoring Record revealed Resident 2 exhibited inappropriate behaviors on nine of 31 days which included refusal of care, confabulation (fabrication of false memories), and verbal aggression. On eight out of nine days, behavior interventions did not alter the outcome. The 8/1/25 through 9/5/25 Progress Notes revealed Resident 2 exhibited no additional behaviors. An 8/12/25…

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

Based on observation and interview it was determined the facility failed to ensure treatment carts were locked and secured appropriately for 2 of 2 treatment carts observed during random observations for medication and treatment cart storage. This placed residents at risk for unsafe access to stored medications. Findings include: 1. On 9/4/25 at 7:15 AM, the North Hall treatment cart was unlocked. Staff and residents were observed to be walking by the treatment cart.On 9/4/25 at 7:17 AM, Staff 17 (CMA) walked by the cart, walked back, and locked the cart. Staff 17 stated she was not in charge of the treatment cart, but noticed it was unlocked and locked it on behalf of Staff 19. She stated Staff 19 was with a resident. On 9/4/25 at 7:19 AM, Staff 19 (RN - Charge Nurse) stated she usually locked the treatment cart before walking away, but was unsure why she did not lock the treatment cart. The treatment cart contained insulin, needles, glucometers, and IV supplies.On 9/8/25 at 12:40 AM, Staff 1 (Administrator) and Staff 3 (Regional Director of QA) stated they expected treatment carts…

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 up on dental services for 1 of 2 sampled residents (#11) reviewed for dental care. This placed residents at risk for lack of dental services. Findings include:The facility's Dental Services policy dated 12/2016 included the following:Social services representatives will assist residents with appointments, transportation arrangements, and reimbursement of dental services. All dental services provided are recorded in the resident's medical record.The facility's Referrals to Social Service Director dated 11/2024 included the following:Any referrals for the following areas will be made to the social services department: dental.Social services is responsible for the follow up and communication with outside providers for any of the above referrals.The Social Services Director will document any referrals made to ancillary services, mental health services, or additional community services/supports and will also document the outcomes following these referrals.Resident 11 was admitted to facility…

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

Based on observation, interview, and record review it was determined the facility failed to provide adequate staffing to meet resident needs for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include:1. Resident 3 was admitted to the facility in 3/2025 with diagnoses including dementia and stroke. A 5/2025 Documentation Survey Report revealed Resident 3’s showers were typically provided during the evening shifts. The resident was scheduled to receive a shower on 5/27/25, and there was no documentation Resident 3’s shower was completed. The 5/27/25 Direct Care Staff Daily Report indicated five CNAs worked during the evening shift with a facility census of 56 residents. A 6/2/25 public complaint was received which alleged, on 5/27/25, each CNA had 12 residents during the evening shift due to call outs, and it was possible resident showers were not provided. A 6/12/25 revised care plan indicated Resident 3 required one person to assist with bathing. On 7/21/25 at 12:14 PM, Staff 13 (LPN) stated she recalled 5/27/25 as a “terrible” 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 respond timely to a resident's grievance for 1 of 2 sampled residents (#8) reviewed for missing property. This placed residents at risk for unresolved concerns. Findings include: A Grievance Policy last revised 1/2017 revealed the facility would promptly address grievances. The grievance would be addressed within five days of its receipt. The Grievance official, administrator, or department head would contact the concerned party to inform them of the resolution of their concern. Resident 8 was admitted to the facility in 4/2021 with a diagnosis of diabetes. Resident 8's 5/14/25 quarterly MDS revealed she/he was cognitively intact. Resident 8's Missing Property investigation initiated on 7/11/25 revealed when she/he went to take money out of her/his wallet, there was only 20 dollars instead of 65 dollars in her his wallet. Resident 8 reported there should have been three 20-dollar bills and five one-dollar bills. With the resident's permission, staff looked in Resident 8's wallet and observed one 20-dollar…

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

Based on interview and record review it was determined the facility failed to ensure a resident's cell phone was not stolen for 1 of 2 sampled residents (#3) reviewed for missing property. This placed residents at risk for loss of property. Findings include:Resident 3 was admitted to the facility in 8/2023 with a diagnosis of a stroke. Resident 3's 2/19/25 quarterly MDS revealed she/he was cognitively intact. Resident 3's 4/7/25 Theft investigation revealed Resident 3 reported her/his cell phone was missing. Resident 3 reported on the evening of 4/6/25 she/he used the phone to call her/his spouse and after the call was completed placed the phone on her/his bedside table. The investigation included staff interviews verifying Resident 3 had her/his phone the evening of 4/6/25. Resident 3's spouse filed a police report the following day. Resident 3's spouse was able to use a phone locator and Resident 3's phone was a few blocks from the facility. A 5/10/25 letter from Witness 1 revealed a request for reimbursement for the lost phone and for the purchase of a new phone.A 5/16/25 bank…

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 resident rights for 1 of 3 sampled residents (# 2) reviewed for resident rights. This placed residents at risk for lack of dignity. Findings include: Resident 2 admitted to facility in 7/2024, with diagnoses including dementia. A 1/2025 Quarterly MDS Assessment indicated Resident 2 was moderately cognitively impaired. The facility's abuse investigation dated 10/3/24 indicated the following: -Staff 4 (CNA) changed Resident 2's soiled shirt. Resident 2 had told Staff 4 to leave her/him alone and not change her/his shirt. -On 10/3/24 Resident 2 stated the lady took her/him to the room and ripped Resident 2's shirt off. Resident 2 stated they refused to have their shirt removed. -On 10/3/24 Staff 4 (CNA) stated she went into Resident 2's room to change her/his shirt. The shirt was a lot dirtier than just wiping it off. Staff 4 stated she explained this to Resident 2, but the resident fought and cussed at her while she changed the resident's shirt. Staff 4 notified Staff 5 (LPN) that Resident 2 was very…

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

Based on observation and interview it was determined the facility failed to follow recipes to meet menu and therapeutic standards for 1 of 1 kitchen. This place residents at risk for lack of meal satisfaction and compromised nutrition. Finding include: The 7/18/24 posted lunch menu included breaded pork cutlet, au gratin potatoes, cauliflower and the alternative menu was sloppy joes, cheddar mash potatoes and broccoli. On 7/18/24 at 11:20 AM Staff 35 (Cook) was observed to assemble lunch and was asked to provide the recipes used to prepare the meal. Staff 35 stated he worked in the facility for three weeks and no recipes were provided during his training. Staff 35 stated no recipes were followed to prepare any of the foods served for lunch. On 7/18/24 at 12:03 PM and 12:53 PM Staff 5 (Certified Dietary Manager) stated a new menu system with recipes was introduced to the facility in 6/2024 and recipes should have been printed for all therapeutic diets and followed.

Based on observation, interview, and record review it was determined the facility failed to ensure proper flavor and food temperatures were maintained for meals served for 1 of 5 sampled resident (#27) and 1 of 1 facility kitchen reviewed for dining services. This placed residents at risk for food that was not palatable, safe, or appetizing. Findings include: 1. The 7/18/24 posted lunch menu included breaded pork cutlet, au gratin potatoes, cauliflower and the alternative menu was sloppy joes, cheddar mash potatoes and broccoli. The desert was ice cream. On 7/18/24 at 1:20 PM two sample plates were received. The first plate included minced and moist textured sloppy joes, mashed potatoes and gravy and broccoli. The second sample plate included easy to chew textured au gratin potatoes and cauliflower. The au gratin potatoes had crunchy pieces of dried potatoes, the moist and minced broccoli was cold with pieces that were firm to chew, the ice cream was melted and the milk was served warm. On 7/18/24 at 1:27 PM Staff 5 (Certified Dietary Manager) acknowledged the au gratin potatoes…

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 sanitation processes were followed for 1 of 1 observed kitchen. This placed residents at risk for food borne illnesses. Findings include: A 7/2024 Dishwasher Temperature Log revealed a low-temperature dishwasher was monitored from 7/1/24 through 7/14/24, but with no evidence chemical concentration levels were documented. On 7/15/24 at 10:02 AM Staff 44 (Dietary Aide) was observed loading dishes into a low-temperature dishwasher that used chlorine to sanitize dishes. Staff 44 stated she cleaned dishes routinely, monitored the wash and rinse temperatures daily, but was never instructed to monitor the chemical concentration of the dish machine. On 7/15/24 at 10:17 AM Staff 45 (Dietary Services Manager) acknowledged she was aware the dish machine chemical concentration was to be monitored with the use of chemical test strips, which did not occur, and relied on monthly dish machine inspections by the chemical supplier to ensure the dish machine operated correctly. On 7/15/24 at 10:55 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to provide a clean homelike environment for 7 of 10 sampled residents (#s 6, 19, 27, 29, 37, 46 and 58) and 1 of 2 halls (North) reviewed for environment. This placed residents at risk for an unclean and unhomelike environment. Findings include: 1. Resident 19 admitted to the facility in 6/2023 with diagnosis including reduced mobility. On 7/15/24 at 10:41 AM approximately 50 dents with black marks were observed on the floor at the foot of Resident 19's bed. Resident 19's roommate mentioned ongoing cleaning efforts by housekeeping that did not remove the marks. Additionally, in the bathroom, there were two gray substance lines, each approximately four inches by 12 inches on an aged and dingy floor. On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) confirmed completion of some work was needed near the toilet and acknowledged flooring damage. 2. Resident 58 admitted to the facility in 4/2024 with diagnosis including end-of-life care. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 8 sampled residents (#16) and 2 of 2 halls (North and 2nd South) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. A review of Council Minutes revealed the following: -4/29/24 Staff were overworked. Staff left a resident unattended during care resulting in the resident being stuck in the bathroom. Another resident was left in the shower for an extended period. Staff checked on one resident in a room but not their roommate. Call light response times were too long while residents were in the bathroom. -5/29/24 staff lacked the time to spend with residents and had poor attitudes. Call lights went unanswered for 20 minutes or more. Staff did not assist each other. If a staff member was not assigned to a resident, they did not answer their call light. On 7/15/24 the following interviews occurred: -8:46 AM, Resident 36…

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

Based on interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day 7 days per week for 34 out of 126 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: Review of the Direct Care Staff Daily Report sheets from 1/1/24 through 1/28/24, 2/3/24 through 2/25/24, 3/10/24 through 3/24/24, 5/1/24 through 5/30/24, 6/14/24 through 6/30/24, 7/1/24 through 7/14/24 revealed the facility did not have RN coverage for eight consecutive hours on the following days: 1/20/24, 1/21/24, 1/28/24, 2/3/24, 2/4/24, 2/5/24, 2/7/24, 2/8/24, 2/10/24, 2/11/24, 2/13/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/21/24, 2/23/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/14/24, 3/15/24, 3/16/24, 3/17/24, 3/18/24, 3/19/24, 3/20/24, 3/21/24, 3/22/24, 3/23/24, 3/24/24, 6/30/24 and 7/3/24. In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated they thought RN coverage was better than what was…

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

Based on observation, interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents and visitors at risk for incomplete and inaccurate staffing information. Findings include: On 7/15/24 at 9:41 AM the DCSDR (Direct Care Staff Daily Report) was observed posted on the wall. The DCSDR did not have any staff hours documented for LPNs or CNAs. On 7/16/24 at 7:38 AM and 8:25 AM the 7/15/24 DCSDR was still posted on the wall. On 7/17/24 at 7:57 AM the DCSDR was observed on posted on the wall with no LPN or CNAs documented on the form. On 7/17/24 at 11:53 AM Witness 1 (Staff) stated in the last few months the nurses were informed to just fill in the staff numbers without staff hours and the administration would complete the form the next day. On 7/18/24 at 7:51 AM and 9:11 AM the 7/18/24 DCSDR was observed posted on the wall with no LPN or CNA hours documented for all three shifts. On 7/18/24 at 8:40 AM a text message was received from Witness 1 which was a photo 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 observation, interviews and record review it was determined the facility failed to ensure resident rooms were free from pests for 1 of 10 sampled residents (#36) and 1 of 3 dining rooms reviewed for environment. This placed residents at risk for pest infestation. Findings include: Resident 36 admitted to the facility in 2024 with diagnoses including diabetes and foot ulcer. A 7/6/24 Work Order indicated there was an excessive amount of flies in the main area and resident rooms in the south part of the building. A 7/13/24 at 6:10 AM SBAR (Situation, Background, Assessment, Recommendation) Change of Condition note indicated on 7/13/24 Staff 26 (RN) reported at 5:00 AM to Staff 27 (LPN) Resident 36 had maggots (fly larva) on her/his bed that came from her/wound dressing. Resident 36 was transported to the hospital. On 7/15/24 at 12:30 PM five flies were observed in the resident dining room around residents' food. Residents continued to swat the flies away from their meals. On 7/16/24 at 8:50 AM Resident 36 stated around 7/4/24 she/he complained about flies in her/his room that…

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 5 of 5 randomly selected staff members (#s 6, 7, 8, 9, and 10) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: - Staff 6 (CNA), hired 5/30/22, had 15 minutes of documented training from 5/30/23 through 5/30/24. - Staff 7 (CNA), hired 6/20/19, had one hour of documented training from 6/20/23 through 6/20/24. - Staff 8 (CNA), hired 5/14/20, had two hours of documented training from 5/14/23 through 5/14/24. -Staff 9 (CNA), hired 3/23/21, had 7.25 hours of documented training from 3/23/23 through 3/23/24 -Staff 10 (CNA) hired 6/16/21, had 15 minutes of documented training from 6/16/23 through 6/16/24. In an interview on 7/19/24 at 12:03 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated staff were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide risk and benefit information related to the use of antipsychotic medications to residents/responsible parties prior to administration for 1 of 5 sampled residents (#10) reviewed for medications. This placed resident responsible parties at risk for lack of informed consent. Findings include: Resident 10 admitted to the facility in 5/2024 with diagnosis including dementia. A review of the 5/2024 MAR revealed instruction staff to administer Haloperidol (an antipsychotic used to treat mental and mood disorders) four times a day for anxiety and agitation with a start date of 5/9/24. The admission MDS dated [DATE] revealed Resident 10 had a BIMS score of 10, which indicated the resident was moderately impaired cognitively. A review of Resident 10's clinical record revealed Witness 2 (Family Member) was Resident 10's responsible party. A review of a Consent for use of Psychotropic Medication Therapy dated 5/16/24 revealed Resident 10…

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 care conferences were completed for 1 of 5 sampled residents (#15) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 15 admitted to the facility in 11/2021 with diagnoses including dementia. On 7/18/24 at 1:30 PM Witness 6 (family member) stated the facility scheduled a care conference on 5/27/24. Witness 6 stated the care conference did not occur and no one contacted her to reschedule. On 7/18/24 at 3:01 PM Staff 15 (LPN Assistant RCM) confirmed Resident 15 had a care conference scheduled on 5/27/24. Staff 15 stated on 5/27/24 Witness 6 came down to the social services office to inquire about the scheduled care conference. Staff 15 stated she spoke with Witness 6 and Witness 6 had no concerns. Staff 15 confirmed Resident 15 was not in attendance. On 7/18/24 at 3:09 PM Staff 33 (Social Service Coordinator) stated on 5/27/24 Witness 6 came to her office to inquire about the scheduled care conference. Staff 33 stated she spoke with Witness 6 and Witness 6 had…

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

Based on observation, interview and record review it was determined the facility failed to include a resident in shower schedule decisions for 1 of 4 sampled residents (#36) reviewed for choices. This placed residents at risk for lack of independent choices. Findings include: Resident 36 admitted to the facility in 2024 with diagnoses including diabetes and a foot ulcer. A 5/22/24 revised care plan indicated Resident 36 required two staff to assist with transfers and was dependent on staff with dressing. A 6/25/24 Census for Resident 36 indicated a room move. On 7/16/24 at 9:09 AM a communication board in Resident 36's room indicated her/his shower days were Monday and Thursday. Resident 36 stated the schedule for her/his showers were recently changed without a conversation with the resident. Resident 36 stated the current shower schedule interferred with her/his weekly medical appointment which was not acceptable. On 7/18/24 at 5:11 PM Staff 28 (LPN-Resident Care Manager) stated when Resident 36 moved to a new room her/his shower scheduled automatically changed. Staff 28…

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

Based on interview and record review it was determined the facility failed to notify provider of CBG check and orthostatic blood pressure refusals for 1 of 5 sampled residents (# 17) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 17 admitted to the facility in 9/2019 with diagnoses including diabetes. A review of Resident 17's Physician Orders revealed a 9/26/23 order to check her/his CBG every Tuesday morning and a 5/11/22 order to check her/his orthostatic blood pressure (blood pressure check when laying down, sitting and standing) every month. A review of Resident 17's 5/2024 MAR revealed she/he refused CBG checks on 5/21/24 and 5/28/24 and she/he refused orthostatic blood pressures on 5/12/24. A review of Resident 17's 6/2024 MAR revealed she/he refused CBG checks on 6/4/24, 6/11/24, 6/18/24 and 6/25/24 and she/he refused orthostatic blood pressures on 6/12/24. A review of Resident 17's MAR from 7/1/24 through 7/18/24 revealed she/he refused CBG checks on 7/2/24, 7/9/24 and 7/16/24 and there was no evidence of documentation…

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 abuse for 1 of 1 resident (#46) reviewed for abuse. This placed residents at risk for abuse. Findings include Resident 46 admitted to the facility in 2024 with diagnoses including PTSD (post traumatic stress disorder) and anxiety disorder. The 4/5/24 admission MDS indicated Resident 46 had a BIMS of 15 which indicated she/he was cognitively intact. The 4/1/24 care plan indicated Resident 46 was on behavior monitoring related to a history of PTSD, depression, and anxiety. Resident 46's triggers for PTSD included: -overwhelmed -feeling loss of control -upset with situation On 6/13/24 a public complaint was received which indicated Resident 46 was being harassed and intimidated by Resident 29. The facility was not doing enough to keep her/him safe and it was an ongoing issue. Witness 8 (Complainant) stated on 6/2/24 Resident 29 came into the dining room and was disruptive. Resident 46 politely asked her/him to to not be disruptive while they were having their meal. Resident 29…

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 investigate allegations of abuse for 1 of 1 sampled resident (#46) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 46 admitted to the facility in 2024 with diagnoses including PTSD (post traumatic stress disorder) and anxiety disorder. The 4/5/24 admission MDS indicated Resident 46 had a BIMS of 15 which indicated she/he was cognitively intact. The 4/1/24 care plan indicated Resident 46 was on behavior monitoring related to a history of PTSD, depression, and anxiety. Resident 46's triggers for PTSD included: -overwhelmed -feeling loss of control -upset with situation On 6/13/24 a public complaint was received which indicated Resident 46 was being harassed and intimidated by Resident 29. The facility was not doing enough to keep her/him safe and it was an ongoing issue. Witness 8 (Complainant) stated on 6/2/24 Resident 29 came into the dining room and was disruptive. Resident 46 politely asked her/him to to not be disruptive while they were having 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to revise care plan interventions for 3 of 13 sampled residents (#s 10, 17 and 24) reviewed for ADLS, medications, positioning and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 10 admitted to the facility in 5/2024 with diagnoses including a broken arm. The admission MDS dated [DATE] revealed Resident 10 had a BIMS score of 10, which indicated the resident was moderately impaired cognitively. Resident 10 was at risk for contracture to the left fingers. A review of a TAR for 7/2024 instructed staff to soak and wash her/his hand in warm water every shift and apply a hand brace every day and evening shift for the hand contracture with a start date of 6/11/24. Review of Resident 10's current care plan revealed no documentation related to the hand contracture. On 7/19/24 at 7:54 AM Staff 16 (CMA) stated she was the one who started soaking Resident 10's hand as her/his hand was crusty 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 ensure dependent residents received required assistance with ADLs for 3 of 6 sampled residents (#s 16, 24, and 40) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: 1. Resident 16 admitted to the facility in 2/2017 with diagnoses including a fractured pelvis. The quarterly MDS dated [DATE] revealed Resident 16 had a BIMS score of 15 indicating the resident was cognitively intact. The resident required substantial to maximal assistance with transfers related to toileting. A review of Resident 16's care plan revised 7/5/21 revealed Resident 16 had bladder incontinence. Interventions included to notify staff of toileting needs. Resident 16 was occasionally incontinent before reaching the bathroom and required one-person assistance for toilet transfers. On 5/30/24 the State Survey Agency received a public complaint which indicated staff were busy with dinner one night the week of 5/20/24.…

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 and provide meaningful activities for 2 of 2 sampled resident (#s 36 and 42) reviewed for activities. This placed residents at risk for lack of social interaction. Findings include: 1. Resident 36 admitted to the facility in 2024 with diagnoses including diabetes and a foot ulcer. A 5/21/24 admission MDS revealed Resident 36 was cognitively intact and it was very important to choose activities which were important to her/him. A 5/28/24 Activity Profile indicated Resident 36 desired group activities which included exercise. A 5/29/24 care plan indicated Resident 36 wanted staff to discuss her/his likes and dislikes related to activities. The 7/15/24 [CNA] Tasks: Activity revealed Resident 36 did not engage in any group or one on one activities during the previous 30 days. On 7/16/24 at 8:42 AM Resident 36 was observed in bed and stated she/he was bored and there were no exercise options presented. On 7/17/24 at 3:09 PM Staff 37 (Activities Director) stated Resident 36 had no interest 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 implement bowel care, notify the physician and follow physician orders for 2 of 8 sampled residents (#s 17 and 33) reviewed for skin, change of condition, and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 17 admitted to the facility in 9/2019 with diagnoses including diabetes. A review of Resident 17's medical record revealed 5/7/24 orders to increase Lisinopril (a medication used to treat high blood pressure). A 6/20/24 Progress Note stated Resident 17's provider wrote orders on 5/7/24 to increase her/his Lisinopril and the order was not entered into Resident 17 chart. On 7/17/24 at 1:31 PM Staff 25 (LPN) stated she discovered the pharmacy sent Lisinopril 7.5 mg, but the order in Resident 17's chart was for Lisinopril 5 mg. Staff 25 stated she checked the orders written by the provider and discovered Resident 17's Lisinopril was increased from 5 mg daily to 7.5 mg daily on 5/7/24. Staff 25 stated she was unsure when the pharmacy sent the correct dose. On 7/17/24…

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 replace hearing aids in a timely manner for 1 of 3 sampled residents (#40) reviewed for sensory needs. This placed residents at risk for a decline in hearing and impaired communication. Findings include: Resident 40 admitted to the facility in 2022 with diagnoses including dementia and depression. A 5/17/24 Quarterly MDS indicated Resident 40's hearing was adequate and she/he was assessed for the use of hearing aids or a hearing appliance. A 6/6/24 revised care plan indicated Resident 40 was to wear hearing aids in both ears in order to address her/his mild hearing deficit. On 7/16/24 at 9:24 AM Resident 40 was observed seated at a dining room table with no hearing aid in either ear. Staff 29 (CNA) stated Resident 40 did not use her/his hearing aids because they were broken for the last three to four months, and the resident was on a list to have her/his hearing aids repaired. On 7/17/24 at 10:07 AM Staff 27 (LPN) stated Resident 40 had no hearing aids since the resident moved to a new hall…

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 pressure ulcer treatments and care plans for 2 of 2 sampled residents (#s 1 and 3) reviewed for pressure ulcers and incontinent care. This placed residents at risk for pressure ulcers. Findings include: 1. Resident 3 admitted to the facility in 7/2021 with diagnoses including stroke. A 5/31/24 Weekly Skin Audit revealed Resident 3 had new skin irregularities with significant redness to the peri area and sacral (large, triangular bone at the base of the spine) area. There was no documentation indicating the physician was informed. Review of the 6/2024 TAR instructed staff to conduct bi-weekly skin checks and document in the assessment tab which was discontinued on 6/16/24. The TAR indicated the task was completed on 6/2/24, 6/5/24, 6/12/24, and 6/16/24. On 6/13/24 it referred the reader to notes. There were no corresponding assessments found in the assessment tab for those dates. A 6/12/24 Order Note revealed the weekly skin check was not completed as it was completed on 6/9/24. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 1 sampled resident (#66) reviewed for accidents, and respond to changes in condition in a timely manner for 1 of 1 sampled resident (#65) reviewed for change of condition. This placed residents at risk for injury and untimely care needs. Findings include: 1. Resident 65 admitted to the facility in 2024 with diagnoses including leg fracture. A progress note dated 12/15/23 at 5:33 PM indicated Resident 65 had a recent fall and her/his right lower extremity was swollen, bruised, and and painful. A STAT (immediate) x-ray was ordered to rule out injury. A progress note dated 12/16/23 at 2:41 AM indicated the x-ray revealed Resident 65 had a right ankle fracture. A progress note dated 12/18/23 at 9:40 AM indicated Staff 41 (LPN) sent a message to the physician that Resident 65 had a fractured ankle. The physician replied the x-ray was noted on…

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

Based on interview and record review it was determined the facility failed to provide adequate catheter care for 1 of 2 sampled residents (#14) reviewed urinary catheter. This placed residents at risk for urinary infections. Findings include: Resident 14 admitted to the facility in 2023 with diagnoses including chronic kidney disease and displacement of a nephrostomy catheter (tube that diverts urine from kidney). A 6/14/23 Discharge Summary indicated Resident 14 had a nephrostomy tube placed. An 10/13/23 through 3/13/24 physician order indicated to cover Resident 14's nephrostomy tube site and change the bandage daily. The 4/2024 TAR indicated to ensure catheter straps were attached to the lower left extremely for the nephrostomy bag. Treatments were discontinued on 4/30/24. A 5/9/24 physician order indicated to change Resident 14's nephrostomy tube dressing, remove the old dressing, cleanse, dry and apply a new dressing. A 7/2/24 revised care plan indicated Resident 14 had a left nephrostomy related to end stage kidney disease, the goal was to have no infections, and interventions…

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

Based on observation, interview, and record review it was determined the facility failed to obtain orders for oxygen for 2 or 2 sampled residents (#s 30 and 63) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include: 1. Resident 30 admitted to the facility in 4/2022 with diagnoses including chronic obstructive pulmonary disease (a lung disease which causes restricted airflow and breathing problems). A review of Resident 30's care plan revealed a 12/21/23 care plan for oxygen use as needed. A 7/18/24 review of Resident 30's medical record revealed no evidence of a current order for oxygen use. On 7/18/24 at 11:49 AM Staff 17 (CNA) stated Resident 30 used oxygen as needed almost daily. On 7/18/24 at 3:37 PM Staff 32 (LPN RCM) stated Resident 30 used oxygen as needed when she/he was short of breath. Staff 32 confirmed Resident 30 had no orders for oxygen use. 2. Resident 63 admitted to the facility in 2024 with diagnoses including COPD (chronic obstructive pulmonary disease). A physician order dated 6/2/24 indicated Resident 63…

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

Based on observation, interview, and record review it was determined the facility failed to ensure residents received proper dialysis care and services after dialysis for 1 of 1 sampled resident (#55) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 55 admitted to the facility in 2024 with diagnoses including end stage kidney disease. On 7/17/24 at 12:37 PM Resident 55 was observed to have a fistula (surgically created connection between an artery and a vein to provide access for dialysis) in her/his left arm. Resident 55 stated she/he had dialysis three times a week, when she/he returned staff were not checking her/his access site for thrill and bruit (two ways to check for good blood flow in a dialysis fistula). The 2/7/24 care plan for dialysis indicated the resident had dialysis three times a week, staff were to monitor the access site for infection and bleeding. Staff were to also obtain and document weights. Resident 55 had six weights documented in the electronic record from 2/7/24 through 6/29/24. No evidence was…

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

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 (#9) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of the facility's performance review records revealed the following: -Staff 9 (CNA) was hired on 3/23/21, the provided performance review was dated 4/30/22. In an interview on 7/19/24 at 12:02 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated the missed review occurred during a staffing transition.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 2 of 5 sampled residents (#s 10 and 17) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include 1. Resident 10 admitted to the facility in 5/2024 with diagnosis including dementia. The 5/31/24 and 6/28/24 Note to Attending Physician Prescriber indicated Resident 10 was prescribed trazodone (an antidepressant to treat depression) PRN and promethazine (an antihistamine to prevent and treat nausea and vomiting) for agitation, both limited to 14 days. The note requested either discontinuation or a rationale for extended use, but lacked the physician's signature, date, or clinical justification. The 7/2024 MAR instructed staff to administer trazodone every 12 hours as needed for agitation starting on 5/9/24. The MAR also indicated to administer Promethazine every four hours as needed for agitation, nausea and vomiting starting 5/8/24. In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3…

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

Based on interview and record review it was determined the facility failed to monitor anticoagulant medication for 1 of 5 sampled residents (#27) reviewed for medications. This placed residents at risk for adverse side effects of medications. Findings include: Resident 27 admitted to the facility in 2023 with diagnoses including stroke and blood clot. A 3/28/24 signed physician order indicated Resident 27 received Apixaban (anticoagulant medication used to treat and prevent blood clots). There was no monitoring in the resident's electronic record for adverse side effects for Apixaban. On 7/18/24 at 9:41 AM Staff 28 (RCM-LPN) acknowledged there was no monitoring for adverse side effects of Apixaban in Resident 27's electronic record.

Based on interview and record review it was determined the facility failed to consistently monitor residents on psychotropic medications and ensure residents did not receive unnecessary medications for 3 of 5 sampled residents (#10, 17 and 27) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 10 admitted to the facility in 5/2024 with diagnoses including dementia. A review of 7/2024 MAR revealed Resident 10 was administered haloperidol (antipsychotic medication) daily. A review of monitors revealed no daily documentation of daily monitoring for antipsychotic side effects. In an interview on 7/19/24 at 12:43 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated the expectation was to monitor daily for adverse side effects. 2. Resident 17 admitted to the facility in 8/2019 with diagnoses including narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents' food preferences were honored for 1 of 1 sampled resident (#27 ) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 27 admitted to the facility in 2023 with diagnoses including malnutrition and diabetes. Resident 27's dietary card had lactose intolerant listed in two places. On 7/17/24 at 1:34 PM Resident 27 was observed to have a glass of milk on her/his meal tray. On 7/18/24 at 1:12 PM Resident 27 was observed to have a glass of milk on her/his meal tray. Resident 27 became angry regarding the milk and asked staff to remove the milk immediately. On 7/18/24 at 1:29 PM Staff 28 (RCM-LPN) acknowledged the resident's dietary card indicated she/he was lactose intolerant and should not receive milk.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 2 sampled residents (#30) and 2 of 2 unsampled residents (#s 6 and 11) reviewed for respiratory care. This placed residents at risk for exposure and contraction of infectious diseases. Findings include. 1. Resident 6 admitted to the facility in 2024 with diagnoses including sleep apnea (sleep related breathing disorder). On 7/16/24 at 9:55 AM Resident 6's CPAP mask was observed under her/his pillow against her/his mattress. On 7/17/24 at 1: 53 PM Resident 6's CPAP mask was observed resting on her/his bedrail. On 7/18/24 at 9:33 AM Resident 6's CPAP mask was observed on the floor. On 7/19/24 at 10:50 AM Staff 27 (LPN) stated Resident 6's CPAP mask should be stored in a sanitary manner. 2. Resident 11 admitted to the facility in 2024 with diagnoses including sleep apnea (sleep related breathing disorder). On 7/16/24 at 9:55 AM Resident 11's CPAP mask was observed on her/his nightstand. On 7/17/24 at 1:53 PM Resident 11's CPAP mask was observed hanging…

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 staffing to meet resident care needs for 2 of 2 halls (200 and 400) reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 3/22/23 the facility provided a list of residents who: -Required assistance or were dependent with eating: three, -Required two-person assistance with a mechanical lift: 16, -Required two-person assistance with sit-to-stand: three, -Required two-person assistance with bathing: three, -Were fully dependent on staff for bathing: three A review of the Direct Care Staff Daily Reports revealed 60 days out of 150 days when the state minimum CNA staffing ratios were not met for one or more shifts. Interviews with residents revealed the following concerns: -On 3/20/23 at 10:27 AM Resident 45 stated the facility was often short staffed and call light response times could take greater than 30 minutes to answer. Resident 45 stated because of long call light response times she/he sat in a soiled brief which burned her/his 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.

Based on interview and record review it was determined the facility failed to complete a comprehensive dementia assessment for 2 of 3 sampled residents (#s 2 and 47) reviewed for dementia. This place residents at risk for unassessed needs. Findings include: 1. Resident 2 admitted to the facility in 2018 with diagnoses including dementia. The 8/28/22 Annual MDS Dementia comprehensive assessment indicated Resident 2 was unable to answer a lot of questions, struggled with the answers and had some dementia. Resident 2 believed her/his memory was due to old age. No further information was provided related to Resident 2's history of dementia, extent of the resident's cognitive loss, mood and behaviors or medical issues that may impact cognition. On 3/23/23 at 9:11 AM Staff 10 (Social Service Director) stated social services completed the dementia MDS assessments. Staff 10 confirmed Resident 2's dementia assessment was not comprehensive. 2. Resident 47 readmitted to the facility in 2022 with diagnoses including dementia. The 12/18/22 Annual MDS Cognitive Loss/Dementia CAA 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 observation, interview and record review it was determined the facility failed to provide diabetic nail care for 1 of 4 sampled residents (# 51) reviewed for ADLs. This placed residents at risk for lack of nail care. Findings include: Resident 51 admitted to the facility in 2022 with diagnoses including diabetes. On 3/20/23 at 1:12 PM and 3/24/23 at 10:00 AM Resident 51 was observed to have long fingernails. Review of Resident 51's current physician orders revealed no orders for diabetic nail care and the 3/2023 TAR revealed no indication diabetic nail care was being completed. On 3/24/23 at 10:03 AM Staff 24 (CNA) stated Resident 51 was diabetic and nursing staff were to complete nail care. On 3/24/23 at 10:10 AM Resident 51 stated her/his nails were long. On 3/24/23 @ 10:11 AM Staff 8 (Resident Care Manager/LPN) stated nursing staff were to monitor diabetic nail care weekly and it was to be documented on the TAR. Staff 2 acknowledged Resident 51's nails were long and there were no orders in place and no diabetic nail care on the TAR.

Based on observation, interview and record review it was determined the facility failed to ensure proper food temperatures for 3 of 9 sampled residents (#s 33, 46 and 218) reviewed for food. This placed residents at risk for cold food and impaired nutrition. Findings include: On 3/20/23 at 10:30 AM Resident 46 stated the food was not warm enough and was always cold. On 3/20/23 at 10:30 AM Resident 218 reported the food was not always warm. On 3/20/23 at 12:59 PM and 3/22/23 at 10:52 AM Resident 33 reported her/his breakfast was the usual, cold eggs, hot cereal and the food is a disaster. On 3/22/23 at 12:30 PM Resident 33 stated the meatloaf served at lunch was good, but not particularly warm. On 3/22/23 at 12:36 PM surveyors sampled a regular textured lunch meal and a mechanical soft/small bites meal. The lunch meals consisted of meatloaf, mashed potatoes, green beans and strawberry shortcake. The surveyors agreed the meatloaf was cool on the regular/small bites tray and cold on the mechanical soft tray. On 3/22/23 at 12:41 PM Staff 4 (Regional Nurse Consultant) sampled 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 and interview it was determined the facility failed to maintain the ice machine reviewed for 1 of 1 kitchen. This placed residents at risk for contamination. Findings include: On 3/20/23 at 9:45 AM the inside of the ice machine was observed to have a black mildew substance across the entire trim of the plastic ice dispenser. Water droplets were observed to fall from the dispenser trim onto the ice on the bottom of the ice machine. On 3/20/23 at 9:50 AM Staff 9 (Dietary Manager) stated the ice machine was used for the entire facility. Staff 9 acknowledged the ice machine should not have a visible black mildew substance and the ice machine needed to be cleaned.