Lebanon Veterans Home

Based on interview and record review it was determined the facility failed to complete a trauma assessment for residents with post-traumatic stress disorder (PTSD) for 2 of 7 sampled residents (#s 3 and 11) reviewed for psychotropic medications and unnecessary medications. This placed residents at risk for triggers related to PTSD. Findings include: 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including post-traumatic stress disorder (PTSD).A 11/19/19 care plan indicated Resident 3 had a history of trauma related to childhood deprivation and abuse. The goal indicated Resident 3 would identify individual strengths by the review date. An intervention indicated Resident 3 needed assistance, supervision, and support to identify precipitating factors and stressors.A review of Resident 3's medical record revealed no indication of a completed trauma screen.On 9/9/25 at 8:21 AM, Staff 30 (Social Service Designee) stated usually upon admission she completed a trauma screen to identify specific types of trauma and triggers for the trauma. With that information she put…

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 medications for 2 of 10 sampled residents (#s 3 and 4) reviewed for nutrition and unnecessary medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including arterial fibrillation (an irregular heartbeat).A review of Physician Orders revealed an 8/29/25 order for warfarin (a blood thinning medication).A review of Resident 3's care plan revealed no evidence of a blood thinning medication care plan or monitoring for adverse side effects of blood thinning medications.On 9/9/25 at 8:40 AM Staff 14 (RCM) stated adverse side effects for warfarin should be listed in a warfarin care plan. Staff 14 acknowledged Resident 3 had no care plan for blood thinning medications and no monitors in place to monitor for adverse side effects of blood thinning medications.On 9/9/25 at 10:52 AM Staff 2 (DNS) acknowledged Resident 3 was not care planned for blood thinners and had no monitors in place to monitor…

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 risk and benefits for the use of an antipsychotic medication to a resident/responsible party before administration and communicate changes in ROM services for 2 of 6 sampled residents (#s 80 and 118) reviewed for medications and positioning. This placed residents and responsible parties at risk for lack of appropriate information. Findings include: 1. Resident 80 admitted to the facility in 2020 with diagnoses including multiple sclerosis (disease of the central nervous system) and degeneration of the spine. A 1/10/24 Restorative Assessment and Referral indicated to utilize a standing frame (a device which allows an impaired individual to stand) for Resident 80 three times each week for 10 minutes for improved quality of life. Precautions required two staff present for set-up and one staff present during standing. A 2/29/24 revised Restorative Assessment and Referral indicated Resident 80 was to direct the frequency of the use of the standing frame. A 3/6/24 revised Task indicated staff were to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to notify a resident's physician of a change in condition for 1 of 3 sampled residents (#36) reviewed for UTIs. This placed residents at risk for delayed treatment. Findings include: Resident 36 admitted to the facility in 2021 with a diagnoses including dementia, urinary retention, and an irregular heart beat. A 2/2024 annual CAA indicated Resident 36 had a diagnosis of dementia, was able to communicate, transfer to the toilet, and was incontinent of urine. Resident 36's 3/2024 MAR revealed she/he was administered a blood thinner daily. Progress Notes revealed the following: -2/24/24 Resident 36 was observed to have small amounts of red-tinged urine during her/his incontinent care. The resident denied pain or painful urination. The not indicate the resident would be monitored. There was no indication Resident 36's physician was notified of the red-tinged urine. -2/25/24 Resident 36 did not have red or pink-tinged urine or discharge.…

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 timely Notice of Medicare Non-Coverage (NOMNC) for 1 of 1 sampled resident (#248) reviewed for notices. This placed residents at risk for lack of appeal information. Resident 248 was admitted to the facility in 2024 with diagnoses including heart attack and dehydration. A NOMNC documented the last covered day as 4/3/24. The NOMNC was signed by Resident 248 on 4/2/24. On 5/2/24 at 2:44 PM Staff 4 (Social Services Designee) confirmed the notice was not provided in the required timeframe to Resident 248.

Based on interview and record review it was determined the facility failed to develop a sufficient grievance policy and a timely grievance response for 1 of 4 sampled resident (#128) reviewed for activities. This placed residents at risk for unaddressed concerns and grievances. Findings include: A 12/2023 revised facility Grievances policy indicated staff were to assist residents with the grievance process, a resolution to a grievance was as soon as possible, and the policy did not indicate a reasonable expected timeframe for the facility to complete the review of grievances. The facility policy neglected to include that a resident had the right to file a grievance orally or anonymously and obtain a written decision. An 4/12/24 hand-written letter from Resident 128 to Staff 6 (Recreation Director) indicated dissatisfaction with recent rule changes to a game activity because of her/his skills for the game. The letter also indicated activity staff were prejudice against Resident 128. On 4/29/24 at 10:00 AM Resident 128 stated she/he filed a complaint about activities and received 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 residents were free from sexual and physical abuse for 2 of 5 sampled residents (#s 38 and 108) reviewed for abuse by Resident 139 and Resident 141. This placed residents at risk for abuse. Findings include: 1. Resident 38 admitted to the facility in 2018 with diagnoses including panic disorder, dementia, and PTSD (Post-Traumatic Stress Disorder). Resident 141 admitted to the facility in 2024 with a diagnosis of Alzheimer's Disease. An 10/11/23 Annual MDS indicated Resident 38 was rarely understood. An 4/4/24 Investigation revealed on 4/4/24 while Resident 38 was on a video call with Witness 1 (Family Member), Resident 141 was sitting next to Resident 38 and reached over and rubbed Resident 38's chest area. Witness 1 stated, Keep your hands to yourself. Staff moved Resident 38 into her/his wheelchair to the nurses' station to complete the video call. Resident 141 was escorted back to her/his unit. The facility substantiated sexual abuse. On 5/1/24 at 10:10 AM Witness 1 stated Resident 38 was seated…

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 timely investigate abuse for 1 of 3 sampled residents (#38) reviewed for abuse. This placed residents at risk for abuse and neglect. Findings include: Resident 38 admitted to the facility in 2018 with diagnoses including panic disorder, dementia, and PTSD (Post-Traumatic Stress Disorder). Resident 141 admitted to the facility in 2024 with a diagnosis of Alzheimer's Disease. An 4/4/24 Investigation revealed an investigation timeframe 4/4/24 through 4/10/24. On 4/4/24 while Resident 38 was on a video call with Witness 1 (Family Member) Resident 141 was sitting next to Resident 38 and reached over and rubbed Resident 38's chest area. Witness 1 stated Keep your hands to yourself. The facility determined sexual abuse was substantiated. On 5/3/24 at 8:57 AM Staff 21 (RCM) confirmed the investigation was not completed timely. Refer to F600

Based on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 5 sampled residents (#118) reviewed for nutrition. This placed residents at risk for unassessed needs. Findings include: Resident 118 admitted to the facility in 2023 with diagnoses including diabetes, pressure ulcer and dementia. A 9/13/24 admission MDS revealed Resident 118's BIMS score was 15 which indicated she/he was cognitively intact. There were no concerns with Resident 118's mood and she/he did not have any behaviors. Resident 118 was frequently incontinent of bowel and had occasional pain presence with PRN pain medications. Resident 118 had one Stage 3 (a deep wound that has broken through the top two layers of skin into the fatty tissue) pressure ulcer and moisture associated skin breakdown. Medications administered to Resident 118 included insulin and antidepressants. A 3/13/24 Quarterly MDS revealed Resident 118's BIMS was nine which indicated moderate cognitive impairment. Resident 118 felt down,…

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 8 sampled residents (#s 38, 101 and 121) reviewed for accidents, pressure ulcers and position and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 38 admitted to the facility in 2018 with diagnoses including Parkinson's disease. A current care plan dated 2/14/22 indicated Resident 108 had a problematic manner of ineffective coping with interventions including taking Resident 108 on walks. An 4/10/24 Quarterly MDS indicated walking 10 feet was not attempted due to medical conditions or safety concerns. An 4/30/24 Abnormal Involuntary Movement Scale indicated Resident 38 could not sit in a chair without leaning back. Resident 38 could only stand with two persons with maximum assistance for balance and she/he twisted her/his feet. On 5/3/24 at 8:57 AM Staff 21 (RCM) stated Resident 38 declined in her/his abilities, no longer walked, and the care…

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

Based on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 4 sampled residents (#80) reviewed for ADLs. This placed resident at risk for inadequate personal hygiene. Findings include: Resident 80 admitted to the facility in 2020 with diagnoses including multiple sclerosis (disease of the central nervous system) and degeneration of the spine. An 10/23/23 revised care plan indicated Resident 80 required one staff to assist with bathing. 3/2024 and 4/2024 shower calendars for Resident 80 indicated the resident received one shower during the week on 3/6/24, 4/18/24, 4/25/24, and 4/29/24. No showers were provided on any Sundays and Resident 80 was to receive her/his showers at night. The 3/12/24 Quarterly MDS indicated Resident 80 required substantial to maximum assistance for bathing. On 4/29/24 at 10:57 AM and 5/1/24 at 11:33 AM Resident 80 stated she/he received no Sunday shower as expected and only one shower during the week for the last 30 days due to lack of staff. Resident 80 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for 2 of 8 sampled residents (#s 36 and 118) reviewed for UTIs and medications. This placed residents at risk for delayed care and unmet needs. Findings include: 1. Resident 36 admitted to the facility in 2021 with a diagnosis of dementia. a. A 2/2024 annual CAA indicated Resident 36 had a diagnoses of dementia, was able to communicate, was able to transfer to the toilet, and was incontinent of urine. Resident 36's 3/2024 MAR revealed she/he was administered a blood thinner daily. Progress Notes revealed the following: -2/24/24 Resident 36 was observed to have small amounts of red-tinged urine during her/his incontinent care. The resident denied pain or painful urination. The not indicate the resident would be monitored. -2/25/24 Resident 36 did not have red or pink-tinged urine or discharge. -2/26/24 through 3/8/29 revealed 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 accurately assess pressure ulcers for 2 of 5 sampled residents (#s 59 and 118) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include: 1. Resident 59 admitted to the facility in 3/2017 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body). A review of Resident 59's care plan revealed a 1/21/24 care plan for a moisture associated wound (inflammation of the skin caused by moisture) to her/his sacrum. A review of a 1/22/24 Wound Evaluation revealed Resident 59 had moisture assoicated damage to her/his sacrum. The Wound Evlauation stated the wound was 12 cm X 8.14 cm with 90% dead tissue on the wound bed. A review of a 1/29/24 Wound Evaluation revealed Resident 59 had an unstageable pressure wound (wound caused by pressure with full thickness tissue loss with exposed bone, tendon, or muscle; dead tissue may be present on some parts of the wound bed; often includes tissue damage beneath the skin) on her/his…

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

Based on observation, interview and record review it was determined the facility failed to assess and care plan a resident's ability to transfer from a reclining chair and timely investigate a fall for 2 of 8 sampled residents (#s 121 and 142) reviewed for dementia care and accidents. This placed residents at risk for falls. Findings include 1. Resident 142 admitted to the facility with a diagnosis of dementia. A 3/25/24 admission MDS indicated Resident 142 walked without assistive devices. The assessment indicated she/he and had a fall prior to and one fall after admission to the facility. Resident 142's risk factors for falls included medication side affects which could cause confusion and dizziness. The resident also had insomnia and was often awake for many hours at a time placing the resident at risk for falls. A care plan initiated 3/18/24 revealed Resident 142 was at risk for falls and the resident was to wear non-skid socks and call staff for assistance. On 4/30/24 at 12:52 PM Resident 142 was observed in a recliner with her/his eyes shut, she/he was covered with blankets,…

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 1 of 1 sampled resident (#86) reviewed for respiratory care. This placed residents at risk for impaired respiratory status. Findings include: Resident 86 admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 86's care plan revealed a 3/3/23 care plan for as-needed oxygen. An 4/8/24 Progress Note revealed Resident 86 received oxygen due to respiratory difficulties and shortness of breath. On 4/29/24 at 10:42 AM an oxygen concentrator was observed by Resident 86's bed. Resident 86 stated she/he used oxygen a couple of times a week, usually in the evenings. A 5/1/24 review of Resident 86's medical record revealed no evidence of oxygen orders. On 5/2/24 at 8:45 AM Staff 30 (CNA) stated Resident 86 used oxygen as needed or requested. On 5/2/24 at 9:41 AM Staff 13 (RCM) acknowledged Resident 86 used oxygen as needed but 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 interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (#118) reviewed for medications. This placed residents at risk of jeopardized health status. Findings include: Resident 118 admitted to the facility in 2023 with diagnoses including partial intestinal obstruction. A signed 3/11/24 physician's order instructed staff to administer Loperamide (to treat diarrhea) by mouth in the morning for diarrhea with a start date of 12/14/23. The physician order also instructed staff to administer Senna (to treat constipation) by mouth in the morning for constipation with a start date of 2/14/23. 2/2024, 3/2024 and 4/2024 MARs instructed staff to administer Loperamide by mouth in the morning for diarrhea with a start date of 12/14/23. The physician order also instructed staff to administer Senna by mouth in the morning for constipation with a start date of 2/14/23. Resident 118 was administered both medications daily as follows: -2/14/24 through 2/23/24, and 2/25/24 through 2/29/24;…

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 interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 5 sampled residents (#118) reviewed for medications. This placed residents at risk for unmet needs Findings include: Resident 118 admitted to the facility in 2023 with a diagnosis of diabetes. A 3/11/24 signed physician order instructed staff to administer insulin (regulates level of blood sugar) injection three times a day for diabetes with a start date of 10/22/23. An 4/2024 Diabetic Orders report instructed staff to administer insulin injection three times a day for diabetes. The following dates and times were documented Resident 118 was sleeping and was not administered her/his insulin 4/1/24 5:00 PM, 4/13/24 7:00 AM, 4/14/24 7:00 AM, 4/16/24 12:00 PM, 4/21/24 12:00 PM, and 4/23/24 12:00 PM. On 5/3/24 at 7:35 AM Staff 21 (RCM) stated the dates listed above were marked in error and Resident 118 was administered her/his medication as physician ordered.

Based on observation, interview, and record review it was determined the facility failed to practice proper infection control procedures for 1 of 5 sampled residents (#59) reviewed for pressure ulcers and sanitize resident care equipment for 1 of 3 halls. This placed residents at risk for infection. Findings include: 1. Resident 59 admitted to the facility in 3/2017 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body). A review of an 4/29/24 Wound Evaluation revealed Resident 59 had a Stage 4 pressure ulcer (wound caused by pressure with full thickness tissue loss with exposed bone, tendon, or muscle; dead tissue may be present on some parts of the wound bed; often includes damage underneath the skin) on her/his sacrum. On 5/1/24 at 10:47 AM Staff 38 (LPN) was observed performing Resident 59's wound care with Staff 37 (CNA). Staff 38 was observed emptying Resident 59's catheter bag, he removed his gloves, and put on new clean gloves. Staff 38 was not observed performing hand hygiene and stated he was not aware he had to perform hand…

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 a resident's ability to safely self-administer medications for 1 of 6 sampled residents (#122) reviewed during medication pass. This placed residents at risk for unsafe medication administration. Findings include: The 7/2021 Self-Administration of Medication Policy indicated the following: -Residents may choose to self-administer medications if the interdisciplinary team determined the resident was safe to self-administer medications. -An assessment of the resident's capabilities to self-administer was to be performed by the Resident Care Manager utilizing the user defined assessment, Medication Self-Administration Assessment and MDS information. -A physician order was to be obtained. Resident 122 was admitted to the facility in 2022 with diagnoses including hypertension (high blood pressure). The 12/15/22 physician orders did not include an order to self-administer medications. A 1/17/23 Self-Administration Assessment was started but was incomplete as of 1/25/23. On 1/25/23 at 8:29 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.

Based on interview and record review it was determined the facility failed to ensure a resident's physician was notified of a change in AIMS (abnormal involuntary movement scale) score for 1 of 5 sampled residents (#128) reviewed for medications. This placed residents at risk for lack of physician notification. Findings include: Resident 128 was admitted to the facility in 7/2022 with diagnoses including dementia. A 7/6/22 CAA indicated Resident 128 was on medications including antipsychotic medications. A 7/2022 AIMS (test to detect repetitive involuntary body movements such as grimacing, sticking out tongue or smacking of lips which can interfere with daily functioning and can be a result of long-term use of medications including antipsychotics) had a total score of zero. A zero indicated no abnormal movement was observed by the evaluator. A 1/2023 AIMS revealed the resident had a total score of four. The evaluator assessed the resident to have minimal movement to the face, jaw, upper extremities and trunk. The resident's record did not have documentation to indicate the physician…

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

Based on interview and record review it was determined the facility failed to ensure resident grievances were addressed in a timely manner for 1 of 2 sampled residents (#116) reviewed for personal property. This placed residents at risk for unaddressed grievances. Findings include: Resident 116 was admitted to the facility in 2021 with diagnoses including dementia. a. A 9/23/22 Loss/Damage Report form revealed Resident 116's spouse reported a missing army shirt. The form was not completed until 1/18/23 On 1/23/23 at 11:22 AM Witness 1 (Family Member) stated months prior she reported to Staff 6 (Social Services) Resident 116 was missing a vintage army shirt and she/he did not receive any follow up. On 1/27/23 at 10:02 AM Staff 6 acknowledged Witness 1 reported Resident 116's missing shirt in 9/2022 and there was no follow up until 1/2023, four months later. b. A 9/13/22 Interdisciplinary Care Conference form revealed Witness 1 (Family Member) reported Resident 116 was missing a medical alert bracelet and a Loss Report form was filed. On 1/23/23 at 11:22 AM Witness 1 stated at a care…

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 centered care plan was developed for 1 of 3 sampled residents (#116) reviewed for activities. This placed residents at risk for lack of care planning. Findings include: Resident 116 was admitted to the facility in 2021 with diagnoses including dementia. A 6/8/22 Recreation Interest Survey indicated the resident liked to watch the news and enjoyed country music and any patriotic music from the 1960's. A current Care Plan indicated the resident liked music but did not indicate the type of music the resident liked and indicated staff were to assist the resident with the television but it did not indicate the type of television shows the resident preferred to watch. On 1/23/23 at 11:17 AM Witness 1 (Family Member) stated the resident liked to listen to music and participate in other activities, not just be provided the fidget board. On 1/23/23 11:43 AM Resident 116 was observed in front of the television with a fidget board. The television channel was set to a western channel and not the…

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

Based on interview and record review it was determined the facility failed to develop an activity program to meet resident's needs for 2 of 3 sampled residents (#s 91 and 116) reviewed for activities. This placed residents at risk for lack of meaningful activities. Findings include: 1. Resident 91 was admitted to the facility in 2019 with diagnoses including dementia. A 11/30/22 significant change MDS and CAAs indicated Resident 91 liked woodworking, spending time with her/his spouse and often refused activities offered by staff. On 1/23/23 at 10:18 AM Witness 3 (Family Member) stated Resident 91 used to do work with her/his hands including woodwork and made jewelry boxes. Witness 91 stated the activities of hitting the ball were not fulfilling for the resident. A Task form for the last 30 days revealed the resident did not do any woodwork activities. On 1/26/23 at 10:08 AM Staff 7 (Assistant Recreational Director Memory Care Coordinator) stated the resident often refused to participate in activities and enjoyed spending time with her/his spouse. Staff 7 stated the last time the…

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

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 106 and 117) reviewed for medication and range of motion. This placed residents at risk for reduced efficacy of medications and decreased range of motion. Findings include: 1. Resident 117 was admitted to the facility in 2022 with diagnoses including hypothyroidism (underactive thyroid). The 12/15/22 physician order indicated Resident 117 was to receive levothyroxine 25 mcg once daily for hypothyroidism. The 12/2022 and 1/2023 MARs indicated levothyroxine was not administered on the following dates: 12/16/22, 12/17/22, 12/21/22, 12/23/22, 12/24/22, 12/30/22, 12/31/22, 1/6/23, 1/10/23, 1/13/23 and 1/14/23. On 1/30/23 at 9:43 AM Staff 2 (DNS) acknowledged Resident 117 had an order for levothyroxine daily and acknowledged the resident did not receive the medication as ordered on the identified dates. 2. Resident 106 admitted to the facility in 2022 with diagnoses including nerve pain. The 11/22/22 physician order indicated Resident 106 had a referral to…

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