Hearthstone Nursing & Rehabilitation Center

Based on interview and record review it was determined the facility failed to follow up on dental services for 1 of 1 sampled resident (#6) reviewed for dental services. This placed residents at risk for unmet dental health needs. Findings include: A 3/2023 facility Dental Service policy indicated the facility was to assist the resident in making dental appointments if necessary or requested. Resident 6 was admitted to the facility in 5/2021 with diagnoses including bipolar disorder (mental health condition characterized by extreme moods) and chronic pain. A 12/5/24 IDT (Interdisciplinary Team) Care plan Conference/Welcome Meeting Form indicated Resident 6 requested follow-up appointments for dental work that began during the prior months. A 3/4/25 Quarterly MDS indicated Resident 6 had a BIMS score of 14 (cognitively intact) and had obvious or probably cavities or broken teeth. A 3/11/25 IDT Care Plan Conference/Welcome Meeting Form indicated Resident 6 required dental services, including routine cleaning. A 3/13/25 revised care plan indicated Resident 6 required one staff to set…

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 properly dispose of expired medications for 1 of 1 medical storage room, 2 of 3 medication carts, and 2 of 3 resident medication storage refrigerators reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: During a review of the medication storage room on 12/2/24 at 12:34 PM Staff 4 (RN) verified the following were found: - 11 bottles of alpha lipoic acid (a supplement) with an expiration date of 11/2024 - two bottles of naproxen 220 mg (a pain reliever) with an expiration date of 11/2024 - one bottle of Prosource No Carb (a supplement) with an expiration date of 12/1/24 - two bottles of Osmolyte 1.5 (a supplement) with an expiration date of 8/2024 - six bottles of Robitussin (a cough suppressant) with an expiration date of 11/2024 During a review of the 300-hall resident medication storage refrigerator on 12/2/24 at 12:58 PM Staff 5 (LPN) verified the following were found: - three bags of IV Vancomycin…

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 update a resident's POLST (physician orders for life sustaining treatment; end of life choices) for 1 of 4 sampled residents (#36) reviewed for ADLs. This placed residents at risk for end-of-life choices not being honored. Findings include: Resident 36 admitted to the facility in 2/2024 with a diagnosis of a brain injury. A POLST dated 2/5/24 indicated Resident 36 was to be resuscitated if her/his heart and breathing stopped. A 3/1/24 admission MDS and 6/1/24 quarterly MDS revealed Resident 36 had moderate cognitive impairment, but was able to make her/his needs known. An 8/26/24 Interdisciplinary Care Conference Form revealed Resident 36 notified staff she/he wanted to change her/his code status (POLST) to a DNR (do not resuscitate) status. At this time of the survey Resident 36's record did not include an updated POLST. On 12/4/24 at 10:59 AM Staff 37 (Social Services) acknowledged during the 8/2024 care conference Resident 36 voiced her/his desire to change her/his POLST from full resuscitation to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled resident (#s 4 and 36) reviewed for hospitalizations. This placed residents at risk of lack of access to an advocate to inform them of their options and rights, and a decreased quality of life. Findings include: Resident 4 admitted to the facility in 3/2021 with diagnoses including epilepsy. A review of Resident 4's nursing progress notes revealed she/he was discharged to the hospital on [DATE] due a seizure, and was readmitted to the facility on [DATE]. No evidence was found in Resident 4's clinical record to indicate a transfer notice with appeal rights was provided in writing to her/his representative or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide information regarding the facility's bed hold policy for 2 of 2 sampled residents (#s 4 and 36) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding the right to return to the same bed within the facility. Findings include: Resident 4 admitted to the facility in 3/2021 with diagnoses including epilepsy. A review of Resident 4's nursing progress notes revealed she/he was discharged to the hospital on [DATE] due a seizure and was readmitted to the facility on [DATE]. No documentation was found in Resident 4's clinical record the facility's bed hold policy was reviewed with the resident or the resident's representative upon discharge to the hospital. On 12/4/24 at 1:53 PM Staff 2 (DNS) stated the facility did not have a system in place to ensure residents and representative were notified of the bed hold policy when discharged from the facility. 2. Resident 36 admitted to the facility 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 observation, interview, and record review it was determined the facility failed to assist residents with hygiene for 2 of 4 sampled residents (#s 8 and 36) reviewed for ADLs. This placed residents at risk for lack of dignity. Findings include: 1. Resident 8 admitted to the facility in 5/2021 with a diagnosis of Parkinson's disease. A 9/10/24 annual MDS revealed Resident 8 was cognitively intact, weak, and had an ADL impairment which required staff to assist with personal hygiene. A Shower form dated from 11/6/24 through 12/6/24 revealed Resident 8 had a shower or bed bath on multiple dates including 11/30/24 and 12/4/24. On 12/2/24 at 1:23 PM, 12/4/24 at 3:37 PM, and 12/5/24 at 11:15 AM Resident 8 was observed to have a mustache and a beard which was starting to grow in. Resident 8 stated she/he preferred to keep a mustache but otherwise liked to be clean shaved. Resident 8 also stated staff needed to help her/him and they usually helped about every two months. On 12/4/24 at 9:28 AM Staff 33 (CNA) stated it did not look like Resident 8 was shaved for awhile. On 12/5/24 at…

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

Based on interview and record review it was determined the facility failed to follow physician's orders and provide care and services to maintain the highest practicable level of well-being for 1 of 7 sampled residents (# 36) reviewed for hospitalization. Findings include: 1. Resident 36 admitted to the facility in 2/2024 with a diagnosis of brain injury. An 8/9/24 Encounter note by Staff 36 (Physician) revealed Resident 36 was referred to GI (gastrointestinal; specialty in digestive system issues) and the Referral is in place to GI for liver disease. An 8/16/24 Encounter note by Staff 36 revealed Resident 36 was assessed for a change in condition. At the time of the assessment Resident 36 was observed to be at her/his baseline. The encounter notes included Resident 36 had liver disease and new orders were provided which included a note Is there GI follow up please .? Resident 36's clinical record revealed no GI consult report. On 12/4/24 at 8:50 AM Staff 22 (LPN) stated if a physician note indicated a referral was to be made, Staff 35 (Reception) was notified, and she made the…

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

Based on interview and record review it was determined the facility failed to ensure falls were evaluated timely and care plan interventions were updated, appropriate and followed for 2 of 2 sampled resident (#s 12 and 32) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 12 admitted to the facility in 10/2024 with diagnoses including stroke and low blood pressure. An 10/9/24 Un-witnessed Fall investigation revealed Resident 12 crawled in her/his room to the doorway and slid herself/himself out of her/his chair. Resident 12 was reminded to use her/his call light and Zoloft (antidepressant medication) was added on 10/10/24 to assist with her/his impulsive behaviors. Investigation notes indicated the investigation was dated 10/30/24 (21 days after the incident) and the care plan was followed. An 10/11/24 at 7:30 AM Un-witnessed Fall investigation had no description of Resident 12's fall and the investigation notes were dated 10/30/24 (19 days after the incident). An 10/11/24 at 7:15 PM Un-witnessed Fall investigation 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 interview and record review it was determined the facility failed to ensure residents received accurate provision of prescribed medications for 3 of 6 sampled residents (#s 2, 4 and 13) reviewed for medications and hospitalizations. This placed residents at risk for not receiving medications as prescribed. Findings include: 1. Resident 2 was admitted to the facility in 12/2020 with diagnoses including heart failure. Review of the revised care plan dated 3/15/23 revealed Resident 2 had altered cardiovascular status due to hypotension with interventions which included to administer medications as ordered and monitor vital signs. Physician orders signed 11/17/24 instructed staff to administer metoprolol succinate (to treat chest pain, heart failure and high blood pressure) one time a day for hypertension, and to hold the medication if the resident's SPB (systolic blood pressure; the measure of force of blood against the artery walls while the heart beats) measured less than 100, or her/his DPB (diastolic blood pressure; the force of blood against the artery walls when 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 address pharmacy recommendations for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: It was determined this citation met the criteria for Past Noncompliance based on the following: On 11/26/24 the Past Noncompliance was corrected when the facility completed an initial audit on 11/22/24 and identified the facility failed to ensure pharmacy recommendations were not addressed. The Plan of Correction included: -Completion of an audit to ensure provider followed up was completed and documented in the resident chart. -Nurse Managers were educated by the [NAME] President of Clinical regarding requirements related to pharmacy consultant recommendations. The DNS was educated on a pharmacy recommendations tracking system and would start the tracking system relative to the 11/2024 pharmacist recommendations to ensure timely follow-up. -Audits would be completed monthly for three months to ensure pharmacy recommendations were…

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

Based on interview, and record review it was determined the facility failed to conduct a resident's psychotropic GDRs (Gradual Dose Reduction) for 1 of 5 sampled residents (#17) reviewed for medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: Resident 17 was admitted to the facility in 2/2019 with diagnoses including a post-operative knee infection. A 2/22/23 Comprehensive (nursing) Summary (NSG) revealed Resident 17 was assessed to have mild depression. An 8/8/24 Patient Health Questionnaire revealed Resident 17 did not voice feeling down, depressed or hopeless. Resident 17's 9/18/24 Psychotropic Medication Review form revealed: Sertraline (antidepressant) was administered daily with a last GDR attempt on 6/15/22. The team agreed not to make changes at that time due to Resident 17's upcoming surgery and the medication review would be done the next quarter. Duloxetine (treats major depression and anxiety) was administered daily with the last GDR attempt on 6/15/22. The team agreed not to make changes at that time due to…

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

Based on interview and record review it was determined the facility misappropriated narcotic medication for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for increased pain. Findings include: Resident 3 was admitted to the facility in May 2024, with diagnosis including arthritis of the joints. The resident was discharged on 7/14/24. Review of a narcotic receipt dated 7/7/24, revealed the facility received 30 pills of morphine and 16 pills remained unadministered. Review of a narcotic receipt dated 7/12/24, revealed the facility received 30 pills of hydrocodone/acetaminophen and 28 pills remained unadministered. Review of a Discharge Planning and Summary form dated 7/14/24, revealed no documentation the resident received any medications on discharge. The discharge paperwork included two paper prescriptions for hydrocodone/acetaminophen and morphine pills. Review of the facility's incident investigation dated 8/5/24, revealed on 7/24/24 at 2:30 PM the DNS was notified Resident 3's medication of(hydrocodone/acetaminophen 28 pills) was missing. Evening…

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

Based on observation, interview and record review it was determined the facility failed to ensure adequate sanitation for 1 of 1 facility kitchen. This placed residents at risk for food-borne illnesses. Findings include: On 6/27/24 at approximately 11:00 AM and 11:35 AM Staff 28 (Cook) was observed to fill one of three sinks and a bucket for sanitizing with sanitizer solution as part of the pot washing process, and routine cleaning of kitchen surfaces. Staff 28 was observed to use a test strip to test the concentration of the sanitizer chemical. The test strip revealed the chemical concentration was at 150. Staff 28 confirmed, based on her observations earlier in the day, the sanitizer concentration was at the same level the morning of the same day when pot washing was completed. Staff 28 did not indicate there was any issue with the sanitizer concentration. On 6/27/24 at 11:31 AM Staff 12 (Dietary Manager) retested the sanitizer concentration level, indicated the sanitizer concentration level was at zero and not 150 and confirmed a measurement of sanitizer concentration at either…

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

Based on observation, interview, and record review it was determine that facility failed to provide appropriate silverware for 1 of 1 dining room and 1 of 1 random resident (#4) reviewed for dining. This placed residents at risk for lack of a dignified dining experience. Findings include: Resident 4 admitted to the facility in 2023 with diagnoses including anxiety and diabetes. A 5/30/24 Quarterly MDS indicated Resident 4 was cognitively intact. A 6/7/24 revised care plan revealed Resident 4 required set-up assistance with meals. On 6/24/24 at 12:44 PM Resident 4 stated she/he felt it was undignified for her/him to eat meals with large tablespoons instead of teaspoons. Resident 4 stated requests for teaspoons and not tablespoons with each meal was an ongoing challenge. On 6/24/23 at 12:46 PM Staff 9 (CNA) stated the facility served residents' meals with tablespoons and not teaspoons since 2/2024 and acknowledged Resident 4 communicated her/his request for teaspoons at each meal during the previous week. On 6/27/24 at 11:48 AM the facility dining room was observed with multiple…

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

Based on observation, interview, and record review it was determined the facility failed to ensure the environment was free of loud noises for 1 of 2 halls reviewed. This placed residents at risk for an uncomfortable environment. Findings include: The 2/15/24, 3/13/24, and 4/16/24 Resident Council meeting minutes revealed residents complained noise levels in the facility were loud on day, evening and night shifts and it was disruptive.The facility's response to the noise levels was to educate the staff. On 6/26/24 the following was observed: -At 2:30 PM multiple individuals in scrubs were in hall one near the nurse's station speaking loudly to each other. -At 4:30 PM staff in hall two yelled to each other down the hall. On 6/27/24 at 8:02 AM multiple staff talking loudly in both halls and the nurses station. On 6/27/24 at 4:45 PM this surveyor was in hall two away from the nurses station and heard multiple staff members who were laughing and talking loudly. On 6/24/24 at 3:08 PM Resident 27 stated she/he heard staff talk loud and yell down the hall all day and night. On 6/26/23 at…

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

3. Resident 3 admitted to the facility in 2023 with a diagnosis of a stroke. Resident 3's clinical record revealed a MDS assessment was completed on 3/30/24. Record review revealed no evidence a care conference was conducted after the 3/30/24 MDS assessment. On 6/25/24 at 12:29 PM Staff 15 (Social Services) acknowledged Resident 3 did not have a care conference after her/his most recent MDS assessment. 4. Resident 24 admitted to the facility in 2024 with a diagnosis of Parkinson's disease. Resident 24's clinical record revealed a significant change MDS was completed on 3/26/24, and indicated Resident 24 was cognitively intact. On 6/24/24 at 9:32 AM Resident 24 stated she/he did not participate in a care conference for a long time. On 6/26/24 3:39 PM Staff 16 (RNCM) stated care conferences were scheduled by social services and conducted after admission, after quarterly and significant change MDSs, and as needed. Staff 16 stated Resident 16 did not have a care conference after her/his latest assessment. Based on observation, interview and record review it was determined the 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 ensure narcotics were disposed timely for 3 of 4 medication carts (Wing 1, Wing 2, and Wing 3) reviewed for medication storage. Findings include: 1. Resident 108 admitted to the facility in 2024 after back surgery. Resident 108's clinical record revealed she/he was discharged on 5/28/24. A Disposal of Controlled Drugs form revealed 62 tablets of Resident 108's diazepam (anti-anxiety medication) was not destroyed until 6/27/24. On 6/27/24 at 10:54 AM Staff 2 (DNS) stated when a resident was discharged or a resident's narcotic medication was discontinued the controlled substance was to be removed from the medication cart and destroyed by two nurses or one nurse and one CMA. Staff should destroy the medication within one or two days. Staff 2 stated she was not aware the medication cart contained controlled substances which needed to be destroyed. 2. Resident 4 admitted to the facility in 2024 with a diagnosis of amputation. Resident 4's orders revealed her/his Norco (narcotic pain medication)…

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

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 1 of 5 sampled residents (#204) reviewed for medications and 1 of 1 dining room during random observations. This placed residents at risk for exposure and contraction of infectious diseases. Findings include. 1. Resident 204 admitted to the facility in 6/2024 a with diagnosis of pneumonitis (inflammation of lung tissue). On 6/26/24 at 7:19 AM Staff 29 (CNA) and Staff 30 (CMA) were in Resident 204's room. A contact precautions sign was posted and a PPE bin in place on the door. A mechanical transfer machine was in front of Resident 204 in her/his wheelchair. Staff 29 and Staff 30 did not have gowns on. At 7:21 AM Staff 29 was observed next to Resident 204's bed with no gown on. At 7:25 AM Staff 30 stated she stood by during Resident 204's transfer from wheelchair to bed and did not have contact with Resident 204. Staff 30 stated Staff 29 did not have a gown on during Resident 204's transfer. On 6/27/24 at 7:13 AM Staff 1 (Administrator) and 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 observation, interview, and record review it was determined the facility failed to ensure a resident or resident's responsible part was involved with decisions related to care for 2 of 6 sampled residents (#s 21 and 31) reviewed for medications and restraints. This placed residents at risk for lack of health care choices. Findings include: 1. Resident 21 admitted to the facility in 2021 with with a diagnosis of diabetes. An 4/6/24 significant change MDS revealed Resident 24 was cognitively impaired. A 5/29/24 Restraint vs (versus) Enabler Screen revealed Resident 21 had poor safety awareness and a scoop mattress (a mattress with raised edges) would allow the resident to move more safely. The screen did not indicate the risk and benefits of the scoop mattress were reviewed with Resident 21 or her/his responsible party. On 6/24/24 at 6:22 PM Resident 21was observed to have a scoop mattress. On 6/26/24 at 3:34 PM Staff 16 (RNCM) acknowledged the use of Resident 21's scoop mattress was not reviewed with Resident 21's responsible party. 2. Resident 31 admitted to the facility 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 observation, interview, and record review it was determined the facility failed to ensure a resident was assessed to self-administer medications for 1 of 4 sampled residents (#6) reviewed for accidents. This placed residents at risk for unnecessary medications. Findings include: Resident 6 admitted to the facility in 2019 with a diagnosis of heart failure. An 4/12/24 quarterly MDS revealed Resident 6 was cognitively impaired. On 6/24/24 at 5:37 PM a bottle of antacid was observed on Resident 6's bedside table. Resident 6's clinical record revealed she/he was not assessed to self-administer antacids. On 6/24/24 at 5:39 PM Staff 18 (LPN) verified Resident 6 had medications at her/his bedside. Resident 18 stated Resident 6 was confused and should not have medications at the bedside unless she/he was assessed to be safe to self-administer medications. Staff stated Resident 6 was not assessed to self-administer medications.

Based on interview and record review it was determined the facility failed to ensure residents' advance directives were in the clinical record and residents were provided advance directive information for 2 of 8 sampled residents (#s 3 and 24 ) reviewed for advance directives. This placed residents at risk for end of life choices not being honored. Findings include: 1. Resident 3 admitted to the facility in 2018 with a diagnosis of a stroke. A Resident Advance Directive Resident Information form revealed Resident 3's responsible party declined advance directive information. The form was signed 11/11/22. A care plan initiated in 2022 revealed Resident 3 declined advance directive information and staff would review Resident 3's end of life choices quarterly. The care plan also indicated Resident 3's advance directive was in Resident 3's clinical record. Resident 3's clinical record did not contain her/his advance directive. On 6/25/24 at 12:29 PM Staff 11 (Social Services) stated advance directive information was provided when a resident was admitted to the facility. During 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 NOMNC (Notice of Medicare Non-Coverage) was provided to 1 of 3 sampled residents (#19) reviewed for beneficiary notices. This placed residents at risk for being uninformed regarding their appeal rights. Findings include: Resident 19 admitted to the facility in 2024 with a diagnosis of a leg fracture. A Beneficiary Protection Notification form revealed Resident 19's covered services ended 6/13/24. The resident signed the form one day prior on 6/12/24, which was less than 72 hours prior notice to services ending. On 6/26/24 at 8:03 AM Staff 10 (Social Services) stated a NOMNC was to be provided 72 hours before services ended. This provided the resident time to appeal the decision and he helped residents with the appeal process if needed. Staff 10 acknowledged the form was provided to Resident 19 one day prior to the end of her/his services. Staff 10 stated he would provide documentation for the reason the resident did not receive the notice within the required timeframe. No additional information…

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 complete a thorough investigation for falls for 1 of 5 sampled residents (#27) reviewed for medications. This placed residents at risk for accidents. Findings include: Resident 27 admitted to the facility in 2022 with diagnoses including PTSD (post-traumatic stress disorder), depression and anxiety. An 8/27/23 Significant Change MDS indicated Resident 27 received psychotropic medication which included the following risk factors: increased falls and impaired balance. The assessment also indicated the care plan would be reviewed to monitor for the effectiveness of the psychotropic medication and any adverse side effects. A 6/6/24 care plan indicated Resident 27 required partial to moderate assistance for sit to stand and partial to moderate assistance for chair to bed and to chair. Resident 27 was at risk for falls related to impaired mobility, impaired cognition, incontinence, medication use, pain, poor safety awareness and impulsiveness. Staff were to attempt to keep the resident's room set-up…

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 oxygen was in place as ordered for 1 of 1 sampled resident (#12) reviewed for respiratory care. This placed residents at risk for impaired respiratory status. Findings include: Resident 12 admitted to the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems). A review of Resident 12's Physician Orders revealed a 6/4/24 order for continuous oxygen. On 6/24/24 at 12:31 PM Resident 12 was observed without oxygen. On 6/24/24 at 5:18 PM Resident 12 was observed without oxygen. Staff 31 (CNA) verified Resident 12 was not using oxygen and stated she/he usually used oxygen. On 6/27/24 at 7:31 AM Staff 26 (LPN Unit Manager) confirmed Resident 12 had orders for continuous oxygen and stated she expected staff to ensure Resident 12 was using oxygen per orders.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 4, 5, and 6) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 6/27/24 indicated the following employees did not receive their annual performance evaluations: - Staff 4 (CNA) was hired on 4/9/07 and the facility was unable to provide a performance review. - Staff 5 (CNA) was hired on 8/28/15 and the facility was unable to provide a performance review. - Staff 6 (CNA) was hired on 1/15/18 and the facility was unable to provide a performance review. On 6/27/24 at 7:15 AM Staff 1 (Administrator) stated he was unable to locate performance reviews for Staff 4, Staff 5, and Staff 6.

Based on interview and record review it was determined the facility failed to monitor anticoagulants for 1 of 5 sampled resident (#20) reviewed for pain and ensure insulin was held for 1 of 5 sampled resident (# 31) reviewed for medications. This placed residents at risk for adverse side effects of medications and low blood sugar levels. Findings include: 1. Resident 20 admitted to the facility in 2023 with diagnoses including PTSD (post- traumatic stress disorder) and pulmonary embolism (blood clot in the lungs). An 4/13/24 signed physician order indicated Resident 20 received Apixiban (anticoagulant medication used to treat and prevent blood clots). The 6/2024 Monitors document revealed the following from 6/5/24 through 6/25/24 for Resident 20: -The Monitor adverse reactions for the use of an anticoagulant section was completed using a checkmark instead of a specific numeric code. Adverse reaction monitoring for an anticoagulant included: monitoring for bleeding, bruising and shortness of breath. On 6/27/24 at 9:41 AM Staff 16 (RNCM) stated he was not notified by nursing staff 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 consistently monitor residents on psychotropic medications for 3 of 5 sampled residents (#s 20, 27 and 38) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 20 admitted to the facility in 2023 with diagnoses including PTSD (post-traumatic stress disorder) and depression. An 10/17/23 signed physician order indicated Resident 20 received Citalopram for depression. The 6/2024 Monitors document revealed the following from 6/5/24 through 6/25/24 for Resident 20: -The monitor adverse reactions for the use of an antidepressant section was completed using a checkmark instead specific numeric code related to the behavior and number of episodes. Adverse reactions included: the resident's behaviors, adverse side effects and interventions. -The monitor behavior code and number of episodes section was completed using a checkmark instead of a specific numeric code related to the behavior and number of episodes. -The…

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

Based on interview and record review it was determined the facility failed to ensure a resident understood an arbitration agreement for 1 of 3 sampled residents (#38) reviewed for arbitration. This placed residents at risk for loss of legal rights. Findings include: Resident 38 admitted to the facility in 2024 with a diagnosis of heart disease. An 4/29/24 admission MDS revealed Resident 38 was cognitively intact. A Patient and Facility Arbitration Agreement revealed Resident 38 signed the agreement on 4/27/24. On 6/26/24 at 11:17 AM Resident 38 stated she/he was in a coma when she/he arrived at the facility and did not recall the arbitration agreement. Resident 38 stated she/he recalled signing a large number of papers and the facility made it seem signing all the papers was urgent. On 6/27/24 at 7:50 AM Staff 59 (Admissions) stated residents signed approximately 13 forms upon admission. Staff stated she informed the resident if they agreed to the arbitration agreement they are giving away their right to trial. Staff 59 stated she told the residents if they agreed and signed, the…

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

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 4, 6 and 8) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of training records on 6/27/24 indicated the following employees did not receive 12 hours of annual in-service training: - Staff 4 (CNA) completed eight hours of in-service training. - Staff 6 (CNA) completed ten hours of in-service training. - Staff 8 (CNA) completed ten hours of in-service training. On 6/27/24 at 7:15 AM Staff 1 (Administrator) stated he would review records for additional hours. At 11:07 AM Staff 3 (Regional Director of Clinical) was informed the additional documentation did not meet the required annual 12 hours of in-service training for Staff 4, Staff 5, and Staff 8.

Based on interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility and for 4 of 4 sampled residents (#s 11, 22, 23 and 24) reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 5/18/24 and 5/20/24 public complaints were received by the State Survey Agency which alleged the facility did not staff at a level to ensure resident care needs were met. Residents had fallen, attempted to elope and many residents were left in urine soaked bed sheets at night. The 4/2024 Resident Council Notes revealed slow call light response times and care staff not returning when residents requested items. The facility's 4/2024 and 5/2024 Direct Care Staff Daily Report revealed the facility was understaffed for CNAs for 7 of 20 days reviewed for the State minimum staffing requirement. On 5/23/24 at 3:50 PM, Resident 11 stated she/he had waited over an hour for her/his call light to be answered. On 5/28/24 at 12:01 PM,…

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

Based on interview and record review it was determined the facility failed to ensure the facility had nursing staff with the appropriate wound care competencies and skills sets for 12 of 12 licensed nurse staff reviewed for nursing services. This placed residents at risk for unmet wound care needs. Findings include: A review of the facility's employee list revealed 12 LPNs and RNs worked at the facility. On 5/22/23 and 5/23/23 a request was made to review documentation to ensure the facility and contract agency licensed nurse staff had the required wound care skills and competencies. No documented proof was provided. On 5/22/24 at 11:53 AM, Staff 19 stated she found Resident 6 had calcium alginate (wound dressing) over her/his surgical wound. This dressing was not ordered so she removed the dressing and reported it to Staff 3 and the physician. On 5/22/24 at 6:05 PM, Staff 8 (LPN), Staff 19 (LPN), and Staff 31 (LPN) all stated the facility did not complete skills competencies to ensure the new staff knew what they were doing before they provided wound and nursing care to the…

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

Based on interview and record review it was determined the facility failed to ensure effective systems were in place to identify problems, and take action to improve and monitor its performance for 1 of 1 facility reviewed for quality assessment and assurance. This failure placed residents at risk for worsening care. Findings include: The facility's undated 2024 Quality Assurance and Performance Improvement (QAPI) Plan for Hearthstone Nursing and Rehabilitation Center included oversight of Administration, Clinical Care Services, Nutrition Services, Pharmacy Services, Quality of Life and Engagement, Maintenance Services, Housekeeping, and Training And Orientation. The plan included use of a QAPI Committee, Analytics, Core Processes, and Medical Oversight for purposes of Performance Improvement Projects, Systematic Analysis, Communication, QAPI Self-Assessment, as well as Feedback and Data Monitoring. A review of the facility's Quality Assessment and Assurance (QAA) records from 10/2023 through 5/28/24 revealed no evidence the facility enacted procedures related to problem…

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 treated with respect and dignity for 1 of 3 residents (#22) reviewed for dignity. This placed residents at risk for being treated in an undignified manner. Findings include: Resident 22 admitted to the facility in 5/2024, with diagnoses including hemiplegia and adult failure to thrive. A 5/18/24 Late Entry Progress Note indicated Resident 22 worked with Staff 29 (Certified OT Assistant) in her/his room when bickering between them was observed because Resident 22 did not want to do the arm exercise. The resident indicated her/his arm hurt and persisted that she/he did not want to use the machine. The observing nurse entered the room to inform Staff 29 the resident was refusing and to disconnect the machine. The 5/18/24 Grievance Form indicated on 5/18/24 Resident 22 got upset with Staff 29 when Staff 29 did not want to stop the TENS (a battery-powered device with electrodes that deliver electrical impulses through the surface of our skin) unit because it hurt the resident. Staff 21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure a RN served as the DNS on a full-time basis for 1 of 1 facility reviewed for DNS staffing. This placed residents at risk for lack of nursing department oversight. Findings include: On 1/24/24 a public complaint was received which indicated Staff 5 (LPN Infection Preventionist - Former Interim Assistant DNS) acted as the DNS under the direction of Staff 8 (MDS Nurse RN). A 12/13/23 Change Request Form for Oregon CLIA Laboratories revealed Staff 8 was listed as the new Laboratory Director as of 12/13/23. Review of facility records including timecards revealed no evidence Staff 8 was the full-time DNS. On 2/15/24 at approximately 11:30 AM Staff 5 stated her position was the assistant interim DNS and Staff 8 was the DNS. Staff 5 stated her duties included completing incident reports with Staff 6 (Former Regional RN) and consulted with Staff 8 frequently about everything including staffing, staff discipline and documentation issues.…

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 there was sufficient nursing staff available to provide care and services to meeting the residents needs for 4 of 4 wings (Wings 1,2,3 and 4) reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: A 1/3/24 Grievance revealed Resident 27 complained she/he asked for help three times with no follow-up. The 1/2024 Resident Council revealed residents requested more CNA staff so they could give good care to the residents. The 1/2024 and 2/2024 Direct Care Staff Daily Report revealed the faciltiy was understaffed for CNAs for seven of 32 days reviewed for the State minimum staffing requirment. On 2/15/24 at 8:44 PM Resident 13 was observed to have her/his call light on. Resident 13 stated the first time her/his call light was activated a staff member came into the room, stated her/his assigned CNA was on break and turned off the call light. Resident 13 stated she/he waited an hour before turning the call light back on 15 minutes ago. Resident 13 stated…

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

Based on observation and interview it was determined the facility failed to ensure medications were properly secured and only accessible to authorized personnel for 3 of 3 random observations reviewed for medication storage. This placed residents at risk for access to potentially harmful medications. Findings include. On 2/15/24 at 8:45 PM a treatment cart which contained diabetic medications was observed to be unlocked and unattended in the long-term care nursing unit. Staff 9 (CNA) verified the cart was unlocked and unattended. On 2/15/24 at 8:56 PM a medication cart was observed to be unlocked and unattended in the skilled hall. Staff 14 (CMA) verified the medication cart was unlocked and unattended. On 2/16/24 at 8:22 AM the treatment cart in the skilled hall near the nursing station, which stored insulin medication, was unlocked and unattended. Staff 17 (CNA) verified the treatment cart was unlocked and unattended.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to complete and implement baseline care plans to ensure resident safety for 1 of 1 sampled resident (#25) reviewed for behaviors. This placed residents at risk for unaddressed needs. Findings include: Resident 25 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (metabolism caused brain dysfunction), cognitive communication deficit and anxiety. Resident 25's Baseline Care Plan did not address the resident's mental status or behaviors. Resident 25's Progress Notes revealed the following: -12/30/23: the resident thought she/he saw gnats in the room. -12/31/23: the resident was agitated, confused and hallucinations were noted. -1/1/24: the resident was confused at times, exhibited paranoia and stated people were coming after her/him; she/he heard a murder the previous evening and people watched her/him. The resident stated she/he saw floating bubbles in the room which would float down and clean the urine…

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 who was a trauma survivor received trauma-informed care for 1 of 6 sampled residents (#13) reviewed for abuse. This placed residents at risk for unmet trauma needs and a decreased quality of life. Findings include: Resident 13 admitted to the facility in 2023 with diagnoses including anxiety. A 9/14/23 care plan indicated Resident 13 had a diagnosis of PTSD (Post Traumatic Stress Disorder) with interventions including to discuss feelings regarding her/his trauma, encourage family to be involved and visit, be by herself/himself, and staff to avoid re-traumatizing by means of thoughtful approaches to care. Interventions also included to reassure, redirect, and monitor trauma triggers. Resident 13 folded her/his hands and placed on her/his chest when feeling stressed or uncomfortable; staff were to recognize signs of trauma and respond appropriately. No documentation in the care plan was found on what Resident 13's trauma triggers were. A 12/15/23 Intake Note for counseling 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 observation and interview it was determined the facility failed to maintain an infection control program and provide a sanitary and comfortable environment for 1 of 1 random observation (room [ROOM NUMBER]) reviewed for infection control. This placed residents at risk for an unsanitary, non-homelike environment. Findings include: A public complaint was received on 12/4/23 which indicated staff routinely threw soiled linen in the corner, on the floor of her/his room, for the two weeks she/he resided at the facility. On 2/15/24 at 9:02 PM room [ROOM NUMBER] was observed to have a full trash bag laying on the floor in the doorway to the room and a soiled, cloth incontinence pad laying on floor in the corner of the room by the clothing closets. No staff was present in the room or hallway. On 2/15/24 at 9:03 PM Staff 16 (CNA) verified the trash bag and the soiled incontinence pad on the floor of room [ROOM NUMBER] and stated she put them there.

Based on interview and record review it was determined the facility failed to ensure care plans were developed for 1 of 3 sampled residents (#7) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include: Resident 7 was admitted to the facility in 2023 with a diagnosis of kidney disease. An 8/28/23 admission MDS and associated CAAs revealed Resident 7 had a pressure ulcer and was at risk for worsening pressure ulcer due to incontinence, immobility, poor cognition and poor nutrition. Resident 7's current record revealed the resident was provided ongoing treatments, assessments, wound consults, and RD evaluations related to a pressure ulcer. Resident 7's comprehensive care plan last revised 12/2023 revealed there was no focused area related to pressure ulcers with measurable objectives and timeframes to meet the resident's needs. On 1/26/24 at 9:25 AM with Resident 7's permission Staff 14 (LPN Wound Nurse) was observed to change the resident's pressure ulcer dressing. The resident was observed to have an unstageable pressure ulcer (wound bed…

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 care plans were revised for 2 of 4 sampled residents (#s 5 and 6) reviewed for adaptive equipment and medical devices. This placed residents at risk for lack of resident specific care. Findings include: 1. Resident 5 was admitted to the facility in 2023 with a diagnoses of traumatic brain injury. Review of Resident 5's 8/5/23 OT note revealed the resident was to use a cup with a sippy lid (detachable lid with a projecting hole). Resident 1's 7/12/23 revised care plan indicated the resident was at risk for fluid deficit and staff were to encourage fluids. The care plan did not indicate the resident was to have a sippy lid. On 1/24/24 at 1:25 PM Resident 5 was observed in bed. Resident 5 had cups with sippy lids. Resident 5 did not drink during the observation. On 1/24/24 at 2:20 PM Staff 2 (LPN Resident Care Manager) stated the kitchen provided the sippy lids and it was on the dietary cards but not on the care plan. On 1/25/24 at 1:03 PM Staff 10 (CNA) stated if a resident needed special…

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 provision of ADL care for 2 of 6 sampled residents (#s 1 and 8) reviewed for eating and bathing assistance. This placed residents at risk for aspiration and poor hygiene. Findings include: 1. Resident 1 was admitted to the facility in 2023 with a diagnosis of arm tremor. A 9/16/23 admission MDS and associated CAAs revealed Resident 1 was alert, able to make her/his needs known, and was able to feed her/himself. A Care Plan initiated 9/10/23 revealed Resident 1 required one staff to set up her/his meal and was able to eat independently. On 1/24/24 at 1:03 PM Resident 1 was observed sitting in her/his wheelchair in her/his room. Resident 1's meal was on a bedside table in front of the resident. Resident 1 was observed to eat without difficulty. A piece of cake in a small bowl, covered with clear plastic wrap, was to the right of Resident 1's plate. At 1:15 PM Resident 1 was observed to have a tremor to the right hand/arm when she/he attempted to remove the clear plastic wrap from the cake bowl.…

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 bowel care for 1 of 3 sampled residents (#1) reviewed for bowel care, failed to monitor residents after a fall for 2 of 3 sampled residents (#s 6 and 9) reviewed for accidents, failed to provide a resident a compression boot for 1 of 3 sampled residents (#1) reviewed for medical equipment and failed to assist a resident with glasses for 1 of 3 sampled residents (#6) reviewed for glasses. This placed residents at risk for unidentified injuries and untreated medical conditions. Findings include: 1. Resident 1 was admitted to the facility in 2023 with diagnosis including obesity. A 12/17/23 quarterly MDS indicated Resident 1 was cognitively intact. a. Resident 1's 1/2024 Bowel Movement record revealed the resident did not have a bowel movement on 1/11/24, 1/12/24, 1/13/24, 1/14/24, 1/15/24, 1/16/24, 1/18/24, 1/19/24, 1/20/24, 1/21/24, 1/22/24, 1/23/24, 1/24/24 and 1/25/24. Resident 1's 1/2024 MAR revealed she/he was to be administered Milk of Magnesia (laxative) PRN if no bowel movement for three days…

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 visitor was monitored to ensure safety for 1 of 3 sampled residents (#7) reviewed for supervision. This placed residents at risk for adverse medical events. Findings include: Resident 7 was admitted to the facility in 2023 with diagnoses including traumatic brain injury and end stage kidney disease. An 8/28/23 admission MDS revealed Resident 7 had lack of safety awareness and difficulty making needs known due to cognitive loss from her/his brain injury. Resident 7 had a tube feeding (surgically placed device in the stomach for nutrition) and facility staff were to manage the resident's nutritional needs and care for the device. Resident 7 was also assessed to be at risk for dehydration related to being on dialysis (procedure to remove waste products and excess fluids from the blood when the kidneys do not function properly), had frequent nausea and vomiting and was on a fluid restriction. A Care Plan initiated 8/22/23 revealed Resident 7 was totally dependent on staff for tube feedings…

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 UA was obtained and results reported timely for 1 of 2 sampled residents (#1) reviewed for UTI. This placed residents at risk for untreated infections. Findings include: Resident 1 was admitted to the facility in 2023 with a diagnosis of obesity. A 11/1/23 Progress Note indicated Resident 1 reported burning with urination and an order for a UA and culture was obtained. A 11/2/23 Laboratory report revealed Resident 1's UA was not performed because the sample was not collected in the correct specimen container. Progress Notes revealed the following: - On 11/2/23, 11/3/23, 11/4/23 and 11/6/23 the resident denied pain with urination - On 11/7/23 a urine sample was collected because the urine sample collected on 11/1/23 was not collected properly. Resident 1 denied urinary pain (the sample was collected five days after the sample was rejected). Resident 1's record indicated the physician was notified the urine sample was collected six days after the UA was ordered. A 11/7/23 Lab Requisition form…

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

Based on observation, interview, and record review it was determined the facility failed to provide assistive devices for 1 of 3 sampled residents (#5) reviewed for care plans. This placed residents at risk for unmet needs. Findings include: Resident 5 was admitted to the facility in 2023 with a diagnosis of traumatic brain injury. A 3/3/24 care plan indicated Resident 5 had a potential nutritional problem. Interventions included assistive devices of weighted utensils and a sippy cup (reduces spills). On 4/8/24 at 11:55 AM and 12:41 PM Resident 5 was observed in bed with a two-handle cup on her/his bedside table with no sippy cup lid. Staff 6 (LPN) brought in Resident 5's lunch tray with a two-handle cup on the tray with no sippy cup lid. Staff 5 stated Resident 5 should have a sippy cup top and sometimes the kitchen forgot to put the lid on. Staff 6 provided Resident 5 the cup without the lid and informed her/him to be careful as there was no lid on the cup. On 4/9/24 at 7:55 AM Resident 5 was in bed and stated she/he was thirsty. A small plastic cup with no handles and no sippy…

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 ADL assistance was provided for 7 of 7 sampled residents (#s 6, 7, 58, 63, 133, 144, and 222) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: 1. Resident 63 admitted to the facility in 2023 with diagnoses including diabetes and dementia. Resident 63's care plan revised on 6/26/23 revealed the resident required the set up assistance of one person for eating and the extensive assistance of one person for personal hygiene. Interventions included to keep fingernails short. On 10/30/23 observations from 12:00 PM through 3:30 PM, revealed Resident 63 was observed in bed and her/his right and left nails were approximately half-inch beyond her/his fingers and the resident's left hand had a dark brownish/black substance on top and under the fingernails. On 11/1/23 at 2:15 PM Resident 63 was observed in bed eating her/his lunch using her/his right hand and the resident's left hand had a dark brownish/black substance on top and under the fingernails. On…

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

Based on observation, interview, and record review it was determined the facility failed to follow physician orders, provide resident positioning, and identify change of condition timely for 4 of 11 sampled residents (#s 9, 46, 58, and 73) reviewed for medications, change of condition, dialysis, and pain. This placed residents at risk for unmet needs. Findings include: 1. Resident 73 was readmitted to the facility in 2023 with diagnoses including depression, anxiety, and schizophrenia. a. A 3/16/23 Nursing Note revealed Resident 73 was alert, able to make her/his needs known, and was pleasant and cooperative. Resident 73 needed one-person assistance with transfers and repositioning. A 3/17/23 care plan revealed Resident 73 required limited assistance of one person for bed mobility, personal hygiene and was independent with eating The care plan also indicated Resident 73 was on antipsychotics with interventions which included labs as ordered. A 3/2023 lab report instructed staff to obtain a blood sample for the following: -CBC with auto diff (complete blood count with automated…

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 in a timely manner for 3 of 24 sampled residents (#s 5, 72, and 73) and 4 of 4 wings (wings 1, 2, 3, and 4) reviewed for staffing and ADLs. This placed residents at risk for unmet needs. Findings include: The 3/23/23 Council Minutes revealed CNAs response to call lights took too long during the night. The 4/13/23 Council Minutes revealed on night shift it was almost impossible to get a CNA to come assist. Residents were getting out of bed late in the mornings. A 10/20/23 Resident Council Department Response Form revealed residents had concerns that meal trays were not delivered as soon as carts were delivered to the halls. 1. Review of the Direct Care Staff Daily Report sheets from 4/5/23 through 5/5/23, 9/29/23 through 10/29/23 revealed the facility did not meet minimum RN coverage for at least eight consecutive hours between the start of day shift and the end of…

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

Based on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 2 out of 63 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 4/5/23 through 5/5/23, 9/29/23 through 10/29/23 revealed the facility did not have RN coverage on all three shifts on the following days: 4/17/23, and 10/25/23. On 11/8/23 at 10:20 AM Staff 1 (Interim Administrator), Staff 2 (DNS), and Staff 3 (Regional Nurse Consultant) stated the facility continued to be active at hiring staff and they continued to take in new admissions of residents. Staff 1 stated there were some concerns with scheduling.

Based on interview and record review it was determined the facility failed to provide risk and benefits for the use of antipsychotic medications to a resident/responsible party prior to administration for 1 of 6 sampled resident (#73) reviewed for medications. This placed residents and responsible parties at risk for lack of informed consent. Findings include: Resident 73 was admitted to the facility in 2023 with diagnoses including depression, anxiety, and schizophrenia. A 3/17/23 care plan revealed Resident 73 used antipsychotics with interventions which included to monitor, document, report any adverse reactions of antipsychotic medications and complete labs as ordered. The 3/15/23 Transfer Discharge Report revealed Resident 73 had physician orders for the following: -olanzapine (an antipsychotic to treat severe agitation). -lamotrigine (to treat bipolar disorder). -amitriptyline (to treat mental and mood problems such as depression). -Abilify injection (used for a short-term treatment for agitation). A 3/21/23 admission MDS and Psychosocial CAA indicated Resident 73 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 assess a resident for a seatbelt for 1 of 1 sampled resident (#58) reviewed for dialysis (the perification of blood through a machine). This placed residents at risk for being restrained. Findings include: Resident 58 was admitted to the facility in 8/2023 with diagnoses including end stage renal disease and obesity. A review of the medical record indicated there was no information related to Resident 58's using a seatbelt or who applied the seatbelt to Resident 58's wheelchair. Resident 58's care plan initiated on 8/22/23 revealed the resident required the assistance of two-people with use of a mechanical lift for transfers. On 11/1/23 at 10:15 AM Staff 47 (CNA) and Staff 28 (CNA) transferred Resident 58 into her/his electric wheelchair and were not sure if the resident was to have the seatbelt fastened or not. Staff 46 (CNA) entered the room at 10:25 AM and indicated the seatbelt was to be fastened whenever the resident was placed in the wheelchair for safety so she/he did not slip out of the electric…

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 prevent and investigate pressure ulcers for 1 of 4 sampled residents (#73) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers. Findings include: Resident 73 was admitted to the facility in 2023 with diagnoses including depression, anxiety, and schizophrenia. A 3/21/23 admission MDS indicated Resident 73 was cognitively intact and was alert and oriented. Resident 73 did not have a pressure ulcer and was at risk for acquiring a pressure ulcer. An 4/10/23 Alert Note indicated Resident 73 was found to have a pressure injury to the coccyx area. An 4/11/23 care plan indicated Resident 73 had an unstageable pressure ulcer to the coccyx with interventions including turn resident every two hours and PRN. Resident 73 needed assistance to turn and reposition more often as needed or requested. An 4/12/23 Wound Evaluation indicated Resident 73 had an unstageable in-house acquired pressure ulcer. The location of the ulcer on the body was not documented, however the photograph of the ulcer…

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 was provided toileting assistance for 1 of 5 sampled residents (#72) reviewed for bowel and bladder. This placed residents at risk for UTIs and lack of dignity. Findings include: Resident 72 was admitted to the facility in 2023 with diagnosis of a broken hip bone. A 9/7/23 care plan indicated Resident 72 required one staff for extensive assistance with toileting. A 9/7/23 through 9/27/23 Documentation Survey Report revealed Resident 72 was provided toileting assistance only once on 9/7/23, 9/9/23, 9/11/23, 9/12/23. 9/14/23 and, 9/22/23. A 9/13/23 admission MDS and CAA revealed Resident 72 was alert and oriented, frequently incontinent of bowel and bladder, and Resident 72 worked with therapy to meet goals to return home. A 9/20/23 IDT (interdisciplinary team) note indicated Resident 72 was able to walk 250 feet and required one person with maximum assistance for toileting. The 9/22/23 and 9/24/23 progress notes indicated Resident 72 was continent of urine and would let staff know when…

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 respiratory equipment filters were clean for 1 of 3 sampled residents (#8) reviewed for environment. This placed residents at risk for impaired respiratory health. Findings include: Resident 8 was admitted to the facility in 2018 with diagnoses including stroke and chronic lung disease. A 3/10/23 revised care plan indicated Resident 8 used oxygen therapy and to clean her/his oxygen concentrator filter as ordered. The 12/2023 TAR indicated staff cleaned Resident 8's oxygen concentrator filter every seven days with soap and water. The filter was last cleaned on 12/31/23. On 1/3/24 at 4:32 PM Resident 8 had oxygen in use and her/his black colored oxygen concentrator filter was observed covered with white debris. On 1/3/24 at 5:48 PM Staff 4 (Infection Preventionist) confirmed Resident 8's oxygen filter was not cleaned and was overlooked during recent environmental audits.

Based on interview and record review it was determined the facility failed to ensure residents records were complete and accurate for 2 of 3 sampled residents (#s 7 and 73) reviewed for nutrition and change of condition. This placed residents at risk for weight loss and abnormal lab values. Findings include: 1. Resident 7 was admitted to the facility in 2019 with diagnosis of irritable bowel syndrome. The 11/2023 MAR instructed staff to administer nutritional supplement three times a day for Resident 7's weight loss. On 11/2/23 the following occurred: -10:03 AM Staff 16 (LPN) was observed to go into Resident 7's room with a small cup with what appeared to be applesauce, a pill in a pill cup and a spoon. Staff 16 was over heard to speak with Resident 7 during her/his medication administration. -10:09 AM The 11/2/23 MAR indicated Resident 7 was administered nutritional supplement. -11:12 AM Staff 16 stated the nutritional supplement was in supply room. Staff 16 stated Resident 7 always refused nutritional supplement. but documented the nutritional supplement as administered. Staff 16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to complete a comprehensive assessment within 14 days of admission for 5 of 6 sampled residents (#s 1, 3, 4, 5 and 6) reviewed for comprehensive assessments. This placed residents at risk for unmet needs. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses including vascular dementia. Review of the resident's MDS tracking record revealed the facility had initiated an Admission, 5-day and 14-day MDS assessments which were still in progress as of 10/16/23. The resident's electronic medical record indicated the assessments were 17 days overdue. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses including post-op knee surgery. Review of the resident's MDS tracking record revealed the facility had initiated an admission MDS assessment which was still in progress as of 10/17/23. The resident's electronic medical record indicated the assessment was 26 days overdue. 3. Resident 4 was admitted to…

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

Based on interview and record review it was determined the facility failed to complete an investigation to rule out neglect within five working days for 1 of 2 sampled residents (#1) reviewed for elopement. This placed residents at risk for accidents. Findings include: Resident 1 was admitted to the facility in 9/2023 with diagnoses including vascular dementia. Review of a care plan dated 9/20/23 revealed the resident was at risk for elopement and was a wanderer. Interventions included the use of a wander guard (device used to alert staff if the resident attempted to exit the building) which was to be checked every shift. Review of an incident report dated 9/28/23 at 1:44 PM revealed staff went to check on the resident who could not be located. Staff initiated a search for the resident who was located outside the building. Resident was returned to the building safe. Review of an incident investigation undated and received on 10/12/23 revealed the resident exited the building through the activities back door to the garden. The resident was found outside the building uninjured and 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 update the care plan after an elopement for 1 of 2 sampled residents (#1) reviewed for elopement. Findings include: Resident 1 was admitted to the facility in 9/2023 with diagnoses including vascular dementia. Review of an incident report dated 9/28/23 at 1:44 PM revealed the resident could not be located in the facility and was found unaccompanied outside of the facility. The resident was returned safely to the facility. Review of a care plan on 10/9/23 dated 9/20/23 revealed the resident was at risk for elopement and wandering. Interventions included the use of a wander guard device to alert staff if the resident attempted to elope. The care did not include the resident recent elopement on 9/28/23 or any changes to the resident's elopement interventions. In an interview on 10/23/23 at 10:16 AM Staff 1 (DNS) acknowledged the resident care plan was not updated to reflect the resident recent elopement and any changes to the interventions.