Myrtle Point Rehabilitation & Care

Based on interview and record review it was determined the facility failed to submit Payroll Based Journal staffing data and other verifiable and auditable data as required for 1 of 1 facility reviewed. This placed residents at risk for inaccurate staffing data reporting. Findings include: Review of the Payroll Based Journal Staffing Data for fiscal year 2024, quarter three (4/1/24 through 6/30/24), revealed the facility failed to submit required data for the quarter. On 11/6/24 at 12:22 PM Staff 1 (Administrator) stated she was unaware the data was not submitted until the survey team alerted her to the omission.

Based on observation, interview, and record review it was determined the facility failed to provide a clean and homelike environment, and failed to ensure residents' belongings were safe for 2 of 7 sampled residents (#s 18 and 19) and 1 of 1 sunroom reviewed for environment and personal property. This placed residents at risk for an unclean, un-homelike environment, and missing belongings. Findings include: 1. Resident 18 admitted to the facility in 4/2023 with a diagnosis of a stroke. A care plan updated 5/21/24 revealed Resident 18 had hearing aids, but chose not to wear them. On 11/4/24 at 1:21 PM Witness 1 (Complainant) stated Resident 18 had hearing aids, but they were not in her/his room. Witness 1 stated this was reported to staff. On 11/6/24 at 11:42 AM Staff 4 (CNA) stated Resident 18 had hearing aids, but she was not aware where the hearing aids were located. On 11/5/24 at 1:25 PM Staff 3 (Social Services) stated she did not have a grievance for Resident 18's hearing aids. On 11/7/24 at 11:56 AM Staff 2 (Interim DNS) stated Resident 18 had hearing aids, but staff were not…

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

Based on interview and record review the facility failed to protect residents' right to be free from verbal abuse by staff and neglect related to failure to provide residents needed supplies for 4 of 5 sampled residents (#3, 14, 18, and 20) reviewed for supplies and abuse. Findings include: 1. Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). A 5/30/24 MDS revealed Resident 14's BIMS score was 15 which indicated she/he was cognitively intact. A 7/14/24 Social Service Note written by Staff 20 (Former Administrator) indicated on 7/11/24 Resident 14 verbalized she/he would inform family members of her/his positive COVID-19 test results in the facility. Review of a Complex Medical Add On note revealed on 7/14/24 Resident 14 tested positive for COVID-19 and refused to stay inside her/his room. On 11/5/24 at 9:15 AM Staff 4 (CNA) stated in 7/2024 when the elevator did not work Staff 20 was yelling and screaming. On 11/5/24 at 11:58 AM Staff 25 (CNA) stated Staff 20 yelled at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide an ongoing activity program to meet the needs of residents for 1 of 1 sampled resident (#6) and 1 of 1 facility reviewed for activities. This placed residents at risk for decrease in quality of life. Findings include: 1. Resident 6 admitted to the facility in 2024 with diagnoses including chronic kidney disease and depression. On [DATE] at 1:40 PM Resident 6 stated she/he wanted to go fishing more often and the facility could not take residents on outings because the facility van was not road legal. On [DATE] at 12:26 PM Staff 3 (Social Services/Activities) stated the facility van's registration was not up-to-date, and she could not take residents on outings. Observation of the facility van's registration stickers on [DATE] at 2:43 PM revealed the registration was out of date. On [DATE] at 10:04 AM multiple residents at the resident council meeting stated they were unhappy the van was not available, and they wanted…

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

Based on observation, interview, and record review it was determined the facility failed to have adequate staff available to meet the needs of residents for 2 of 4 residents (#s 14 and 18) reviewed for ADLs, and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 18 admitted to the facility in 2023 with diagnoses including dementia and cognitive impairment. A 5/4/24 annual MDS revealed Resident 18 had moderate cognitive impairment. A 7/19/24 provider note stated Resident 18 had dementia and arrived at her/his appointment without their required facility staff escort. The note stated the provider called the facility and was told no escort was available due to short staffing. On 11/8/24 at 11:35 AM Staff 1 (Administrator) stated she expectated staff to accompany residents to their appointments as required. She acknowledged the provider note stating no facility staff escort was provided due to short staffing. 2. On 7/25/24 the State Survey Agency received a public complaint which indicated the facility was short staffed,…

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 nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents for 3 of 5 staff (#s 18, 26, and 27) reviewed for competencies. This placed residents at risk for poor quality of care and lack of competent staff. Findings include: On 11/5/24 Staff 1 (Administrator) was asked to provide documentation of a completed competency checklist for Staff 17 (CNA), Staff 18 (CNA), Staff 26 (CNA), Staff 27 (CNA), and Staff 28 (CNA). On 11/6/24 at 10:00 AM Staff 1 provided completed competency checklists for Staff 17 and Staff 28. Staff 1 stated she did not have the requested completed competency checklists for Staff 18, Staff 26, and Staff 27.

Based on interview and record review it was determined the facility failed to ensure the required annual CNA training and annual performance reviews were completed for 2 of 5 sampled CNA staff (#s 26 and 28) reviewed for staffing. This placed residents at risk for unmet needs and lack of competent staff. Findings include: On 11/5/24 at 1:00 PM Staff 1 (Administrator) was asked to provide annual performance reviews and documentation of annual in-service training for Staff 26 and Staff 28. No annual performance reviews or in-service training documentation were provided for the identified staff members. On 11/6/24 at 10:00 AM Staff 1 (Administrator) stated in-service training was completed for CNA staff during staff meetings and via internet-based services. She stated she was recently hired and was not sure when or how evaluations were completed for staff. She acknowledged the identified CNA staff records did not show 12 hours of annual in-service training and did not include annual performance reviews. She stated the facility was not able to access the previous internet-based training…

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 food was stored appropriately and was discarded in a timely manner for 1 of 1 resident refrigerator reviewed for food storage and handling. This placed residents at risk for food-borne illness and cross-contamination. Findings include: On 11/4/24 at 11:34 AM the resident refrigerator located in the sunroom contained the following food items that were labeled with expired dates: - Applesauce was dated 10/28/24 (expired for 7 days). - A sandwich was dated 10/30/24 (expired for 5 days). - A dish of pineapple was dated 10/30/24 (expired for 5 days). - A plastic bag of carrots was dated 10/31/24 (expired for 4 days). On 11/4/24 at 11:46 AM Staff 23 (Dietary Manager) confirmed the food items should have been discarded by the expiration dates.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 7 sampled residents (#27) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: Resident 27 admitted to the facility in 2/2024 with a diagnosis of a fracture to the right hip. A 5/20/24 Nursing Note indicated Resident 27 discharged from the facility to the hospital because she/he had copious amounts of pus drainage from her/his surgical site. A 6/6/24 hospital transfer orders indicated Resident 27 had active infection of Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium which can cause serious infections in humans, is multi-drug resistant, and carriers could spread the infection even if they are not sick themselves). A 6/11/24 Nursing Note indicated Resident 27 had IV antibiotic treatment for an infected wound. No documentation was found in Resident 27's clinical record she/he was placed on precautions after readmitting to the facility on 6/6/24. On 7/25/24…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to accommodate resident needs for 2 of 7 sampled residents (#s 8 and 14) reviewed for environment. This placed residents at risk for lack of independence. Findings include: 1. Resident 8 admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness on one side of the body) and depression. On 11/5/24 at 2:38 PM Resident 8 complained she/he was moved to a different room because of a ceiling leak. She/he wanted to move back to the original room because that was where her/his adaptive equipment (trapeze and side rails) were installed to assist Resident 8 with bed mobility. When asked if there was adaptive equipment in her/his current room she/he replied, no it's in my old room. When asked how long she/he was without her/his adaptive equipment, she/he stated it was a few months. On 11/6/24 at 9:06 AM observation of Resident 8's previous room revealed the installed adaptive equipment. Observation of Resident 8's…

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 report allegations of abuse for 1 of 2 sampled residents (#14) reviewed for abuse reporting. This placed residents at risk for abuse. Findings include: Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). A 5/30/24 MDS revealed Resident 14's BIMS score was 15 which indicated she/he was cognitively intact. Review of a Complex Medical Add On note revealed on 7/14/24 Resident 14 tested positive for COVID-19 and refused to stay inside her/his room. On 11/5/24 at 11:58 AM Staff 25 (CNA) stated Staff 20 (Former Administrator) yelled at Resident 14 and there were other residents who also heard the yelling. On 11/6/24 at 9:42 AM Resident 14 stated in 7/2024 she/he tested positive for COVID-19. Staff paused the elevator operation so other residents did not come up the elevator while Resident 14 sat by the elevator, and staff went to get her/him a mask so she/he could go downstairs. Staff 20 came up 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 investigate an allegation of abuse for 1 of 2 sampled residents (#14) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). A 5/30/24 MDS revealed Resident 14's BIMS score was 15 which indicated she/he was cognitively intact. Review of a Complex Medical Add On note revealed on 7/14/24 Resident 14 tested positive for COVID-19 and refused to stay inside her/his room. On 11/5/24 at 11:58 AM Staff 25 (CNA) stated Staff 20 (Former Administrator) yelled at Resident 14. On 11/6/24 at 9:42 AM Resident 14 stated in 7/2024 she/he tested positive for COVID-19. Staff paused the elevator operation so other residents did not come up the elevator while Resident 14 sat by the elevator, and staff went to get her/him a mask so she/he could go downstairs. Staff 20 came up the stairs and saw Resident 14 and told her/him to go to 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 ensure dependent residents received required assistance with ADLs for 1 of 4 sampled residents (#14) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). A 5/30/24 MDS revealed Resident 14's BIMS score was 15 which indicated she/he was cognitively intact. A 11/6/23 care plan indicated Resident 14 had an ADL self-care performance deficit with interventions including she/he would activate her/his call light for assistance, and she/he required one-person assistance with most ADLs. On 11/6/24 at 9:42 AM Resident 14 stated Staff 13 (CNA) and Staff 19 (CNA) responded to her/his call light while her/his roommate was sleeping, so she/he told staff to keep quiet and to not turn on the light. Staff 13 and Staff 19 left the room. Resident 14 then waited another 45 minutes to an hour to receive assistance, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to respond to changes in condition and follow physician orders for 2 of 7 sampled residents (#s 4 and 29) reviewed for change of condition. This placed residents at risk for delayed treatment and unmet needs. Findings include: 1. Resident 4 admitted to the facility on [DATE] with diagnoses including Parkinson's disease, constipation and chronic kidney disease. A review of the 10/2024 MAR revealed a physician order for Miralax to be administered if Resident 4 had no BM for three days. Resident 4 was noted to have no BM from 10/19/24 through 10/23/24; a period of five days. Resident 4 was administered Miralax on 10/24/24, day six, and it was noted to be effective. Staff 2 (DNS) confirmed the medication was not given in accordance with physician orders. 2. Resident 29 admitted to the facility in 9/2018 with diagnoses including dementia and UTI. A review of a 1/21/24 POLST revealed Resident 29's preference was limited treatment which included…

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 maintain an environment free from accident hazards and to monitor a resident after a fall for 2 of 4 sampled residents (#s 6 and 18) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 6 admitted to the facility in 5/2023 with diagnoses including stroke. A review of Resident 6's care plan dated 6/2024 revealed Resident 6 was at risk for falls, with interventions including she/he was a high fall risk and to meet her/his needs. On 7/24/24 the State Survey Agency received a public complaint which indicated Resident 6 fell because the main entrance door did not work, and there was a sign to use the back door. The back door had a wheelchair ramp with no railing, and she/he fell and hurt her/his back and bruised her/his hip after the tire of her/his electric wheelchair slipped off the edge of the ramp. A 7/24/24 Fall investigation revealed at about 2:30 PM Resident 6 was found lying on the ground with her/his electric wheelchair next to her/his side. A…

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

Based on interview and record review the facility failed to provide pain medications as ordered for 1 of 2 sampled residents (#14) reviewed for pain management. This placed residents at risk for uncontrolled pain. Findings include: Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). A 11/6/23 Care plan indicated Resident 14 had chronic pain with interventions including to administer pain medications as ordered by the physician. A 2/2024 MAR instructed staff to administer Methadone (to treat moderate to severe pain) three times a day for chronic pain with a start date of 1/11/24. On 2/7/24 at 4:00 AM, 2/20/24 at 8:00 PM and 2/21/24 at 4:00 AM the MAR referred the reader to review Medication Administration Notes. A 2/7/24 Medication Administration Note indicated Methadone was not administered to Resident 14 because the facility was waiting on the delivery from the pharmacy. No documentation was found in Medication Administration Note for 2/20/24 why Resident 14 did not…

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

Based on interview and record review it was determined the facility failed to provide accurate and timely pharmaceutical services for 1 of 2 sampled residents (#14) reviewed for pain management. This placed residents at risk for medication errors. Findings include: Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). A 11/6/23 Care plan indicated Resident 14 had chronic pain with interventions including to administer pain medications as ordered by the physician. A 2/2024 MAR instructed staff to administer Methadone (to treat moderate to severe pain) three times a day for chronic pain with a start date of 1/11/24. On 2/7/24 at 4:00 AM, 2/20/24 at 8:00 PM and 2/21/24 at 4:00 AM the MAR referred the reader to review Medication Administration Notes. A 2/7/24 Medication Administration Note indicated Methadone was not administered to Resident 14 because the facility was waiting on the delivery from the pharmacy. No documentation was found in Medication Administration Note for…

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

Based on observation, interview and record review it was determined the facility failed to ensure a follow-up dental appointment was made for 1 of 2 sampled residents (#18) reviewed for dental. This placed residents at risk for dental pain. Findings include: Resident 18 admitted to the facility in 4/2023 with a diagnosis of diabetes. A 3/19/24 dental Clinical Notes Report revealed an oral exam was performed and findings included cavities. Recommendations included a referral for treatment and a full crown. A 5/15/24 Clinical Notes Report revealed Resident 18 was seen for a dental visit. X-rays were not able to be performed due to the resident's mental capacity. Resident 18's clinical record did not indicate she/he was referred to another dental provider. On 11/8/24 at 10:16 AM Staff 1 (Administrator) stated Resident 18 was not setup for a dental referral related to the treatment recommendations from the previous dental appointments.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' food preferences were honored for 1 of 3 sample residents (#14) reviewed regarding food. This placed residents at risk for unmet needs. Findings include: On 7/24/24 the State Survey Agency received a public complaint which indicated Resident 14 was not getting enough food and did not always get what other residents were served. On 11/6/24 at 9:42 AM and 1:13 PM Resident 14 stated the facility served their largest meal at lunch and in her/his culture the largest meal of the day was at dinner time. Resident 14 stated the facility did not provide choices during meals and residents received what was served. At times Resident 14 was served beets or Brussels sprouts, and she/he did not like those types of vegetables. Resident 14 stated when a request for a salad was honored it was very small and with hardly anything on the salad. Resident 14 received her/his lunch meal tray with mashed potatoes and gravy, vegetables, and a pork chop. Resident 14 stated the pork chop was dry. A…

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

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accessible for 2 of 2 sampled residents (#s 11 and 18) whose records were reviewed. This placed residents at risk for unmet needs. Findings include: 1. Resident 11 admitted to the facility in 6/2019 with diagnoses including blindness and dementia. On 8/1/24 the State Survey Agency received a public complaint which indicated Staff 20 (Former Administrator) disposed of residents' medical records which included tuberculosis (TB) testing records. The nurse had to re-do residents' TB testing. Resident 11 stated staff attempted to poke her/him to re-do the TB test. No documentation was found in Resident 11's clinical records she/he was offered or received TB testing prior to 6/2024. A review of Resident 11's Immunization Details revealed on 8/2/24 Resident 11 refused a TB skin test. On 11/5/24 at 12:31 PM Staff 9 (LPN) stated she remembered a concern with lost medical documents and having to re-do TB testing on some residents. On 11/8/24 at 11:57 AM Staff 1…

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

Based on interview and record review it was determined the facility failed to timely obtain radiology services for 1 of 3 sampled residents (#300) reviewed for specialized medical appointments. This placed residents at risk for lack of radiology services. Findings include: A public complaint was received on 9/17/24 which alleged Resident 300 did not receive a timely radiology appointment. Resident 300 admitted to the facility in 9/2023 with diagnoses including spinal stenosis (narrowing of the spinal canal). On 9/19/24 at 11:28 AM Witness 1 (Complainant) stated Resident 300 had an order for a MRI (medical imaging used to take pictures of the body) for her/his left knee on 6/19/24, but the resident was not seen until 9/11/24 due to inaccurate facility documentation including no physician signature on the order, and what imaging the resident was to receive. Witness 1 stated the facility was called numerous times to update the order and add the physician signature, but there was lack of communication by the facility and the radiology appointment was delayed until 9/11/24. A 6/19/24…

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 follow care plan interventions to ensure residents were free from physical abuse for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia. Resident 1 was admitted to the facility in June 2022 with diagnoses including dementia with agitation. Review of a progress note dated 7/17/23 at 4:45 PM, stated Resident 1 was observed to slap a resident on the left hand. Review of Resident 1's care plan updated 7/17/23, stated Resident 1 was to be at arms length away from other residents. Review of a facility investigation dated 7/21/23, stated Resident 1 had a history of striking out at other residents, verbal comments and aggression. The investigation indicated Resident 1's care plan would be updated to keep Resident 1 at arms length away from other residents and abuse was ruled out. Review of a Facility Reported Incident (FRI) dated 7/24/23, stated on 7/23/23…

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

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours per day seven days per week for 64 of 81 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: Review of the facility's Direct Care Staff Daily Reports revealed no designated RN coverage on the following dates: - 10/15/22 through 10/31/22 (16 days) - 11/15/22 through 11/27/22 (12 days) - 2/26/23 - 3/14/23, 3/15/23, 3/16/23, 3/18/23, 3/19/23, 3/20/23, 3/21/23, 3/22/23, 3/23/23, 3/24/23, 3/25/23, 3/27/23, 3/28/23, 3/29/23, 3/30/23 and 3/31/23 (16 days) - 7/1/23, 7/2/23, 7/3/23, 7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 7/9/23, 7/10/23, 7/13/23, 7/15/23, 7/16/23, 7/18/23, 7/19/23, 7/21/23, 7/22/23, 7/23/23 and 7/24/23 (19 days) On 7/27/23 at 8:38 AM Staff 1 (Administrator) confirmed the facility did not have the adequate RN coverage on the dates identified. He stated the facility used agency staff but they just did not have any RNs willing to go…

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 staff annual performance reviews were completed for 4 of 5 CNA staff (#s 6, 7, 10 and 16) reviewed for sufficient staffing and abuse. This placed residents at risk for inadequate care. Findings include: The following CNA staff were reviewed for staff annual performance reviews: - Staff 6 (CNA) was hired on 4/19/17; - Staff 7 (CNA/CMA) was hired on 11/17/13; - Staff 10 (former CNA) was employed by the facility from 2015 through 11/2019; - Staff 16 (CNA) was hired on 12/4/18. On 7/25/23 at 8:59 AM Staff 6 stated she did not know how many training hours she had and said she thought Staff 1 (Administrator) or Staff 2 (DNS) tracked them. On 7/25/23 the personnel file of Staff 10 (former CNA) was requested. On 7/27/23 at 8:45 AM Staff 3 (Clinical Operations Education Director) stated the facility did not have a policy regarding the completion of annual performance reviews. On 7/28/23 at 3:15 PM she stated there was no documentation of staff training and there were no completed staff competencies or annual…

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 Dietary Manager (DM) did not possess the required certification to provide DM services for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: On 7/27/23 at 8:07 AM documentation was requested regarding the dietary certification of Staff 12 (Dietary Manager). On 7/27/23 at 8:07 AM Staff 12 stated the facility was cited the previous year by the State Agency regarding the lack of a certified dietary manager. Staff 12 stated she needed to file an extension because she did not complete the training to be certified.

Based on immediate jeopardy situations and the number of citations including deficient practice in the areas of resident rights, freedom from abuse, comprehensive assessments and care planning, quality of care, nursing services, food and nutrition services, and QAPI and training requirements, it was determined the facility was not managed in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This resulted in two immediate jeopardy situations and substandard quality of care. Findings include: 1. Residents 11, 19 and 20 were not assessed, offered or assisted to make advance care planning decisions. Refer to F578 2. The facility failed to maintain a clean and homelike environment. Refer to F584 3. The facility failed to prevent verbal abuse, determine staff eligibility for hire, address abuse policies and concerns with the QAPI Committee, report potential abuse or neglect and thoroughly investigate allegations of abuse for Residents 6, 20, 179 and 180.…

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 a Quality Assessment and Assurance (QAA) program that identified quality deficiencies and develop and implement action plans to correct identified quality deficiencies. The facility failed to conduct an analysis of quality data, design interventions, test those interventions, and determine if the desired outcome was achieved or sustained. This failed practice placed all residents at risk for not receiving the care and services necessary for optimal resident outcomes. Findings include: An 4/2014 facility Quality Assurance and Performance Improvement (QAPI) Plan revealed: The objectives of the QAPI Plan are to provide structure and processes to correct identified quality and/or safety deficiencies; establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcomes. The QAPI Committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. 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 Quality Assessment and Assurance (QAA) program which systematically identified issues related to infection control, nursing care and services, sufficient RN nursing staff and to ensure that improvements were realized and sustained. Two immediate jeopardy situations were identified with coincident identification of substandard quality of care. Findings include: On 7/31/23 at 2:51 PM Staff 2 (DNS) stated the facility had a program to collect infection information but the data was not shared because no QAPI meeting occurred in over a year. On 8/2/23 at 10:07 AM Staff 1 (Administrator) stated he and Staff 2 were aware staff education was lacking. Staff 1 did not provide any documents related to a QAPI plan or meetings. Staff 1 acknowledged there was no follow-up to any QAPI process that was to start after the 2022 annual survey, and corrections were not implemented or maintained. Refer to F684, F698 and F835

Based on interview and record review it was determine the facility failed to have a quality assessment and assurance committee that met and which included required members to systematically identify issues. This placed all residents at risk. Two immediate jeopardy situations were identified with coincident identification of substandard quality of care. Findings include: A 6/30/23 Facility Assessment indicated the QAPI (Quality Assurance and Performance Improvement) committee last reviewed the document on 3/22/22. On 7/31/23 at 3:39 PM Staff 1 (Administrator) stated there was no working document related to QAPI issues the facility identified, the Medical Director was only available through video and did not attend any QAPI meetings, and QAPI meetings were informal and only involved discussions between Staff 1 and Staff 2 (DNS). Refer to F867

Based on interview and record review it was determined the facility failed to have an effective training program for 1 of 1 facility reviewed for training. This placed residents at risk for untrained staff. Findings include: On 8/2/23 at 8:15 AM Staff 1 (Administrator) was asked to provide staff training records related to Resident Rights, Abuse, Neglect and Exploitation, the QAPI program and the Infection Control program. On 8/2/23 at 9:34 AM Staff 3 (Clinical Operations Education Director) stated she could find only a couple trainings offered and there were no additional trainings located specific to the requested training records.

Based on interview and record review it was determined the facility failed to ensure CNA staff completed the required 12 hours annual training for 1 of 1 facility reviewed for CNA staff training and performance reviews. This placed residents at risk for untrained CNAs. Findings include: On 8/2/23 at 8:15 AM Staff 1 (Administrator) was asked to provide staff training records related to Resident Rights, Abuse, Neglect and Exploitation, the QAPI program and the Infection Control program. On 8/2/23 at 9:34 AM Staff 3 (Clinical Operations Education Director) stated she could find only a couple trainings offered and there were no additional trainings located.

Based on observation and interview it was determined the facility failed to maintain a clean and homelike environment for 2 of 2 halls reviewed for environment. This placed residents at risk for an unclean and non-homelike environment. Findings include: Observations made during the week of 7/24/23 through 7/29/23 revealed 2 of 2 carpeted hallways had multiple dark brown and black areas. There were also dark brown and black spots on the carpet in the entryways and resident rooms. On 7/28/23 at 9:00 AM Staff 1 (Administrator) acknowledged the carpets were old, had stains and needed to be replaced.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to comprehensively assess 4 of 8 sampled residents (#s 2, 20, 24 and 129) reviewed for medications and nutrition. This placed residents at risk for unassessed needs. Findings include: 1. Resident 20 was admitted to the facility in 2023 with diagnoses including weakness and history of falls. The 3/10/23 admission MDS CAA for ADLs included the following: - This care area was triggered because the resident required assistance with activities of daily living from staff. A care plan would be initiated because the resident required staff assistance with most activities of daily living related to limited mobility. The Fall CAA included the following: - This care area was triggered because the resident had previous falls and was at risk for a fall that can subject the resident to an injury. A care plan would be initiated because the resident was at risk for a fall or injury from possible side effects of the medication. On 7/27/23 at 10:08 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 observation, interview and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders for 3 of 3 sampled residents (#s 14, 20 and 130) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: 1. Resident 14 was admitted to the facility in 2023 with diagnoses including chronic obstructive pulmonary disease (lung disease). A 5/31/23 Discharge Order revealed Resident 14 had no orders for oxygen equipment. The 7/2023 MAR revealed no orders for oxygen therapy or oxygen equipment maintenance and cleaning. A 7/25/23 Safety Event-Fall Report indicated Staff 5 (LPN) completed the report and Resident 14's oxygen saturations were at 96 percent with a two liter flow of oxygen after a fall. On 7/25/23 at 11:01 AM and 7/26/23 at 11:15 AM Resident 14 was observed sleeping in bed with a nasal cannula (tubing) and the use of two liters per minute (LPM) of continuous oxygen. On 7/26/23 Staff 6 (CNA) stated she could provide Resident 14 up to two LPM of oxygen as needed…

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 serve food in a sanitary manner and keep refrigerators and the ice machine clean for 1 of 1 kitchen observed. This placed residents at risk for food borne illnesses. Findings include: On 7/24/23 at 12:35 PM the refrigerator in the main kitchen was observed with multiple rusted wire racks. A head of purple cabbage was on the top shelf placed directly on the refrigerator's wire rack. On 7/26/23 the following occurred: -11:28 AM Staff 12 (Dietary Manager) stated the rusty refrigerator shelves were usually taken out each year and sprayed with a rubberized material which was not completed this year. -11:36 AM the floor around the drain pipe running from the ice machine to the floor was covered in dust, debris and build up. The linoleum flooring was peeled away from the floor. There was black mildew was on the inside of the ice machine door and when in the open position the mildew hung from the door approximately a quarter of an inch. -11:39 AM Staff 12 confirmed the ice machine door required cleaning. -11:48 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 make a good faith effort to obtain a transfer agreement with the local hospital(s) for 1 of 1 facility reviewed for transfer agreements. This place residents at risk for delayed transfers. Findings include: On 8/1/23 Staff 1 (Administrator) was asked to provide a transfer agreement with the local hospital(s). On 8/2/23 9:34 AM Staff 1 stated he could not locate any transfer agreements and was not aware if any were pursued.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to follow infection control procedures for vital sign machines and implement a water management plan for 4 of 4 rooms during random observations and 1 of 1 facility reviewed for infection control. This placed residents at risk for cross contamination and communicable diseases. Findings include: 1. On 7/31/23 at 2:51 PM Staff 29 (CMA) was completing blood pressure and oxygenation checks in rooms 11, 12, 14 and 15. Staff 29 was stopped before entering room [ROOM NUMBER] due to not sanitizing the equipment after each use. On 7/31/23 at 2:59 PM Staff 29 acknowledged she did not sanitize the blood pressure cuff or oxygen saturation monitor after each resident in the above rooms. Staff 29 stated there were no sanitizing wipes on the vital sign cart. 2. The 7/2023 Scheduled Maintenance log indicated general facility water temperatures were monitored monthly. No information related to the analysis of potential areas of growth and…

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

Based on interview and record review it was determine the facility failed to implement an antibiotic stewardship program for 1 of 1 facility reviewed for infection control. This place residents at risk for developing antibiotic resistance. Findings include: A 7/27/23 Infection Surveillance Report dated from 6/1/23 through 7/24/23 revealed a list of facility residents who received specific antibiotics for a variety of infectious diseases and symptoms but no labs or cultures were listed. On 7/31/23 at 2:51 PM Staff 2 (DNS/IP) stated it was difficult to obtain data related to residents' lab results before physician prescribed antibiotics and no physician was involved in the antibiotic stewardship program. Staff 2 stated he was the only one who looked at the available antibiotic usage data, his monitoring of facility infections was based solely on each resident's infectious disease title, and acknowledged the antibiotic stewardship program and monitoring of antibiotic usage in the facility was incomplete.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to assess immunization status and provide vaccines for 5 of 5 sampled residents (#s 5, 6 14, 18 and 20) reviewed for immunizations. This placed residents at risk for illnesses and being uninformed about vaccinations. Findings include: A 3/2022 facility Pneumococcal Vaccine policy indicated residents were to be assessed for eligibility to receive the pneumococcal vaccine series and offered within 30 days of admission. The 2/2023 CDC Pneumococcal Vaccination website, section titled Pneumococcal Vaccination, indicated the following: - Vaccines help prevent pneumococcal disease which is any type of illness caused by Streptococcus pneumoniae bacteria. There are two kinds of pneumococcal vaccines available in the United States: * Pneumococcal conjugate vaccines (PCV13, PCV15 and PCV20) * Pneumococcal polysaccharide vaccine (PPSV23) - CDC recommends pneumococcal vaccination for adults [AGE] years old and older; On 7/28/23 at 8:45 AM an undated,…

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 up regarding advance directives for 3 of 3 sampled residents (#s 11, 19 and 20) reviewed for advance directives. This placed residents at risk for not having their healthcare wishes honored. Findings include: 1. Resident 11 was admitted to the facility in 2023 with diagnoses including kidney disease. On 5/23/23 at 5:47 PM a Social Service note indicated Resident 11 read and signed an Advance Directive form. A 5/31/23 Care Conference note indicated Resident 11 elected to be full code (wished to receive life-saving measures if found without a pulse) on her/his POLST (Physician Orders for Life Sustaining Treatment) form. On 7/26/23 at 9:02 AM Resident 11 stated she/he did not complete an Advance Directive but rather completed a POLST form. Review of the medical record revealed no information related to follow-up regarding an Advance Directive. On 7/26/23 at 10:08 AM Staff 34 (Social Service Director) stated she reviewed advanced directives with residents upon admission as part of the admission packet.…

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 notify a physician regarding medication refusals and errors for 1 of 5 sampled residents (#20) reviewed for unnecessary medications. This placed residents at risk for lack of physician oversight. Findings include: Resident 20 was admitted to the facility in 2023 with diagnoses including weakness, history of falls and gastric intestinal metaplasia (precancerous change of the mucosa in the stomach). The 5/25/23 through 6/24/23 MAR indicated Resident 20 refused medications or medications were unavailable for the following: -metformin (for diabetes) 12 times -metoclopramide (for reflux disease)10 times -metoprolol (for Blood pressure) seven times -pantoprazole (for gastric issues) five times -potassium chloride (for low potassium) nine times -Thermotabs (For low sodium) seven times and unavailable 10 times -cymbalta (antidepressant) unavailable three times -hydralazine (for blood pressure) 10 times -levothroxine (for thyroid) two times The 7/1/23 through 7/25/23 MAR indicated Resident 20 refused…

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 a written grievance resolution or communicate with a resident or resident's representative regarding the resolution of a resident grievance for 1 of 1 sampled resident (#129) reviewed for grievances. This placed residents at risk for unaddressed concerns and grievances. Findings include: Resident 129 was admitted to the facility in 2022 with diagnoses including heart attack. On 12/15/22 a public complaint was received which indicated Resident 129 expressed concerns about nursing staff behavior during a care conference on 9/29/22. Resident 129 expressed concerns that the nurses were mean to her/him, and Resident 129 started to cry during the meeting. Resident 129 stated staff said mean things and insisted her/his requests be made earlier in the evening. The complaint also reported Resident 129 did not feel safe in the facility. The DNS was notified and wrote down what Resident 129 reported. On 7/28/23 at 10:58 AM Staff 34 (Social Services Director) stated Resident 129 brought up some concerns during…

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 protect residents' rights to be free from verbal abuse by staff and physical abuse by a resident for 2 of 4 sampled residents (#s 6 and 179) reviewed for abuse. This placed residents at risk for verbal and physical abuse. Findings include: The facility's undated Abuse/Neglect Prevention, Reporting and Investigation policy revealed the facility would .not permit residents to be subjected to abuse or neglect by anyone, including staff, residents .or any other individual that comes into the facility. 1. Resident 179 was admitted to the facility in 2019 with diagnoses including Methicillin-resistant Staphylococcus aureus infection (MRSA) and bilateral leg amputations. Resident 179's 10/2019 Quarterly MDS revealed she/he had a BIMS score of 14 indicating no cognitive impairment. The facility's 11/26/19 abuse investigation revealed Staff 10 (former CNA) and Staff 14 (former RN) attempted to transfer Resident 179 to her/his bed when Staff 10 told Resident 179 We are going to put you to bed and you are going 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 the facility failed to ensure staff were employable for 1 of 6 staff (#10) reviewed for personnel files. This placed residents at risk for abuse. Findings include: On 7/25/23 at 3:08 PM Staff 10's (former CNA) personnel file was requested from Staff 1 (Administrator) as a result of a staff to resident verbal abuse allegation. On 7/26/23 at 1:40 PM Staff 17 (Regional Director of Operations) stated Staff 10's personnel file was in a storage unit offsite. Staff 1 confirmed the file was in an offsite storage unit. On 7/31/23 at 12:26 PM Staff 1 stated he could not find Staff 10's file. No documentation was provided to confirm Staff 10 was employable by the state licensure agency.

Based on interview and record review it was determined the facility failed to implement abuse policies and failed to address abuse with the QAPI committee for 2 of 5 sampled residents (#s 6 and 180) reviewed for abuse. This placed residents at risk for abuse by staff and other residents. Findings include: The facility's undated Abuse/Neglect Prevention, Reporting and Investigation policy revealed .we protect our residents from all issues of abuse through facility preventative measures. It is our policy that all allegations of abuse be reported and thoroughly investigated ., and .will not permit residents to be subjected to abuse or neglect by anyone, including staff, residents or any other individual that comes into the facility. On 12/26/22 Resident 180 was found by facility staff with bruising over her/his eyebrow. Resident 180 was unable to state how she/he sustained the injury. A thorough investigation was not completed and abuse was not ruled out. The facility did not report the injury of unknown origin to the state agency. On 2/19/23 staff witnessed Resident 8 approach…

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 report an injury of unknown origin for 1 of 4 sampled residents (#180) reviewed for abuse. This placed residents at risk for being abused, sustaining injury and unmet care needs. Findings include: The facility's undated Abuse/Neglect Prevention, Reporting and Investigation policy revealed All incidents of skin condition changes are investigated by the RCM or the DNS for potential abuse or neglect, and .If abuse canot be reasonably ruled out as a cause, then it must be reported . 1. Resident 180 was admitted to the facility in 2012 with diagnoses including diplegia of upper limbs (a form of paralysis affecting both arms) and cervical spinal cord injuries affecting multiple vertebrae. Resident 180's 11/4/22 Quarterly MDS revealed she/he had a BIMS score of 5 indicating severe cognitive impairment. Resident 180 was assessed to need extensive assistance with dressing and total assistance with eating and personal hygiene. A 12/26/22…

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 thorough investigation was completed for an injury of unknown origin for 1 of 5 sampled residents (#180) reviewed for abuse. This placed residents at risk for being abused, sustaining injury and unmet care needs. Findings include: The facility's undated Abuse/Neglect Prevention, Reporting and Investigation policy revealed All incidents of skin condition changes are investigated by the RCM or the DNS for potential abuse or neglect, and .If abuse canot be reasonably ruled out as a cause, then it must be reported . Resident 180 was admitted to the facility in 2012 with diagnoses including diplegia of upper limbs (a form of paralysis affecting both arms) and cervical spinal cord injuries affecting multiple vertebrae. Resident 180's 11/4/22 Quarterly MDS revealed she/he had a BIMS score of 5 indicating severe cognitive impairment. Resident 180 was assessed to need extensive assistance with dressing and total assistance with eating and personal hygiene. A 12/26/22 progress note revealed Resident 180 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to implement a baseline care plan for 1 of 3 sampled residents (#405) reviewed for catheter care. This placed residents at risk for unmet care needs. Findings include: Resident 405 was admitted to the facility on [DATE] with diagnoses including heart disease. A 9/26/23 review of Resident 405's clinical record revealed no baseline care plan. On 9/27/23 at 3:38 PM Staff 5 (LPN) stated the admission process for Resident 405 was never completed, there was no baseline care plan for Resident 405 and she was asked to complete a care plan on 9/27/23. On 9/27/23 at 4:13 PM Staff 3 (Clinical Operations Education Director) stated the new admission process was not completed for Resident 405. Staff 3 acknowledged Resident 405 had no baseline care plan.

Based on interview and record review it was determined the facility failed to develop and implement comprehensive care plans for 2 of 5 of sampled residents (#s 20 and 129) reviewed for accidents and change of condition. This placed residents at risk for unmet needs. Findings include: 1. Resident 20 was admitted to the facility in 2023 with diagnoses including weakness and respiratory failure. The 6/14/23 care plan did not address resident 20's ADLs or transfer status. On 7/27/23 at 10:08 AM Staff 3 (Regional operations Education Director) acknowledged Resident 20's care plan did not address her/his ADLs or transfer status. 2. Resident 129 was admitted to the facility in 2022 with diagnoses including heart attack. A 7/4/22 admission MDS indicated Resident 129 received anticoagulant therapy. An 10/4/22 signed physician order instructed staff to administer Eliquis (a blood thinner). A review of Resident 129's 10/13/22 care plan did not identify the use of a blood thinner or interventions. On 7/31/23 at 11:22 AM Staff 3 (Clinical Operations Education Director) confirmed there was 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 update care plans for 2 of 5 sampled residents (#s 20 and 26) reviewed for accidents and UTIs. This placed residents at risk for unmet needs. Findings include: 1. Resident 20 was admitted to the facility in 2023 with diagnoses including a history of falls and respiratory failure. A 3/15/23 progress note revealed Resident 20 returned to the facility after a 3/14/23 fall with a diagnosis of a broken leg. The 6/14/23 revised care plan indicated the resident had a history of falls, would not sustain any further falls, and to place frequently used items within reach of the resident. The revised care plan did not include interventions in place after the 3/14/23 fall related to Resident 20's transfer status or nursing and personal care related to her/his broken leg. On 10/27/23 at 10:08 AM Staff 3 (Clinical Operations Education Director) acknowledged Resident 20's revised care plan did not include interventions related to the fall with fracture. 2. Resident 26 admitted to the facility in 2023 with diagnoses…

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

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#26) reviewed for UTI. This placed resident at risk for unmet needs. Findings include: Resident 26 was admitted to the facility in 2023 with diagnoses including stroke and diabetes. A 7/2023 MAR instructed staff to complete diabetic nail care by a nurse weekly as needed. On 7/10/23 it was documented unable to complete. On 7/17/23 it was documented not needed at this time. On 7/24/23 it was documented as completed. On 7/24/23 at 1:46 PM Resident 26 stated she/he had to ask for a washcloth to wash her/his hands and one was not provided at every meal. There was no sink in her/his room. On 7/27/23 at 1:56 PM, 7/28/23 at 8:00 PM and 7/31/23 at 8:56 AM Resident 26 was observed to have dark brown debris under her/his nails with nails approximately 1/2 inch beyond fingertips. On 7/31/23 at 10:17 AM light brown discoloration was observed under Resident 26's nails and her/his nails were approximately 1/2 inch…

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 properly assess, follow physician orders and provide adequate catheter care for 1 of 2 sampled residents (#26) reviewed for UTI. This placed residents at risk for unmet catheter needs. Findings include: Resident 26 admitted to the facility in 2023 with diagnoses including UTI. A 5/5/23 admission Observation revealed Resident 26 had a urinary catheter. A review of the 5/6/23 baseline care plan revealed Resident 26 required a urinary catheter. A signed 5/8/23 Order Communication Form requested removal of Resident 26's urinary catheter, monitor for urinary retention, insert straight catheter (intermittent catheter removed after each use) as necessary and replace urinary catheter if the resident was unable to void. A 5/2023 review of Point of Care History document revealed Resident 26 had a urinary catheter in place from 5/6/23 through 5/21/23. A 5/9/23 admission MDS CAA indicated Resident 26 was frequently incontinent of bladder and…

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

Based on interview and record review it was determined the facility failed to maintain healthy parameters of nutritional status for 1 of 4 sampled residents (#129) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 129 was admitted to the facility in 2022 with diagnoses including muscle weakness, and vitamin D and B12 deficiencies. A 6/27/22 admission Observation revealed no concerns with dental, had upper and lower dentures, dentures were in good repair and in the resident's possession. Resident 129 had expressive dysphasia (affects speech and language output). The diet slip was sent to dietary and orders faxed to the pharmacy. A 7/4/22 admission MDS indicated Resident 129 had broken or loosely fitting dentures and weighed 158 pounds. The Nutritional CAA indicated the CAA was triggered because Resident 129 was potentially at risk for nutritional deficit because of weakness, confusion and pain. A care plan would be initiated because the resident was at potential risk for a nutritional deficits. Additionally the CAA referred the reader…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure residents were seen as required by a physician for 2 of 5 sampled residents (#s 20 and 24) reviewed for medications. This placed residents at risk for unmet medical needs. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses including falls and respiratory failure. Records revealed Resident 20 had in-person physician visits on 4/7/23, 5/5/23 and 7/14/23. The were no in-person physician visits in 6/2023. On 8/2/23 at 9:56 AM Staff 3 (Regional operations Education Director) confirmed resident 20 was not seen in-person by a physician in 6/2023. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses including depression. Record review revealed the resident did not see her/his physician within 40 days from time of admission. On 8/2/23 at 9:14 AM Staff 3 (Clinical Operations Education Director) confirmed Resident 24 was not seen by a physician within the required timeframe.

Based on interview and record review it was determined the facility failed to ensure residents were free of unnecessary psychotropic medications for 2 of 5 sampled residents (#s 5 and 18) reviewed for unnecessary medications. This placed residents at risk for receiving unnecessary psychotropic medication. Findings include: 1. Resident 5 was admitted to the facility in 2023 with diagnoses including neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), chronic congestive heart failure and conversion disorder with seizures (a condition causing physical and sensory problems such as paralysis, numbness, blindness, deafness or seizures with no neurologic pathology). Resident 5 had a long list of allergies which included many medications. The 5/11/23 Quarterly MDS revealed Resident 5 had a BIMS score of 14 indicating no cognitive impairment. The 7/2023 MAR revealed an entry for the medication sertraline (used to treat depression) 150mg with instructions to administer one capsule once a day with a…

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

Based on interview and record review it was determined the facility failed to ensure residents' food preferences were honored for 1 of 5 sampled residents (#129) reviewed regarding food preferences. This placed residents at risk for unmet dietary preferences. Findings include: Resident 129 was admitted to the facility in 2022 with diagnoses including muscle weakness, and vitamin D and B12 deficiencies. A 6/27/22 admission Observation and Notes revealed Resident 129's diet slip (a form to communicate physician prescribed dietary needs) was sent to dietary. A 6/27/22 through 11/27/22 review of Resident 129's clinical record found no documented food preference assessment. A 11/4/22 Physician Progress Note indicated on 10/27/22 and 10/28/22 Resident 129 expressed she/he did not like meat but was served warmed tuna fish for dinner. An undated diet card revealed Resident 129 was on a heart-healthy mechanical soft diet and was allergic to nuts and tuna. Resident 129 disliked all meats, corn, peas and green beans. On 7/31/23 at 2:42 PM Staff 12 (Dietary Manager) stated the facility normally…

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 3 of 8 sampled residents (#s 18, 26 and 129) reviewed for change of condition, dialysis and medications. This placed residents at risk for inaccurate care. Findings include: 1. Resident 26 was admitted to the facility in 2023 with diagnoses including acute kidney failure. a. On 7/24/23 at 1:43 PM Resident 26 stated she/he had one dialysis port that was not taken out and it was not working. Resident 26 reported she/he went to dialysis one time. Resident 26 stated she/he was in pain and had bruising from the procedure. On 7/25/26 6:54 AM Staff 8 (CNA) stated Resident 26 went to dialysis and was not in the facility. On 7/27/23 at 8:12 AM Staff 20 (CNA) stated Resident 26 was picked up at 4:45 AM every Tuesday, Thursday and Saturday for dialysis. On 7/27/23 at 8:24 AM a note was observed on a CNA clipboard at the nurses' station which indicated Resident 26 was transported to dialysis between 4:45 AM and 5:45 AM. On 7/28/23 at 2:04 PM Witness 6 (Dialysis…

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

Based on interview and record review it was determined the facility failed to ensure a hospice agreement was in place with a hospice provider for 1 of 1 sampled resident (#4) reviewed for hospice services. This placed the resident at risk for unmet hospice care needs. Findings include: Resident 4 was admitted to the facility in 2016 with diagnoses including dementia, Alzheimer's disease and muscle weakness. Resident 4's 2/19/23 Quarterly MDS revealed she/he received hospice services while she/he was a resident in the facility. Resident 4's revised 5/30/23 Care Plan revealed she/he received hospice services with a start date of 5/15/21. There was no evidence in the resident's record of a hospice agreement with the facility. On 7/26/23 at 1:03 PM Staff 2 (DNS) confirmed Resident 4 received hospice services and added hospice staff visited Resident 4 weekly. On 7/26/23 at 2:45 PM Staff 1 (Administrator) stated the facility did not have a hospice contract, but Resident 4 received Hospice services at the facility for two years.