Chehalem Post Acute

Based on interview and record review it was determined the facility failed to ensure performance reviews were completed at least once every 12 months for 3 of 3 CNAs (#s 29, 30 and 31) reviewed for staffing. This placed residents at risk for a lack of care by competent staff. Findings include: Annual performance reviews and hire dates were requested on 3/25/25 and 3/28/25 from Staff 2 (DNS) for the following staff: -Staff 29 (CNA),hired on 6/12/23. -Staff 30 (CNA), hired on 9/12/22. -Staff 31 (CNA), hired on 4/10/84. No annual performance reviews were submitted to the survey team. On 3/25/25 at 1:47 PM and 3/28/25 at 9:00 AM Staff 2 acknowledged Staff 29, Staff 30 and Staff 31 worked at the facility for over one year and did not receive an annual performance reviews in the past 12 months.

Based on interview and record review it was determined the facility failed to obtain and administer medication to residents timely to ensure the provision of routine medications for 10 of 17 sampled residents (#s 15, 22, 33, 34, 35, 44, 53, 62, 166, 167) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 22 admitted to the facility in 2018 with diagnoses including alcohol dependence and osteoarthritis. a. A 3/15/25 physician order indicated the use of trazodone for sleep related to alcohol dependence. A 3/18/25 progress note by Staff 12 (CMA) indicated trazodone was ordered and would arrive in the pharmacy delivery. Review of the 3/2025 MAR revealed Resident 22 was not administered trazodone until 3/20/25 (five days after the order date). On 3/21/25 at 8:23 AM Staff 11 (CMA) stated Resident 22 did not have trazodone for three or four days. Staff 11 stated the resident received the medication only after contacting the pharmacy. On 3/25/25 at 10:07 AM Staff 12 (CMA) stated she contacted the pharmacy on 3/18/25 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 observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 1 of 3 medication carts and 1 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications. Findings include: The facility's 1/2023 Storage of Medications Policy specified the following: -The medication supply shall be accessible only to licensed nurses, pharmacy staff, and those lawfully authorized to administer medications such as medication aides. Medication carts, rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 1. On 3/24/25 at 12:12 PM a treatment cart was observed to be unlocked and unattended in the hallway near the nurses station. On 3/24/25 at 12:15 PM Staff 8 (LPN) returned to the treatment cart and stated she left the cart unlocked and unattended and the cart contained resident insulin, creams and other treatment supplies. On 3/24/25 at 1:09 PM Staff 2 (DNS) stated the expectation was for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed during meals for 2 of 3 halls reviewed for dining. This placed residents at risk for cross contamination. Findings include: The 8/1/24 Hand Hygiene Policy and Procedure indicates effective hand hygiene reduces the incidence of healthcare-associated infections. All members of the healthcare team will comply with current Centers of Disease Control and Prevention hand hygiene guidelines. The procedure included: 3. Hand hygiene is the primary means of preventing the transmission of infection and should be performed as soon as possible after hands become contaminated and frequently during the working day. The following is list of some situations that require hand hygiene: c. Before and after direct resident contact; f. Before and after eating or handling food; g. Before and after assisting a resident with meals; s. After handling soiled equipment or utensils; On 3/19/25 between 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 inform residents and/or resident's responsible party of the risks and benefits, and to ensure consent was obtained, for the use of psychotropic medications for 2 of 5 sampled residents (#s 22 and 30) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent of psychotropic medications. Findings include: 1. Resident 22 admitted to the facility in 2024 with diagnoses including anxiety. A 3/15/25 physician order indicated the use of trazodone for sleep disorder. Review of Resident 22's medical record revealed no indication the resident was informed of the risks and benefits of the medication. On 3/26/25 Staff 37 (Regional RN) acknowledged Resident 22 was not informed of the risks and benefits of the use of trazodone. 2. Resident 30 was admitted to the facility in 2/2025 with diagnoses including anxiety and post-traumatic stress disorder. Resident 30's 2/2025 MAR revealed the resident received Quetiapine fumarate (an antipyschotic medication) one time a day for anxiety.…

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

Based on observation, interview, and record review it was determined the facility failed to ensure resident rooms were clean and in good repair for 2 of 3 sampled residents (#s 37 and 54) reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Resident 37 admitted to the facility in 2023 with diagnoses including hemiplegia. a. On 3/19/25 at 10:22 AM Resident 37's shared bathroom was observed to have dried feces inside and outside the toilet bowl. The toilet also was observed to have splattered layers of caked on old feces between the seam of the bowl and tank. Splatters of feces were observed on the floor. Review of Resident Council notes revealed the following: - 1/2025 residents indicated issues with the bathrooms not being cleaned daily. - 2/2025 residents indicated confusion on which staff cleaned the bathrooms and toilets. On 3/19/25 at 10:22 AM Witness 4 (Family) stated the bathroom toilet was in the observed condition for about a day or two. Resident 37 stated she/he used the toilet that morning. On 3/19/25 at 11:08 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 interview and record review it was determined the facility failed to develop a person-centered comprehensive care plan related to bowel care for 1 of 1 sampled resident (#16) reviewed for constipation. This placed residents at risk for lack of personal preferences being honored. Findings include: Resident 16 admitted to the facility in 2018 with diagnoses including quadriplegia. Resident 16's revised 11/12/23 Care Plan indicated Resident 16 was incontinent of bowel related to quadriplegia and was at risk for constipation. Resident 16 received a bowel regimen that included medications and a suppository. Interventions included a bowel regimen including digital stimulation and suppository. On 3/19/25 at 11:51 AM Resident 16 stated nursing staff, mostly consisting of agency staff, tried to tell her/him when she/he could and coud not have a suppository and she/he was upset about it. On 3/25/25 at 9:31 AM Staff 22 (LPN) stated she was an agency nurse. Staff 22 stated when she worked with Resident 16 she was unaware the resident preferred a suppository instead of oral medications.…

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 32 (LPN) adhered to professional standards for medication management. This placed residents at risk for adverse side effects of medication. Findings include: Resident 39 admitted to the facility in 2023 with diagnoses including schizophrenia and major depressive disorder. The 2/2024 MAR indicated Resident 39 received escitalopram, also known as Lexapro (antidepressant) 20 mg once daily. The 3/4/24 provider note indicated I will half the dose of Celexa [also known as citalopram]. A review of the prior physician orders and 2/2024 MARs indicated Resident 39 did not receive Celexa prior to 3/4/24. The 3/4/24 Celexa order was transcribed by Staff 24 (LPN) and indicated 10 mg daily was set to start on 3/5/24 at 7:00 AM. The escitalopram was discontinued, and the reason documented was decrease to 10 mg. On 3/24/25 at 8:46 AM Staff 24 stated she often worked with Resident 39 and the resident often went back and forth with meds. Staff 24 stated she did not remember the 3/4/24 incident with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to clarify insulin orders with the physician, monitor and provide bowel medications as ordered and failed to identify medication discrepancies for 3 of 7 sampled residents (#s 22, 39 and 114) reviewed for medications. This placed residents at risk for not receiving medications. Findings include: 1. Resident 22 admitted to the facility in 2018 with diagnoses including congestive heart failure. The 9/2/24 care plan indicated Resident 22 was continent of bowel. Interventions included to record bowel movement patterns each day and to monitor for signs or symptoms of constipation related to opioid use. The care plan did not indicate any history of Resident 22 refusing bowel medication. A 10/2/24 physician order indicated the use of Milk of Magnesia as needed for no bowel movement after three days. Review of Resident 22's bowel record indicated no bowel movement from 2/26/25 to 3/1/25 (four days) and from 3/3/25 to 3/6/25 (four days). Review of…

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

Based on observation, interview and record review it was determined the facility failed to assess a resident's fall for 1 of 2 sampled residents (#53) reviewed for falls. This placed residents at increased risk for injury from falls. Findings include: Resident 53 admitted to the facility in 2024 with diagnoses including dementia. The 10/12/24 9:14 AM progress note indicated Resident 53 had an unwitnessed fall, and included, the CNA reported the fall to the nurse, vital signs were taken and within normal limits, Assessed the resident for injuries, skin intact and no signs of immediate bruising or injuries. Resident appeared to be confused. Neuro checks were started immediately. The resident was assisted by the nurse and CNA from the floor to [her/his] wheelchair. On 3/27/25 a request was made for the fall assessment for the 10/12/24 fall. On 3/28/25 at 12:28 PM Staff 2 (DNS) acknowledged a fall assessment was not completed for the 10/12/2 fall.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 of 6 sampled residents (#53) reviewed for unnecessary medication. This placed residents at risk for adverse side effects. Findings include: Resident 53 admitted to the facility in 2024 with diagnoses including dementia. The 2/24/25 physician order indicated Resident 53 was to receive the following: -lorazepam (antianxiety psychotropic medication) 0.25 mg every two hours PRN for anxiety and agitation. May not give within two hours of the morphine dose. -morphine sulfate (narcotic medicatin) give 0.25 ml every hour PRN for pain or shortness of breath. May not give morphine within two hours of the lorazepam dose. The 3/2024 controlled substance log indicated Resident 53 received the following medications: *3/21/25: -lorazepam at 9:42 AM and morphine at 9:48 AM. Both medications were signed as administered by Staff 11 (CMA). -lorazepam at 12:07 PM and morphine at 12:07 PM. Both medications were signed as administered by Staff 11.…

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

Based on interview and record review it was determined the facility failed to provide timely diagnostic services for 1 of 2 sampled residents (#164) reviewed for lab services. This placed residents at risk for undiagnosed care needs. Findings include: Resident 164 admitted to the facility in 2024 with diagnoses including diabetes. The 10/3/24 physician order indicated staff were to obtain a stool sample from the resident to rule out Clostridium Difficile (c-diff, a bacterial infection that can cause severe diarrhea). The 10/9/24 1:20 PM progress note by Staff 25 (RN) indicated Resident 164's stool sample was collected and picked up by the lab. On 3/25/25 at 11:55 AM Staff 25 stated Resident 164's stool sample was obtained initially after the 10/3/24 order was received and staff accidentally put another resident's name on it. Staff 25 stated due to the error, staff had to obtain another sample on 10/9/24, delaying the lab results. On 3/28/25 at 12:41 PM Staff 2 (DNS) acknowledged the physician order to obtain Resident 164's stool sample was received on 10/3/24 and the facility did…

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

Based on interview and record review it was determined the facility failed to notify the ordering physician of the results of a critical lab value for 1 of 2 sampled residents (#53) reviewed for accidents. This placed residents at risk for delayed treatment. Findings include: Resident 53 admitted to the facility in 2024 with diagnoses including dementia. On 10/9/24 labs were obtained, and the results were completed and reported to the facility the same day. The results indicated Resident 53 had a critical hemoglobin level of 5.8 g/DL (grams per deciliter) (normal reference range was 12.5-14.9 g/DL). It was noted on the lab report that a critical value was identified, and the facility was contacted, but there was no one available to take critical value. The 10/16/24 progress note indicated Resident 53 had abdominal pain and later had vomiting and absent bowel tones. The resident was transported to the hospital. The 10/16/24 4:57 PM progress note by Staff 2 (DNS) indicated a chart review was completed, and a critical lab value was in an unreviewed state. A call was placed to Staff 39…

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 administer a pneumococcal vaccine for 1 of 5 sampled residents (#24) reviewed for immunizations. This placed residents at risk for contracting communicable illnesses. Findings include: A review of the facility 9/1/2024 Influenza and Pneumococcal Immunizations policy indicated it was the policy of the center to offer the Influenza and Pneumococcal immunizations to residents in accordance with federal regulations and current CDC (Centers for Disease Control and Prevention) guidelines. Resident 24 was admitted to the facility in 6/2024 with diagnoses including diabetes and heart failure. A review of the 1/18/25 Quarterly MDS indicated Resident 24 was cognitively intact. A review of Resident 24's clinical record revealed an undated pending consent for Prevnar 20 (a type of Pneumococcal vaccination). On 3/26/25 at 1:33 PM and on 3/28/25 at 10:12 AM Staff 7 (Infection Preventionist) stated she recalled talking with Resident 24 in October or November 2024 to educate and offer a pneumococcal vaccination that 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 obtain resident representative consent for a Covid-19 vaccine for 1 of 5 sampled residents (#40) reviewed for immunizations. This placed residents at risk for a lack of informed education and consent and at risk for contracting communicable illnesses. Findings include: A review of the facility's 9/1/24 Covid-19 Vaccination policy and procedure indicated residents were offered recommended Covid-19 vaccinations upon admission and as eligible per CDC (Centers for Disease Control and Prevention) recommendations. Consent for approved vaccines were obtained prior to or at the time of vaccination. Resident 40 was admitted to the facility in 4/2023 with diagnoses including dementia and adult failure to thrive. A review of the 8/5/24 Quarterly MDS indicated Resident 40's cognition was severely impaired. A review of Resident 40's clinical record revealed Witness 5 (Family Member) was Resident 40's Power of Attorney and Healthcare Decision maker. A review of Resident 40's immunization list revealed on 10/16/24 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 advance written notice to a resident or their responsible party prior to a room change for 1 of 4 sampled residents (#10) reviewed for resident rights. This placed residents at risk for potential adjustment difficulties related to room changes. Findings include: Resident 10 was admitted to the facility in 8/2024, with diagnoses including dementia and visual disturbances. Resident 10 was also receiving hospice services. Resident 10's admission Record revealed Witness 4 (Family Member) was Resident 10's spouse and signed the consent to treat upon admission. Resident 10's census record revealed Resident 10 was moved from room [ROOM NUMBER]-2 to 21-2 on 10/30/24. On 12/26/24 at 9:10 AM, Witness 4 (family member) stated they entered the facility and were disturbed when Resident 10 was not in her/his room (17-2), there was just an empty bed. Witness 4 stated Resident 10's behavior and demeanor were more anxious and aggressive after…

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 when transferring for 1 of 4 sampled residents (#7) reviewed for accidents. This failure put residents at risk for injury. Findings include: Resident 7 admitted to the facility in 3/2019, with diagnoses including spinal fusion and anxiety. Resident 7's 5/1/24 care plan revealed Resident 7 required two-person assistance with a gait belt for transfers. The resident's care plan also revealed she/he frequently falsely accused staff. Resident 7's 5/10/24 Quarterly MDS indicated she/he was cognitively intact with a BIMs of 15. The facility's Fall Investigation initiated on 8/3/24 revealed the following: -On 8/3/24 Staff 10 (Agency CNA) attempted to transfer Resident 7 without a second staff member. -Staff 10 stated Resident 7 had told her/him that they were a one-person stand and pivot transfer. -Staff 10 attempted to transfer Resident 7, was unsuccessful, and returned Resident 7 to her/his bed and went to find help. - Resident 7 stated Staff 10 had dropped her/him on the floor. -…

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 the resident's right to be free from verbal and physical abuse by a resident for 1 of 7 sampled residents (#3) reviewed for abuse. This placed residents at risk for isolation. Findings include: Resident 3 admitted to the facility in 2024 with diagnoses including obesity. Resident 4 admitted to the facility in 2024 with diagnoses including dementia with behaviors. A 1/30/24 facility Event Summary Report indicated Resident 4 became easily agitated and was verbally aggressive. Common behaviors of Resident 4 included verbal aggression toward others and a history of yelling, cursing and kicking others. Resident 4 was noted to be often confused and was cognitively impaired. The report indicated Resident 3 was sitting near Resident 4 during an activity. Upon getting agitated, Resident 4 kicked Resident 3 in the left foot three times and yelled profanities at Resident 3. Both residents were separated and Resident 4 was escorted back to her/his room in the Memory Care Unit. The report concluded verbal 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 promptly respond to grievances and recommendations from the resident council for 2 of 2 months reviewed. This placed residents at risk for unresolved quality of life and care issues. Findings include: The 3/2019 Grievance Policy indicated the Activities Director or designee was to complete a grievance form when a global issue was raised at a resident council meeting. The form was to be given to the appropriate department head for follow up and a response. During a resident group meeting on 11/30/23 at 1:00 PM, residents stated facility staff did not consistently respond to suggestions and concerns offered by the resident council. Residents indicated they did not feel staff communicated with them effectively and did not feel fully informed of the actions taken in response to their concerns. Resident Council Minutes on 6/2023, 7/2023, 8/2023, 9/2023, 10/2023 and 11/2023 revealed the following resident issues with staff responses documented: -10/2023 Evening call lights taking 30 minutes, then staff…

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 3. On 11/27/23 at 12:27 PM Resident 37's room was observed to have a loose doorknob plate and a plastic kick plate on the front left edge of the door that was jagged, sharp and peeling away from the door. On 11/27/23 at 12:27 PM Witness 5 (Family Member) stated she was concerned about the loose doorknob plate and the plastic kick plate on the front left edge of the door that was jagged, sharp and peeling away from the door. She stated she complained to staff about the issues several times. On 11/28/23 at 12:26 PM Staff 15 (Maintenance Director) observed Resident 27's room and acknowledged the loose doorknob plate and plastic kick plate on the front left edge of the door was jagged, sharp and peeling away from the door. 4. On 12/4/23 at 12:00 PM the carpet in the hallways was observed to have dark brown or black spots throughout the facility. room [ROOM NUMBER] was observed to have a missing threshold in the doorway with frayed carpet and the carpet was observed to be frayed between the dayroom and hallway. 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 ensure sufficient staffing to meet resident care needs for 1 of 4 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 12/1/23 the facility provided lists of residents who: -Required assistance with eating: 4. -Required two-person assistance with transfers: 17. -Required mechanical lift with transfers: 14. -Required assistance with dressing: 31. -Required assistance with bathing: 29. -Required assistance with toileting: 32. -Residents who were incontinent: 27. -Had wandering behaviors: 4. -Had behavioral healthcare needs: 6. Interviews with residents revealed the following concerns: -On 11/27/23 at 9:56 AM Resident 8 stated she/he waited up to an hour for her/his call light to be answered. -On 11/27/23 at 11:01 AM Resident 21 stated she/he waited up to an hour for her/his call light to be answered. Resident 21 stated on one occasion she/he almost peed in my pants waiting for her/his call light to be answered and night shift was…

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

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports (DCSDR) were correct and complete for 15 of 27 days reviewed for staff postings. This placed residents and the public at risk for incorrect staffing information. Findings include: The Direct Care Staff Daily Reports from 11/1/23 through 11/27/23 revealed 15 days without census information included. Resident Census information was missing on the DCSDR for one or more shifts on the following dates: 11/1/23, 11/6/23, 11/9/23, 11/12/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/20/23, 11/21/23, 11/23/23, 11/24/23 A review of facility payroll records from 11/1/23 through 11/27/23 revealed inconsistencies with the DCSDR. Staff 1 (Administrator) acknowledged the missing census information on the DCSDR on 11/30/2023 at 10:34 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 2 of 2 treatment carts and 1 of 1 medication room, and failed to ensure medication carts were properly secured during a random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include: 1. On 12/1/23 at 12:26 PM two open, undated vials of Tuberculin (used for the testing in the diagnosis of Tuberculosis) were observed in the medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening. On 12/1/23 at 12:26 PM Staff 13 (LPN) acknowledged the two vials of Tuberculin were open and not labeled with an open date. 2. On 12/1/23 at 12:40 PM two open insulin glargine pens, and one open Lantus insulin vial were observed in the medication cart with no open dates. On 12/1/23 at 12:40 PM Staff 13 (LPN) acknowledged the two insulin glargine pens and one Lantus…

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 offer residents a menu to accommodate their preferences for 2 of 2 sampled residents (#s 8 and 10) reviewed for food choices. This placed residents at risk for not having food preferences honored and weight loss. Findings include: 1. On 11/27/23 at 9:56 AM Resident 8 stated she/he had a hard time getting a copy of the pre-printed menu. Resident 8 stated it sometimes took a few days to get a copy of the pre-printed menu. Resident 8 stated the menu and alternate menus were determined by the facility and she/he was not able to make individual food choices. On 11/27/23 at 2:27 PM Resident 10 stated she/he was served food items that she/he did not like and was not given a menu for individualized food choices. On 11/28/23 at 12:02 PM Staff 14 (CNA) stated some residents were given pre-printed menus and an alternate food menu was posted on the bulletin board near the nurses' station. Staff 14 stated if a resident did not want what was being served, staff had to go back to the kitchen and it took about ten minutes…

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 store and handle food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include: On 11/27/23 at 9:09 AM during the initial tour of the main kitchen the following were observed: Dry Storage: -Large dented can of pineapple tidbits on rack with non-dented cans. Walk-in refrigerator: -An uncovered and undated container of sliced cucumbers that appeared dry. -A covered tray of deviled eggs undated. -Four small covered bowls of salad undated. On 11/27/23 at 9:29 AM Staff 23 (Dietary Aide) confirmed the identified items were not appropriately covered and/or dated as they should have been. Staff 23 stated the deviled eggs were from Thanksgiving Day, 5 days prior. On 12/1/23 at 9:03 AM during a follow up tour of the kitchen, Staff 22 (Dietary Manager) stated it was her expectation food items were to be dated and covered as they were prepared.

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 recieved informed Advance Beneficiary Notification (ABN) information for 1 of 3 sampled residents (#44) reviewed for discharge. This placed residents at risk for financial hardship. Findings include: Resident 44 admitted to the facility on [DATE] with diagnoses including dementia. The 10/9/23 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 44's skilled days ended on 10/11/23. The resident's POA (Power of Attorney) was informed Resident 44's long-term care would begin 10/12/23. Review of Resident 44's medical record indicated the resident remained in the facility pending Medicaid. There was no further documentation indicating advance beneficiary information was provided to the resident's POA. On 11/29/23 at 9:12 AM Staff 16 (Social Services Director) stated Resident 44 was pending Medicaid and acknowledged the Resident's POA did not receive advance beneficiary information, including the daily cost if Medicaid…

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 the resident's right to be free from verbal abuse by a resident for 2 of 9 sampled residents (#s 14 and 35) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 34 admitted to the facility in 2022 with diagnoses including quadriplegia. Resident 14 admitted to the facility in 2022 with diagnoses including anxiety and obesity. The 12/6/22 admission MDS indicated Resident 14 was cognitively intact. Resident 35 admitted to the facility in 2023 with diagnoses including obesity. The 5/30/23 admission MDS indicated Resident 35 was cognitively intact. A 7/19/23 facility investigation indicated on the evening of 7/19/23 an altercation occurred between Resident 34 with Resident 14 and Resident 35. Staff indicated Resident 34 was outside the shared room of Resident 14 and 35. Resident 34 indicated to staff she/he wanted to get back into bed and was waiting. Staff informed Resident 34 she/he would be assisted once they were done assisting Resident 14 and Resident 35. 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 report the results of an abuse investigation to the State Survey Agency within five business day to the State Agency for 2 of 9 sampled residents (#s 21 and 201) for abuse. This placed residents at risk for continued abuse. Findings include: A 9/2/23 Facility Reported Incident for abuse involving a staff member potentially abusing Residents 21 and 201 was submitted to the State Survey Agency. On 9/12/23 the State Survey Agency emailed the facility and requested the abuse investigation. On 9/13/23 the facility emailed the completed investigation to the State Agency. On 12/4/23 at 12:11 PM Staff 1 (Administrator) acknowledged the facility investigation was not reported to the State Survey Agency within five working days.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 1 sampled resident (# 8) reviewed for insulin. This placed residents at risk for adverse side effects of medication. Findings include: Resident 8 admitted to the facility in 2023 with diagnoses including diabetes. The 9/29/23 physician order indicated Resident 8 was to receive NPH insulin 150 units twice daily. The 11/26/23 progress note indicated the morning nurse was unable to give the insulin due to it being unavailable. The 11/26/23 Diabetic Administration Record indicated Resident 8's CBG was 265 at 5:00 PM. There was no documented CBG for 8:00 AM. On 11/27/23 at 9:56 AM Resident 8 stated she/he did not receive NPH Insulin on the morning of 11/26/23 because the nurse could not find it. On 12/3/23 at 7:08 PM Staff 25 (LPN) stated she worked the morning of 11/26/23 and Resident 8's insulin was not available in the treatment cart or the facility emergency kit. Staff 25 stated she called the pharmacy to have it sent stat, but there was a delay, and it 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 ensure residents received appropriate care and services for a feeding tube for 1 of 1 sampled resident (#42) reviewed for feeding tubes. This placed residents at risk for complications related to the use of a feeding tube including infection. Findings include: Resident 42 was admitted to the facility in 7/2023 with a PEG tube in place (tube feed) and diagnoses including stroke and dysphagia (difficulty swallowing). According to the 6/2014 National Library of Medicine, the PEG tube (a feeding tube placed in your stomach held by a balloon that is inflated with sterile water), along with T-tacks (buttons on the exterior skin that help hold the stomach up against the abdominal wall) was inserted during the resident's 7/7/23 hospitalization for dysphagia secondary to stroke based on the resident's lack of ability to safely consume fluids. A 7/7/23 hospital discharge summary stated the T-tacks were to be removed at an outpatient clinic in four weeks. The clinic's phone number was provided for the facility 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 observation, interview and record review it was determined the facility failed to ensure a CPAP (Continuous Positive Airway Pressure, assists to keep breathing airways open while sleeping) mask was in good repair for 1 of 1 sampled resident (#14) reviewed for respiratory care. This placed residents at risk for lack of respiratory care. Findings include: Resident 14 admitted to the facility 2022 with diagnoses including sleep apnea. A 6/28/23 physician order indicated Resident 14's CPAP mask was to be checked for damage and/or non-function. The 8/4/23 Care Plan indicated Resident 14 had difficulty breathing related to sleep apnea. The goal was for the resident to have no signs of poor oxygen absorption. On 11/27/23 at 8:18 AM the front of Resident 14's CPAP mask was observed to be held together entirely with layers of white surgical tape. A portion of the front mask tubing was broken off. On 11/27/23 at 8:19 AM Resident 14 stated she/he needed help getting medical equipment. The resident stated her/his CPAP mask strap was broken and she/he had asked for a new one for months.…

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 narcotic drug records were accurate for 1 of 1 sampled resident (#28) reviewed for narcotic medication. This placed residents at risk for inaccurate clinical records related to narcotics and drug diversion. Findings include: Resident 28 was admitted to the facility in 2023 with diagnoses including hypertension. The 1/11/23 physician order indicated Resident 28 was to receive the following: -oxycodone 5 mg twice daily for pain; -oxycodone 5 mg every 24 hours PRN pain. The 6/2023 MARs and narcotic logs were reviewed, and the following discrepancies were noted: -On 6/3/23 oxycodone 5 mg was signed out on the narcotic log but not on the MAR. -On 6/12/23 oxycodone 5 mg was signed out on the narcotic log but not on the MAR. -On 6/16/23 oxycodone 5 mg was signed out as administered at 12:01 AM and 5:00 PM on the narcotic log but not on the MAR. The MAR indicated oxycodone was administered at 10:26 PM but it was not documented on the narcotic log. -The narcotic log indicated oxycodone 6/_/23 was…

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

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were considered for 2 of 5 sampled residents (#s 4 and 12) reviewed for medication. This placed residents at risk for unnecessary medication. Findings include: 1. Resident 12 admitted to the facility in 2018 with diagnoses including depression and insomnia. A physician order dated 10/16/22 indicated the use of bupropion (antidepressant) every morning and at bedtime. A pharmacy recommendation completed between 11/1/23 and 11/3/23 for Resident 12 indicated a recommendation to administer Wellbutrin (bupropion) twice daily with at least eight hours apart, the last dose no later than 5:00 PM to help reduce the risk of insomnia. A review of Resident 12's medical record revealed no documentation of a physician response or consideration of the pharmacy recommendation. A review of Resident 12's 11/2023 MAR indicated the resident received bupropion in the morning and at bedtime. Resident 12 received bupropion after 5:00 PM on 18 occasions. On 11/30/23 at 11:04 AM Staff 7 (Regional…

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's use of Dilantin (seizure medication) was monitored for toxicity levels for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for adverse medication side effects and toxicity. Findings include: Pfizer, the manufacturer of Dilantin (phenytoin) recommended: Therapeutic drug monitoring of phenytoin is necessary to ensure therapeutic and nontoxic levels. Resident 4 was readmitted to the facility in 6/2021 with diagnoses including epilepsy (a seizure disorder) and a stroke. Resident 4's 10/18/23 Quarterly MDS did not contain a BIMS score. Resident 4 resided in the Memory Care Unit. Resident 4's 11/2023 MARs revealed: Dilantin (phenytoin) oral suspension 125mg/5ml. Give 5 ml by mouth every morning and at bedtime related to epilepsy. There was no order for serum blood work to monitor Dilantin levels. Resident 4's 11/2023 Care Plan indicated the resident had impaired cognition and had epilepsy managed by anticonvulsant medications. The Care Plan…

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 a medication error rate of less than 5 percent. There were three errors in 25 opportunities resulting in a 12 percent error rate for 1 of 2 sampled residents (#12) reviewed for medication administration. This placed residents at risk for adverse medication side effects. Findings include: Resident 12 was readmitted to the facility in 11/2023 with diagnoses including Quadriplegia and Chronic Obstructive Pulmonary Disease (COPD). The 11/25/23 physician orders included the following: -Advair Diskus Inhalation Aerosol Powder (asthma medication) 250-50 MCG/ACT. One puff inhale orally two times a day related to COPD. Rinse mouth after every use. -Lidocaine External Patch 5%. Apply to right neck topically one time a day for pain. Leave on for 12 hours, then off for 12 hours. -Movantik (treat constipation caused by opioids) Oral Tablet 25 MG. Give 1 tablet by mouth one time a day related to Gastro-Esophageal Reflux Disease (GERD). Give before breakfast. On 12/1/23 at 9:40 AM Staff 31 (CMA) 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 complete laboratory monitoring as ordered for 1 of 1 sampled resident (#37) reviewed for lab orders. This placed residents at risk for worsening conditions. Findings include: Resident 37 admitted to the facility in 2023 with diagnoses including stroke. The 4/11/23 physician order indicated Resident 37 was to have a urinalysis with culture completed for possible UTI. The 4/11/23 TAR indicated Staff 8 (LPN) obtained the urinalysis at 10:06 PM. The 4/24/23 facility investigation indicated Staff 8 documented a urinalysis was completed on 4/11/23 for Resident 37, but he did not collect the urinalysis. On 11/28/23 at 3:03 PM Staff 8 stated he recalled working with Resident 37 on 4/11/23. Staff 8 stated he did not collect a urinalysis for Resident 37, but documented it as completed. On 12/1/23 at 2:31 PM Staff 1 (Administrator) acknowledged Staff 8 documented a urinalysis was completed on 4/11/23 for Resident 37, but he did not collect the urinalysis.

Based on interview and record review it was determined the facility failed to ensure records were accurate and complete for 1 of 1 sampled resident (#37) reviewed for lab orders. This placed residents at risk for inaccurate medical records. Findings include: Resident 37 admitted to the facility in 2023 with diagnoses including stroke. The 4/11/23 physician order indicated Resident 37 was to have a urinalysis with culture completed for possible UTI. The 4/2023 TARs indicated Staff 8 (LPN) obtained the urinalysis at 10:06 PM. The 4/24/23 facility investigation indicated Staff 8 documented a urinalysis was completed on 4/11/23 for Resident 37, but he did not collect the urinalysis. On 11/28/23 at 3:03 PM Staff 8 stated he recalled working with Resident 37 on 4/11/23. Staff 8 stated he did not collect a urinalysis for Resident 37, but documented it as completed. On 12/1/23 at 2:31 PM Staff 1 (Administrator) acknowledged Staff 8 documented a urinalysis was completed on 4/11/23 for Resident 37, but did not collect the urinalysis. Staff 1 acknowledged the medical record was inaccurate.

1. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of potentially hazardous microorganisms. This placed residents at risk for water borne infections. Findings include: On 10/18/22 at 1:51 PM Staff 4 (Maintenance Director) was asked about the facility's water management program including a risk assessment related to potential areas of Legionella growth. Staff 4 stated he was not aware of a program. A few minutes later, Staff 4 showed the surveyor blank pages of a potential water management program and stated he would talk with Staff 1 (Administrator) to determine if there was a developed and implemented system. On 10/18/22 at 2:14 PM Staff 4 confirmed the facility did not have a developed and implemented water management program. On 10/21/22 at 9:20 AM Staff 2 (DNS) and Staff 13 (Corporate Operations) were informed of the lack of a facility water management program. No further information was provided. 2. Based on interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure the building was maintained in good repair for 12 of 40 resident rooms (#s 17, 20, 29, 30, 35, 36, 39, 40, 41, 42, 43 and 44) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: Observations on 10/17/22 and 10/18/22 revealed the following: - rooms 17, 36, 40, 42, and 43 had wall damage with exposed sheetrock; - rooms 20, 39, 44 and the window outside Staff 16's (RNCM) office had blinds with missing or damaged slats; - rooms [ROOM NUMBERS] had missing or damaged floor tiles in the path of ambulation; - and rooms [ROOM NUMBERS] had large stains or uncleaned areas on the floor. On 10/19/22 at 12:30 Staff 4 (Maintenance director) confirmed the floors, walls and blinds needed repair or replacement and had known that for a while. 2. On 10/17/22 at 10:57 AM Resident 29's room floor was observed to be sticky and dirty in the area from the right side of the resident's bed to the wall…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled residents (# 29) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 29 was admitted to the facility in 2018 with diagnoses including diabetes and stroke. The facility Self-Administration of Medications policy and procedure, last revised 3/2020, stated the following: -Medications at beside are stored in closed, locked cupboards or drawers. This includes over the counter medications. -No medications are stored at beside nor self-administered until an evaluation is complete. -A physician order is obtained indicating the specific medications the resident is able to self-administer. Observations from 10/17/22 through 10/21/22 between the hours of 8:00 AM through 3:30 PM revealed Resident 29 had unsecured eye drops on the beside table or sitting on a stack of boxes in the corner of her/his room. Resident 29 was also…

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

Based on interview and record review it was determined the facility failed to follow physician orders related to insulin for 1 of 5 sampled residents (#29) reviewed for unnecessary medications. This placed residents at risk for low blood sugar. Findings include: Resident 29 was admitted to the facility in 2018 with diagnoses including diabetes and stroke. A 1/11/22 physician order indicated Resident 29 was prescribed Humalog 10 units subcutaneously in the evening. Hold for CBGs less than 120 or if resident consumes less than 50% of meal. Give an additional PRN dose if glucose is greater than 300; notify provider if glucose is greater than 400. An 8/20/22 physician order indicated Resident 29 was prescribed Humalog 8 units subcutaneously one time a day. Hold for CBGs less than 120. Call the medical provider if CBG is less than 90. (This insulin was scheduled for AM administration.) A review of Resident 29's 9/2022 and 10/2022 Diabetic Administration Records (DARs) indicated the following times when the resident received Humalog insulin when the resident's blood sugars were less than…

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 accurately and consistently assess a pressure ulcer for 1 of 2 sampled residents (#11) reviewed for pressure ulcers. This placed residents at risk for worsening or delayed healing of pressure ulcers. Findings include: CMS Appendix PP revision 207 dated 9/30/22 defined the following: - Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. - Eschar is dead…

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 resident care equipment was maintained in safe operating condition for 2 of 6 residents (#s 13 and 29) reviewed for environment. This placed residents at risk for accidents. Findings include: 1. On 10/17/22 at 1:06 PM Resident 13 was observed speaking to Staff 20 (Dietary Manager). Resident 13 stated her/his wheelchair was broken, told everyone her/his wheelchair was broken, but was told maintenance did not repair wheelchairs. Resident 13 further stated the exercise bike in the therapy department was also broken and maintenance could not repair that either. On 10/17/22 at 1:46 PM Resident 13's wheelchair was observed and the material on the back of the wheelchair was torn. On 10/18/22 at 5:29 PM Staff 18 (Director of Rehab) stated she made the facility aware of the broken exercise machine on 9/13/22 and 9/20/22, and her staff made Staff 4 (Maintenance Director) aware on 9/20/22. On 10/20/22 at 1:05 PM Staff 4 stated all facility staff should have access to log a repair request in 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.