Avamere Rehabilitation Of Oregon City

Based on observation, interview and record review it was determined the facility failed to provide palatable food for 4 of 5 sampled residents (#s 3, 9, 12 and 13) reviewed for dietary services. This placed residents at risk for unmet nutritional needs. Findings include: Resident 3 was admitted to the facility in 6/2023 with diagnoses including unspecified severe protein-calorie malnutrition and Vitamin D deficiency. Resident 9 was admitted to the facility in 11/2024 with diagnoses including malnutrition and hepatic encephalopathy (a loss of brain function when a damaged liver doesn't remove toxins from the blood). Resident 12 was admitted to the facility 5/2024 with diagnoses including hypertension and chronic kidney disease. Resident 13 was admitted to the facility 1/2025 with diagnoses including diabetes and Vitamin D deficiency. On 1/9/24 at 12:20 PM, a test tray was delivered to two members of the survey team. The lunch tray consisted of chicken fried steak, mashed potatoes with gravy and cooked spinach. The lunch meal was not palatable. The chicken fried steak was tough 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's quality assessment and assurance committee (QAA) failed to implement and oversee appropriate plans of action to correct identified deficiencies related to: investigation of abuse, sufficient staffing, inaccurate daily staff postings, medication error rate and reference checks. This placed residents at risk for lack of quality of life and quality of care. Findings include: 1. A review of four residents for investigation of abuse revealed two were not thoroughly investigated. -This deficiency was also cited on the 1/13/23 recertification survey. 2. A review of 12 of 14 sampled residents (#s 2, 8, 10, 15, 19, 23, 26, 28, 33, 34, 42, 46, 157 and 259) and 3 of 3 halls reviewed for call light wait times and staffing revealed sufficient nursing staff was not provided to attain or maintain residents highest practicable level of well-being. -This deficiency was cited on the 1/13/23 recertification survey. 3. A review of the daily staff posting information revealed inaccurate daily staff postings. -This deficiency 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 for 4 of 5 sampled resident (#s 26, 34, 52 and 259) reviewed medications. This placed residents at risk for side effects and of lack medication efficacy. Findings include: 1. Resident 34 was admitted to the facility in 7/2023 with diagnoses including chronic heart failure and strain of the right quadriceps muscle and tendon. The 1/4/24 Annual MDS revealed Resident 34 had a BIMS score of 15, which indicated the resident was cognitively intact. A physician's order dated 1/25/24 directed staff to administer hydroxyzine (an anti-anxiety) every four hours for anxiety. Administration times were 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. A review of the 1/2024 MAR and the Medication Audit Report revealed the following: -1/27/24 8:00 AM dose was given at 11:13 AM (over three hours late). -1/27/24 12:00 PM was marked as given in the MAR however the Medication Audit Report did not show the medication was administered on 1/27/24 at 12:00 PM. -1/28/24 8:00 AM dose was given 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 the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 12 of 14 sampled residents (#s 2, 8, 15, 19, 23, 26, 28, 33, 34, 42, 46, and 157) and 3 of 3 halls reviewed for call light wait times and staffing. This placed residents at risk for delayed care. Findings include: 1.On 2/5/24 the facility provided lists of residents who: -Required assistance with eating: 10 -Required two-person assistance with transfers: 9 -Required a mechanical lift for transfers: 22 -Required assistance with dressing: 45 -Required assistance with bathing: 39 -Required assistance with toileting: 33 -Residents who were incontinent: 33 -Had wandering behaviors: 1 -Had behavioral healthcare needs: 2 Interviews with residents revealed the following concerns: On 2/5/24 at 9:05 AM Resident 2 indicated call light response wait times were a concern and were ongoing as far back as…

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 CNAs received annual performance reviews for 4 of 5 randomly selected CNA staff (#s 19, 21, 22 and 23) reviewed for staffing. This placed residents at risk for lessened quality of care. Findings include: Performance reviews were requested on 2/12/24 for Staff 19 (CNA), Staff 21 (CNA), Staff 22 (CNA), and Staff 23 (CNA). Staff 1 (Administrator) was unable to produce the documentation. On 2/13/24 at 1:15 PM Staff 1 acknowledged Staff 19, Staff 21, Staff 22, and Staff 23 annual performance reviews were not completed.

Based on observation, interview, and record review it was determined the facility failed to ensure the Direct Care Daily Staff Reports (DCSDR) were accurate for 79 of 188 days reviewed for staffing. This placed residents and the public at risk for lack of knowledge of accurate staffing. Finding include: A review of the DCSDR from 7/1/23 through 7/31/23, 8/1/23 through 8/31/23, 9/1/23 through 9/30/23, 10/1/23 through 10/31/23, 11/1/23 through 11/30/23 and 1/1/24 through 2/4/24 revealed 79 instances where the actual number of RNs working was not recorded accurately. On 2/9/24 at 2:02 PM Staff 38 (Staffing Coordinator) and Staff 39 (Business Office Manager and Human Resources) indicated they did not realize they were to include all RNs on the DCSDR. On 2/13/24 at 1:15 PM Staff 1 (Administrator) confirmed the DCSDR did not reflect the actual count of RNs working and those available to staff.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 21, 22, and 23) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: - Staff 21 (CNA) received 6.5 hours of annual training. - Staff 22 (CNA) received 7.0 hours of annual training. - Staff 23 (CNA) received 3.0 hours of annual training. On 2/13/24 at 1:15 PM Staff 1 (Administrator) confirmed Staff 21, Staff 22 and Staff 23 lacked the required 12 hours of in-service training.

Based on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#33) reviewed for self-administration of medications. This placed residents at risk for adverse side effects. Findings include: Resident 33 was admitted to the facility in 2023 with diagnoses including respiratory failure. On 2/7/24 at 12:35 PM Resident 33 was observed to have a bottle of lidocaine (anesthetic) lotion on her/his bedside table. Resident 33 stated she/he applied the lotion to her/his rashes to help reduce her/his pain. A review of Resident 33's medical record did not reveal a self-administration of medication assessment was completed. On 2/8/24 at 12:38 PM Staff 4 (LPN-RCM) acknowledged Resident 33 had lidocaine lotion in her/his room and a self-administration of medications assessment was not completed for the resident.

Based on interview and record review it was determined the facility failed to ensure residents received written information in a manner they understand for 1 of 1 sampled residents (#24) and failed to follow-up regarding advance directives for 2 of 5 sampled residents (#s 15 and 42) reviewed for advance directives. This placed residents at risk for not having their health wishes honored. Findings include: 1. Resident 24 was admitted to the facility in 2023 with diagnosis including cancer. A 6/24/23 admission MDS indicated Resident 24 was Spanish speaking with limited English. A 12/6/23 Care Conference Progress note indicated Resident 24 was able to answer simple questions, but was unable to understand more complex ideas. On 2/12/24 at 11:35 AM, with the assistance of an interpreter, Resident 24 stated she/he was not aware of an advance directive being offered. On 2/12/24 at 2:42 PM Staff 7 (Social Service Director) stated Resident 24 was not given paperwork to formulate an advance directive in Spanish, a manner which she/he could understand. 2. Resident 15 was admitted to the…

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

Based on observation, interview and record review it was determined the facility failed to maintain adequate room temperatures for 1 of 1 resident (#156) reviewed comfortable environments. This placed residents at risk for uncomfortable environments. Findings include: Resident 156 was admitted to the facility in 2/2024 with diagnoses including back fracture. Resident 156's 2/4/23 BIMS assessment indicated the resident was cognitively intact. On 2/6/24 at 3:52 PM Resident 156 was in her/his room in bed with a shawl wrapped around her/his body talking with Staff 47 (PT). Resident 156 stated her/his room was freezing and she/he was always cold. Resident 156 stated she/he reported her/his concerns regarding the temperature of her/his room to multiple staff since the day she/he admitted to the facility, but her/his concern was not addressed. On 2/7/24 at 12:24 PM Resident 156 was in her/his room sitting in her/his wheelchair wearing a sweater. Resident 156 stated her/his room was freezing since she/he admitted to the facility, and one night she/he asked for four blankets to keep warm,…

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 drug records including narcotics were accurate for 1 of 1 sampled resident (#259) reviewed for medications. This placed residents at risk for inaccurate clinical records related to narcotics and drug diversion. Findings include: Resident 259 was admitted to the facility on 1/2024 with diagnoses including lumbar radiculopathy (inflammation of a nerve root in the lower back). A 1/25/24 admission MDS indicated Resident 259 had a BIMS score of 15, which indicated the resident was cognitively intact. On 2/7/24 at 3:04 PM Resident 259 stated Staff 20 (LPN) brought in the resident's gabapentin (nerve pain medication) and oxycodone (pain medication) at approximately 6:00 AM on 2/5/24. Resident 259 stated she/he refused the oxycodone because she/he did not need it at that time. Staff 20 stated he would destroy the oxycodone. Resident 259 stated she/he requested an oxycodone from Staff 42 (CMA) around 10:00 AM on 2/5/24 and asked if her/his oxycodone was destroyed from 6:00 AM. Staff 42 stated…

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

Based on interview and record review it was determined the facility failed to timely report an allegation of abuse and injury of unknown origin to the State Survey Agency for 2 of 4 sampled residents (#s 42 and 46) reviewed for abuse and accidents. This placed residents at risk for abuse and neglect. Findings include: 1. Resident 42 was admitted to the facility in 2023 with diagnoses including leg fracture. A Grievance document dated 10/20/23 revealed Resident 42 reported to Staff 44 (CNA) a male CNA was rough with her/him during care and she/he told the CNA to stop. Staff 44 indicated this was reported to Staff 45 (LPN). A Progress Note dated 12/8/23 indicated Resident 42 was heard screaming in her/his room. Staff 25 (LPN) entered the resident's room and saw two CNAs providing ADL care. Resident 42 was screaming for staff to stop but they continued. On 2/5/24 at 2:42 PM Resident 42 stated she/he experienced two episodes of care from CNA staff where she/he felt abused. The first episode two CNAs came into her/his room and were rough with her/him during cares, she/he yelled for 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.

Based on interview and record review it was determined the facility failed to investigate an allegation of abuse and injury of unknown origin for 2 of 4 sampled residents (#s 42 and 46) reviewed for abuse and accidents. This placed residents at risk for abuse and injuries. Findings include: 1. Resident 46 was admitted to the facility in 10/2023 with diagnoses including chronic kidney disease. Resident 46's 10/31/23 admission MDS indicated the resident was moderately cognitively impaired, had no upper or lower extremity impairment and required partial/moderate assistance when going from sitting to standing and with bed-to-chair transfers. Resident 46's 11/2023 ADL Task Form revealed the following: -From 11/1/23 through 11/23/23 the resident was noted to be independent to requiring substantial/maximal assistance when going from sitting to standing. On 11/24/23 and 11/25/23 the resident was dependent on staff to go from the sitting to standing position. -From 11/1/23 through 11/24/23 the resident was noted to be independent to requiring substantial/maximal assistance with bed-to-chair…

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 ongoing assessments of a skin condition for 1 of 1 sampled resident (#33) reviewed for skin conditions. This placed residents at risk for worsening skin conditions. Findings include: Resident 33 admitted to the facility on [DATE] with a diagnosis of heart failure. An 10/17/23 admission Data Base Evaluation indicated Resident 33 had open skin and redness under bilateral breasts and in the creases of the groin. A review of the resident's clinical record did not indicate any skin assessments or physician's order for wound treatment. On 2/5/24 at 10:25 AM Resident 33 stated she/he had open red areas under her/his breast and groin area. Resident 33 stated she/he used her/his own lidocaine powder because the areas were painful. On 2/8/24 at 12:16 PM Staff 4 (LPN-RCM) acknowledged Resident 33's skin assessment was completed on the admission Data Evaluation but no further skin assessments of the open red areas or physician's order 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 Based on observation, interview and record review it was determined the facility failed to ensure a significant change of condition assessment was completed for 1 of 3 sampled residents (#46) reviewed for accidents. This placed residents at risk for unmet care needs. Findings include: Resident 46 was admitted to the facility in 10/2023 with diagnoses including chronic kidney disease. Resident 46's 10/31/23 admission MDS indicated the resident was moderately cognitively impaired, occasionally incontinent of bladder and bowel and had no pressure ulcers. The MDS also indicated the resident required partial/moderate assistance with showers, upper and lower body dressing, personal hygiene and transfers and required substantial/maximal assistance with toilet hygiene. A 11/27/23 Progress Note revealed Resident 46 fractured her/his right femur and she/he was transferred to the hospital. Resident 46 was readmitted to the facility on [DATE] with diagnoses including fracture of the right femur and a Stage 3 pressure ulcer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to accurately code MDS assessments for 2 of 3 sampled residents (#s 2 and 33) reviewed for dental and pressure ulcers. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 2 was admitted to the facility in 2018 with diagnoses including Multiple Sclerosis and depression. An 10/14/23 Skin Incident Report revealed Resident 2 had a history of multiple old wounds to her/his buttocks region, and the skin was fragile. Staff 34 (LPN) was called into the room and determined the resident had some scant bleeding from a wound with two rounded mountain peak shapes that joined together in an oval pattern. The wound was approximately 4.0 cm x 1.5 cm, and the wound site exhibited full-thickness skin loss to the right gluteal area due to bowel incontinence, friction, and shearing. On 10/16/23 Staff 5 (RN-MDS Coordinator) inspected the wound and the wound appeared to be full-thickness skin loss caused by bowel…

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 comprehensive care plans for 2 of 3 sampled residents (#s 17, and 33) reviewed for dialysis and dental. This placed residents at risk for lack of ADL care needs. Findings include: 1. Resident 17 was admitted to the facility in 2022 with diagnoses including chronic kidney disease and received dialysis (a procedure to remove waste products from the blood when the kidneys stop working). Resident 17's Psychotropic Drug Use CAA dated 12/11/23 indicated Resident 17 had a long term use of Wellbutrin (used to treat depression) and hydroxyzine (used to treat anxiety). A review of Resident 17's clinical record revealed no comprehensive care plan was completed related to the resident's use of Wellbutrin and hydroxyzine. On 2/12/24 at 2:14 PM Staff 3 (RNCM) acknowledged Resident 17's comprehensive care plan did not include any information regarding the use of Wellbutrin and hydroxyzine 2. Resident 33 was admitted to the facility in 2023 with a diagnoses of atrial fibrillation (irregular heart rhythm) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to revise care plans and conduct person-centered care conferences for 2 of 5 sampled residents (#s 15 and 42) reviewed for care planning and care conferences. This placed residents at risk for unmet needs. Findings include: 1. Resident 15 admitted to the facility in 2023 with diagnoses including pressure ulcer and weakness. On 2/5/24 at 4:07 PM Resident 15 stated she/he had a care conference when she/he first admitted to the facility in 10/2023 but did not have another care conference. A 12/7/23 Comprehensive Plan of Care Review Included Staff 8 (Social Services Coordinator), Staff 4 (LPN-RCM) and Staff 11 (Activities Director). There was no mention Resident 15 or department managers were in attendance. On 2/13/24 at 10:47 AM Staff 2 (DNS) and Staff 12 (Regional RN) stated all care conferences should include the Resident or Resident Representative and the following department managers: Resident Care Manager, Dietary,…

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 facility staff failed to meet professional standards for medication administration for 2 of 2 unsampled residents (#s 13 and 37) and 1 of 1 sampled resident (#17) observed during medication administration. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 13 admitted to the facility in 2022 with diagnosis including diabetes. A 12/6/23 physician order indicated Resident 13 received Humalog (fast acting) insulin before meals. On 2/7/24 at 5:16 PM a student nurse supervised by Staff 25 (LPN) administered insulin to Resident 13. Resident 13 did not receive her/his evening meal until 6:41 PM. Staff 25 and the student nurse acknowledged the resident should have food within five to 15 minutes after administration of insulin and the meal was not provided to the resident within the appropriate timeframe. On 2/8/24 at 10:49 AM Staff 2 (DNS) stated she expected nurses to administer fast-acting insulin with a meal. 2. Resident 17 admitted to the facility in 2022 with diagnosis…

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 showers to maintain appropriate hygiene for 2 of 7 sampled residents (#s 8 and 34) reviewed for ADLs. This placed residents at risk for lack of showers and grooming. Findings include: 1. Resident 34 admitted to the facility in 7/2023 with diagnoses including chronic heart failure and strain of the right quadriceps muscle and tendon. A care plan dated 12/24/23 revealed Resident 34 required one to two person maximum assistance with bathing and to encourage independence with upper body hygiene. The 1/4/24 Annual MDS, revealed Resident 34 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of the Shower CNA Document Report Survey from 12/2023 through 2/2024 revealed the following: -Resident 34's showers were scheduled every Monday and Thursday evenings. 12/2023: Resident 34 had eight opportunities for showers. -12/4/23, 12/7/23, 12/11/23, 12/14/23, 12/8/23 and 12/21/23, but they were blank or had an x. -12/25/23 and 12/28/23 were marked with the 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 observation, interview, and record review it was determined the facility failed to ensure treatment and services to maintain vision abilities were provided for 1 of 1 sampled resident (#1) reviewed for vision. This placed residents at risk for impaired vision. Findings include: Resident 1 was admitted to the facility in 2020 with diagnoses including chronic heart failure and hypertension. A Grievance Communication Form dated 12/29/23, revealed Resident 1 was upset because she/he was not scheduled for an eye appointment. On 1/4/24 Staff 7 (Social Service Director) contacted the clinic and learned Resident 1 asked to schedule her/his own eye appointments. Staff 7 spoke with Resident 1 about the call with the clinic and Resident 1 stated she/he would alert Staff 7 if she/he needed any assistance. A Quarterly MDS dated [DATE] revealed Resident 1 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Random observations from 2/5/24 through 2/7/24 revealed the resident wore…

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 appropriate foot care for 2 of 2 sampled residents (#19 and 34) reviewed for foot care. This placed residents at risk for lack of nail care, pain, and increased infections. Findings include: 1. Resident 34 admitted to the facility in 7/2023 with diagnoses including chronic heart failure and strain of the right quadriceps muscle and tendon. The 1/4/24 Annual MDS revealed Resident 34 had a BIMS score of 15, which indicated the resident was cognitively intact. A Progress Note dated 1/8/24 revealed Staff 25 (LPN) delivered Resident 34's medications and the patient asked Staff 25 to trim her/his nails. Staff 25 filed her/his nails and the resident complained Staff 25 did not cut or file them short enough. Staff 25 explained her/his nails were too thick to be cut and she/he needed a podiatry appointment. On 2/5/24 at 3:50 PM Resident 34 stated her/his toenails were long and thick and she/he wanted her/his nails trimmed. Resident 34 stated her/his concern to staff but no one made a podiatry…

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 a restorative program to prevent further decline in range of motion as ordered for 1 of 1 sampled resident (#3) reviewed for ROM. This placed residents at risk for decline in their range of motion abilities. Findings include: Resident 3 admitted to the facility in 2013 with diagnoses including Multiple Sclerosis. On 2/5/24 at 10:18 AM Resident 3's was observed with her/his right upper extremity tightly held against her/his body. Resident 3 stated the facility did not do any ROM to her/his arms or leg and it upset her/him. On 2/7/24 at 9:19 AM Staff 19 (CNA Restorative Aide) stated Resident 3 was previously on restorative services but no longer received restorative services and CNAs were responsible to provide ROM for Resident 3. Staff 19 stated CNAs were expected to complete ROM for Resident 3 which included upper and lower extremities and was implemented several months ago. On 2/7/24 at 9:32 AM Staff 22 (CNA) stated ROM was completed by Staff 19, not by the CNAs. Staff 22 stated she…

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 staff followed the care plan related to fall safety for 1 of 2 sampled residents (#46) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 46 was readmitted to the facility in 12/2023 with diagnoses including fracture of the right femur. Resident 46's 1/11/24 Falls Care Plan indicated the resident was to have fall mats to the bilateral sides of her/his bed. Resident 46's 1/31/24 Quarterly MDS revealed the resident was severely cognitively impaired, required substantial/maximal assistance from staff with transfers and experienced two or more falls since her/his prior assessment. Observations of Resident 46 on 2/6/24 at 3:40 PM, 2/7/24 at 3:15 PM and 2/8/24 at 3:10 PM revealed the resident to be in her/his room in bed. No fall mat was observed on the floor on the resident's left side. On 2/9/24 at 11:23 AM Staff 25 (LPN) stated Resident 46 was considered at risk to fall. Staff 25 further stated the resident required a fall mat when she/he was in…

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

Based on observation, interview and record review it was determined the facility failed to follow physician orders related to oxygen and BiPAP (breathing support through a face mask) administration for 1 of 1 sampled resident (#33) reviewed for respiratory care. This placed residents at risk for difficulty breathing. Findings include: Resident 33 admitted to the facility in 2023 with diagnoses including heart failure and respiratory failure. The 10/2023 TAR revealed the resident required continuous oxygen at two liters when not using her/his BiPAP machine. -The 1/2024 TAR indicated the resident was to have a humidifier connected to her/his oxygen concentrator and indicated Resident 33 was to wear her/his BiPAP machine while sleeping with four liters of oxygen connected to the machine. Random observations from 2/5/24 through 2/8/24 on day and evening shifts revealed Resident 33 not wearing oxygen continuously and there was no humidifier connected to the oxygen concentrator. On 2/8/24 at 12:38 PM Resident 33 stated staff did not place her/his oxygen on when her/his BiPAP machine 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.

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 appropriate and timely pain management for 1 of 4 sampled residents (#156) reviewed for pain. This placed residents at risk for experiencing pain. Findings include: Resident 156 admitted to the facility in 2/2024 with diagnoses including back fracture and restless leg syndrome (a condition that causes discomfort in the legs and a strong urge to move the legs, especially at night and when sitting or lying down, and can disrupt sleep). Resident 156's 2/4/24 BIMS revealed the resident was cognitively intact. Resident 156's 2/4/24 Vitals and Pain Only Evaluation revealed the resident experienced constant pain over the last five days in her/his lower back. The resident rated her/his pain as moderate (five out of 10 on a pain scale). Resident 156's SNF/ICF admission Orders directed the resident to receive the following: -acetaminophen, take two tablets every six hours; -ropinirole (used to treat symptoms of restless less…

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 the facility failed to ensure ongoing communication with the dialysis center for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 17 was admitted to the facility in 2022 with diagnoses including chronic kidney disease and was dependent on dialysis (a procedure to remove waste products from the blood when the kidneys stop working). Resident 17's care plan for renal failure dialysis, created on 12/2/24, indicated the resident's scheduled dialysis days were Tuesday, Thursday, and Saturday. A dialysis communication form was reviewed and indicated the facility was to complete the section for Resident 17s last recorded weight, current blood pressure, any concerns, and the nursing staff signature and date. The dialysis center was to complete the section for pre and post dialysis weights, labs performed, treatment provided (medication given), problems, date, and signature. The facility staff was to complete blood pressure, pulse, respirations,…

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%. There were 3 errors in 26 opportunities resulting in an 11.54% error rate. This placed residents at risk for adverse medication side effects. Findings include: A 2/1/24 Mayo Clinic Insulin Administration document included: -Inject Humalog rapid acting insulin within five to 10 minutes before or after a meal -Inject NPH intermediate acting insulin 30 to 45 minutes before a meal 1. Resident 13 was admitted to the facility in 2022 with diagnosis including diabetes. A 12/6/23 physician order indicated Resident 13 to receive Humalog (fast acting) insulin before meals. On 2/7/24 at 5:16 PM a student nurse supervised by Staff 25 (LPN) administered insulin to Resident 13. Resident 13 did not receive her/his evening meal until 6:41 PM. Staff 25 and the student nurse acknowledged a meal was not provided to the resident within the appropriate timeframe. On 2/8/24 at 10:49 AM Staff 2 (DNS) acknowledged nurses should give fast-acting insulin with a meal.…

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 dental services to meet resident needs for 1 of 1 sampled resident (#33) reviewed for dental. This placed residents at increased risk for decline in oral health. Findings include: Resident 33 admitted to the facility in 2023 with diagnosis including heart failure. On 2/5/24 at 10:32 AM Resident 33 stated she/he recently spoke with a nurse regarding her/his missing and loose teeth which bothered her/him, she/he wanted a dental appointment, but did not receive any response to the request. Resident 33's 10/17/23 admission Data Base indicated Resident 33 had no missing teeth. Resident 33's 10/21/23 admission MDS indicated the resident had all natural teeth without impairments. A 10/30/23 SLP evaluation indicated Resident 33 had missing left and right molars and a loose molar. On 2/8/24 at 12:06 PM Staff 4 (LPN-RCM) indicated when a resident or staff member notified her an appointment was needed for a resident she notified Social Services. On 2/8/24 at 2:41 PM Staff 7 (Social Service Director)…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents received adaptive utensils for 1 of 7 sampled resident (#16) reviewed for ADLs. This placed residents at risk for unmet care needs and weight loss. Findings include: Resident 16 was admitted to the facility in 2013 with diagnoses including dementia. On 2/7/24 at 11:48 AM Resident 16 was observed in the assisted dining room with regular utensils. Resident 16's meal ticket indicated adaptive built-up silverware for all meals. On 2/7/24 at 11:50 AM Staff 19 (CNA Restorative Aide) stated the kitchen always forgot Resident 16's adaptive utensils and staff had to ask the kitchen for the adaptive utensils. On 2/7/24 at 1:20 PM Staff 10 (Dietary Manager) acknowledged the kitchen staff often forgot to place the adaptive utensils on the tray, but the facility was changing the meal ticket form which would make it easier for the kitchen staff to see/read the adaptive utensils on the meal tickets.

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 physical and occupational therapy services as ordered for 2 of 2 sampled residents (#s 8 and 49) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: The facility's 11/2005 Rehab Services Policy revealed a therapist will provide therapy upon written order of the resident's attending physician. 1. Resident 8 admitted to the facility in 12/2023 with diagnoses including stroke. Resident 8's 12/1/23 admission Orders directed the resident to receive skilled physical and occupational therapy. Resident 8's 12/6/23 Physician Orders revealed physical and occupational therapy to be provided as indicated. Resident 8's 12/10/23 admission MDS indicated the resident was cognitively intact, had lower extremity impairment and required substantial to maximal assistance with most transfers. The MDS indicated the resident 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 observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to attain and maintain the highest practicable wellbeing for 3 of 3 halls (100, 200 and 300 halls) reviewed for staffing. This placed residents at risk for lack of timely assistance for ADL care needs. Findings include: 1. On 1/8/23 at 1:03 PM Resident 298 stated she/he was new to the facility and staff were not timely with assisting her/him in bed when using her/his call light. Resident 298 stated she/he was scared because no one helped her/him timely. On 1/8/23 at 1:46 PM Resident 26 stated call lights were a concern and the wait time was from 15 minutes up to an hour to receive help to use the bathroom. Resident 26 stated one CNA was always on their phone and not attending to her/his ADL care needs. Resident 26 further started she/he did not always get her/his pain medications timely. On 1/8/23 at 2:12 PM Resident 3 stated she/he was dependent on staff for cares and there was not enough staff in the building to answer call lights timely. Resident 3 stated…

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

Based on observation and interview it was determined the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service for 1 of 1 kitchen reviewed. This placed residents at risk for delayed meals and cold food. Findings include: On 1/10/23 at 11:06 AM a sign on the kitchen door was observed stating Please hold all resident requests/needs/wants etc. until after tray service times. As soon as we are finished with tray service, we will reopen window to assist you. Times on the door for tray service indicated: Breakfast 8 AM, Lunch 12 PM, Dinner 5:15 PM. On 1/10/23 at 11:08 AM Staff 13 (Dietary Aide) stated she just started working in the kitchen 1/3/23 and there was one cook to serve meals for about 45 residents. Staff 13 was observed to be the only kitchen personnel. Staff 13 stated the cook was supposed to come in at 11 AM and the dietary manager had just left. On 1/10/23 at 11:57 AM Staff 12 (Cook) stated he just started his shift and not everything for lunch was prepped so he had to complete that prior to serving…

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 proper flavor, food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchens reviewed for food service. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include: 1. Resident 4 admitted to the facility in 10/2013 with diagnoses including multiple sclerosis (a progressive disease which damages the sheaths of nerve cells in the brain and spinal cord). On 1/9/23 at 1:05 PM Resident 4's lunch arrived which had popcorn shrimp on her/his plate and Resident 4 indicated the popcorn shrimp was cold and she/he did not like it. On 1/9/23 at 1:08 PM Staff 18 (CNA) stated Resident 4's meals were often cold and she/he would request an alternative meal because the meal was either cold or Resident 4 did not like the taste of what she/he originally ordered. On 1/10/23 at 12:46 PM Resident 4 was observed in bed and she/he was brought her/his meal which included enchiladas, rice and beans. Staff 31 (CNA) removed the lid…

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 kitchen equipment was clean, food was stored and labeled according to appropriate food handling guidelines, and all kitchen staff wore hairnets while working in for 1 of 1 kitchen reviewed. This placed residents at risk for cross-contamination and foodborne illness. Findings include: 1. On 1/8/22 at 10:44 AM initial kitchen tour observations revealed: *Two unopened containers of buttermilk with a use by date of 12/28/22. *A bag of opened pie crust dated 1/3 with the bag open to air. *Wilted lettuce in a bag open and undated in the fridge. *Coleslaw in an opened bag that was soggy on the bottom and undated in the fridge. *A new bag of freezer burned broccoli. *An opened container of undated and partially eaten pie in the freezer. On 1/8/23 at 10:52 AM Staff 12 (Cook) acknowledged the unlabeled and undated food items and stated the freezer-burned veggies came to them two days ago in that condition. Staff 12 agreed the food items were expected to be discarded. On 1/12/23 at 9:29 AM 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.

Based on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to implement and oversee appropriate plans of action to correct identified deficiencies related to: To bowel care, sufficient staffing, food procurement, sufficient staffing and CNA staffing ratios. This placed residents at risk for unmet needs. Findings include: 1. A review of five residents for bowel care revealed one was not provided appropriate bowel care. This deficiency was also cited on the 1/11/22 recertification survey. 2. A review of 3 of 3 Halls (100, 200 and 300 Hall) revealed sufficient nursing staff was not provided to attain or maintain residents highest practicable level of well-being. A review of minimum CNA staffing requirements were did not meet the minimum CNA ratios. This deficiency was cited on the 1/11/22 recertification survey. 3. A review of the daily staff posting information revealed inaccurate daily staff postings. This deficiency was also cited on the 1/11/22 recertification survey. 4. A review of one of one kitchen revealed the…

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

Based on interview and record review it was determined the facility failed to ensure resident council requests or grievances were followed up on for 1 of 1 Resident Council reviewed for grievances. This placed residents at risk for unaddressed needs. Findings include: On 1/9/23 at 12:00 PM resident council Notes were requested for any grievances or concerns regarding residents' care needs from 10/2022 through 12/2022. On 1/10/23 at 1:43 PM Staff 1 (Administrator) stated there were no resident council notes located for 10/2022 or 11/2022 which would address concerns regarding resident care needs. Staff 1 stated 12/2022 the resident council meeting was canceled due to a COVID-19 outbreak. Staff 1 stated the only resident council notes located were from 8/2022 and 9/2022. On 1/10/23 at 1:57 PM Resident 24 (Resident Council President) stated they had monthly meetings and concerns were reviewed and discussed at the resident council meetings. Resident 24 indicated conversations had been on-going regarding insufficient staffing, ADL care needs and dietary concerns. Resident 24 further…

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 an ongoing activities program designed to meet the individual interests and needs of residents for 4 of 5 sampled residents (#s 4, 13, 16, and 25) reviewed for activities. This placed residents at risk for diminished physical, emotional and psychosocial well-being. Findings include: 1. Resident 4 admitted to the facility in 10/2013 with diagnoses including multiple sclerosis (a progressive disease which damages the sheaths of nerve cells in the brain and spinal cord). A care plan revised on 10/29/13 revealed the following: - Staff were to invite Resident 4 to activities; preferred in room activities such as manicures, crossword puzzles, word searches and TV programs. - Resident 4 enjoyed playing bingo. - One-to-ones with staff, visitors and family. On 1/8/23 at 12:39 PM Resident 4 stated she/he preferred to stay in her/his room and never got out of bed. Resident 4 stated the facility had bingo but no other activities and she/he was not provided an activities calendar. Resident 1 stated…

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

Based on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for the facility. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include: On 1/10/23 at 10:39 AM Staff 5 (Activity Coordinator) stated she had been in the activities position since 8/2022 and was still figuring out what her responsibilities were. Staff 5 stated she had no official training, did not have an activities certificate but had assisted with activities in the past. On 1/12/23 at 1:13 PM Staff 1 (Administrator) stated Staff 5 had prior experience working in activities but did not have an activities certificate.

Based on observation, interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 18 out of 31 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information. Findings include: On 1/8/23 at 11:36 AM the Direct Care Staff Daily Report was observed and had 1/6/23 through 1/7/23 attached behind the 1/8/23 form. The forms were missing census, staff type and hours worked. On 1/8/23 at 3:30 PM the Direct Care Staff Daily reports were provided from 12/8/22 through 1/7/23 revealed 18 instances when portions of the form were left blank or were inaccurate. The incomplete or inaccurate information included census, number of staff working and number of hours worked. On 1/12/23 at 10:29 AM Staff 4 (HR/Payroll/Staffing Coordinator) acknowledged the Direct Care Staff Daily Report forms were inaccurate regarding staff, staff hours worked and census. Staff 4 stated the Direct Care Staff Daily Report form was to be completed by the nurse coming onto the next shift and the nurses were…

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

Based on observation, interview and record review it was determined the facility failed to develop a policy that identified staff responsible for monitoring the use and storage of food in resident personal refrigerators for 4 of 4 sampled residents (#s 1, 3, 4 and 12). This placed residents at risk for cross-contamination and foodborne illness. Findings include: A review of the December 2016 Facility Personal Food Storage Policy indicated personal room refrigeration units would be monitored by designated facility staff for food safety, perishable foods would be dated, and all units were to have internal thermometers to monitor safe food storage temperature. The policy did not indicate the staff designated. On 1/9/23 at 11:49 AM pre-packed Jell-O cups with an expiration date of 10/18/21 and pre-packaged mandarin oranges with an expiration of 12/20/21 were observed on the floor below a small personal refrigerator in Resident 12's room. Resident 12 stated she/he could not reach the refrigerator independently. Inside the refrigerator were four Jell-O cups which had an 10/18/21…

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

Based on observation, interview and record review it was determined the facility failed to ensure a resident received a recliner chair for 1 of 2 sampled residents (#26) reviewed for accommodation of needs. Findings include: Resident 26 admitted to the facility in 11/2022 with diagnoses including a pubic bone fracture. The 11/28/22 admission MDS indicated Resident 26 was cognitively intact and required extensive staff assistance with transfers. The 1/5/23 Physical Therapy Note indicated Resident 26 was still requesting a lift recliner to be installed in the room. On 1/8/23 at 1:50 PM Resident 26 stated she/he requested a recliner for easier transfers to the commode but had not received one. Resident 26 stated she/he spoke with Staff 10 (Physical Therapist) and the facility had an extra recliner but needed permission to put it in Resident 26's room. There was no recliner observed in Resident 26's room. On 1/9/23 at 12:16 PM Staff 10 stated she asked administrative staff to get Resident 26 a recliner for two weeks as the resident needed to be able to transfer from a recliner in order…

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 the facility failed to assist a resident with transportation to a medical appointment for 1 of 1 sampled residents (#98) reviewed for medical transportation. This placed residents at risk of not attending scheduled medical appointments. Findings include: Resident 98 was admitted to the facility in 11/22/22 with diagnoses including amputation and diabetes. Resident 98's hospital Skilled/Intermediate Nursing Facility Transfer Orders dated 11/22/22 included: - Schedule an appointment as soon as possible for a visit in one week. Please make the appointment with [the resident's surgeon] at [a specific office location]. A Transportation Request Checklist dated 11/23/22 indicated Resident 98 had a podiatry appointment scheduled for 12/7/22 with a different provider and location than what was ordered. The checklist also incorrectly indicated the resident was not diabetic and also indicated the resident required a wheelchair van for transportation but would be transported by Witness 3 (Family). A Progress Note dated 12/7/22 at 10:07 AM indicated Resident 98…

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 update the care plan for feeding assistance for 1 of 5 sampled residents (#25) reviewed for food. This placed residents at risk for unmet needs and aspiration. Findings include: Resident 25 admitted to the facility in 2018 with diagnoses including Alzheimer's disease. The 11/30/22 Quarterly MDS indicated Resident 25 was rarely/never understood and required extensive assistance with eating. The 11/2/21 Care Plan indicated the Resident 25 was at risk for aspiration and required 1:1 therapeutic dining assistance with all oral intake. The Care Plan instructed staff to ensure the head of the bed was elevated above 30 degrees, the resident took slow sips and bites, and had completed swallowing without pocketing food. There was no information indicating the resident's spouse (Resident 8) assisted Resident 25 with eating. On 1/8/23 at 11:42 AM Resident 8 stated she/he fed Resident 25 most of the time because the resident was less irritable and consumed more food when she/he assisted the resident. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to consistently document behaviors and update and implement care plan interventions to ensure residents with dementia maintained their highest practicable level of well-being for 2 of 4 sampled residents (#s 16 and 25) reviewed for dementia. This placed residents at risk for a lack of psychosocial well-being and increased behaviors. Findings include: 1. Resident 16 admitted to the facility in 2015 with diagnoses including dementia and anxiety. The 11/5/22 Annual MDS indicated Resident 16 was rarely/never understood and had memory deficits. The resident had physical, verbal and other behaviors multiple days during the seven-day look-back period. The 12/14/22 through 1/11/23 Behavior Task Sheet indicated the resident had behaviors including: crying, yelling/screaming, kicking/hitting, pushing, pinching/scratching/spitting, abusive language, grabbing, threatening behavior, and/or rejection of care 27 out of the 30 days reviewed.…

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 not administer a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#15) reviewed for unnecessary medications. This placed residents at risk for low blood pressure. Findings include: Resident 15 was re-admitted to the facility in 2020 with diagnoses including high blood pressure. Resident 15's physician's orders as of 1/11/23 included amlodipine besylate (treats high blood pressure) every day at bedtime and to hold the medication if the resident's systolic (the upper number in a blood pressure reading) blood pressure was less than 110. Resident 15's 1/2023 MAR revealed the amlodipine besylate was administered on 1/2/23, 1/3/23 and 1/4/23 when the resident's systolic blood pressure was less than 110. On 1/10/23 at 1:10 PM Staff 3 (Corporate Nurse Consultant) verified Resident 15 was administered amlodipine besylate on 1/2/23, 1/3/23 and 1/4/23 when the resident's systolic blood pressure was less than 110.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 4 sampled residents (#15) reviewed for medication administration. The facility had 12 errors out of 25 opportunities for an error rate of 48 percent. This placed residents at risk for adverse medication consequences. Findings include: The facility's Administering Medications policy revised 12/2012 indicated residents could self-administer their own medications only if the physician and the Interdisciplinary Care Planning Team determined the resident had the decision-making capacity to do so safely. Resident 15 was re-admitted to the facility in 2020 with diagnoses including dementia. Resident 15's physician's orders as of 1/11/23 included the following medications: - omeprazole (for heartburn) - calcitriol (for inflamed gall bladder) - calcium carbonate (antacid) - creon (for inflamed gall bladder) - Elequis (prevents blood clots) - hydroclorothiazide (treats high blood pressure) - imatinib mesylate (chemotherapy) - laratadine…

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 accommodate resident food preferences for 1 of 5 sampled residents (#25) reviewed for food. This placed residents at risk for weight loss. Findings include: Resident 25 admitted to the facility in 2018 with diagnoses including Alzheimer's disease. The 11/30/22 Quarterly MDS indicated Resident 25 was rarely/never understood and required extensive assistance with eating. On 1/10/21 at 12:50 PM Resident 25 was observed sitting up for lunch with staff present in the room. The resident's lunch tray was observed to have Mexican food including: rice, beans, and chicken mole. The meal card on Resident 25's tray indicated the resident disliked Mexican food. Staff 18 (CNA) verified the resident was brought food that was on her/his dislikes list and stated the resident often received the wrong food items. On 1/12/23 at 9:29 AM Staff 16 (Dietary Manager) acknowledged the food preference concern.