Gracelen Care Center

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 medication storage was free from expired biologicals for 1 of 1 medication rooms and treatment carts were locked and secured appropriately for 2 of 2 treatment carts observed (West Hall and East Hall) during random observations for medication and treatment cart storage and medication rooms. This placed residents at risk for unsafe access to stored medications and diminished treatment efficacy. Findings include:The facility's 11/2020 Storage of Medications Policy specified the following: - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1.On [DATE] at 11:15 AM, one open, vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) dated [DATE] was observed inside the refrigerator located in 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 observation, interview and record review it was determined the facility failed to perform hand hygiene for 1 of 1 sampled resident (#11) reviewed for wound care. This placed residents at an increased risk of infected wounds. Findings include:Resident 11 was admitted to the facility in 2025 with diagnoses including quadriplegia (partial or complete paralysis of all four limbs).The 2024 CDC Clinical Safety: Hand Hygiene for Health care workers specified the following:-Clean your hands immediately after glove removal to prevent the spread of germs and potential infections.A review of Resident 11's Quarterly MDS dated [DATE] indicated the resident was admitted with four pressure ulcers.A review of Resident 11's Annual MDS dated [DATE] indicated the resident acquired an in-facility pressure ulcer.A review of Resident 11's 7/2025 MAR indicated daily wound care to the sacrum (a bone at the base of the spine) and the right ischium (a bone forming the lower and back part of the hip bone) pressure ulcers.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 protect a resident's right to be free from mental abuse by staff for 1 of 5 sampled residents (#8) reviewed for abuse. This placed residents at risk for further mental abuse. Findings include: On 9/5/24 the State Survey Agency received a public complaint which alleged Resident 8 was spoken to rudely and threatened by a CNA. Resident 8 was admitted to the facility in 9/2024, with diagnoses including vascular dementia and a hip fracture. Resident 8's 9/9/24 admission MDS indicated she/he was cognitively intact. On 12/17/24 at 9:00 AM, Staff 5 (CNA) stated Staff 3 (CNA) stated to her and Staff 4 (CNA) tell Resident 8 that you will put them in a room by herself/himself with the door closed and no call light if Resident 8 was on the call light too much. Staff 5 stated Staff 3 informed them she knew Resident 8 from the hospital and saying those things worked there. Staff 5 stated they immediately reported to management. On 12/19/24 @ 8:03 AM, Staff 4 (CNA) stated Staff 3 (CNA) stated to her 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 document the basis for transfer and failed to include code and health status to the receiving provider for 1 of 3 sampled residents (#7) reviewed for hospitalization. This placed residents at risk for inaccurate health care. Findings include: Resident 7 was admitted to the facility in 8/2024, with diagnoses including traumatic brain injury and delirium. Resident 7's 10/3/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 7's medical record revealed no documentation to indicate the basis for the transfer and if appropriate information was communicated to the receiving hospital. There was no information demonstrating why the facility could not meet the resident's needs and whether the discharge was initiated by the resident or the facility. On 12/19/24 at 10:40 AM, Staff 1 (DNS) was informed of the findings of this investigation and acknowledged the discharge information was not documented in Resident 7's medical record.

Based on observation and interview it was determined the Dietary Manager failed to obtain the required certification to provide dietary management services for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: From 4/2/24 through 4/8/24 between the hours of 8:00 AM and 5:00 PM, Staff 33 (Dietary Manager) was observed providing Dietary Manager services in the facility kitchen. On 4/5/24 at 11:31 AM Staff 33 stated he had been the Dietary Manager since 4/2022 and had not completed the required certification required for his position as Dietary Manager. On 4/8/24 at 11:04 AM Staff 1 (Administrator) confirmed she was aware Staff 33 had not obtained the required certification.

Based on interview and record review it was determined the facility failed to ensure nursing staff competencies for 5 of 5 sampled staff (#s 14, 22, 23, 24 and 25) reviewed for competencies. This placed residents at risk for poor quality of care. Findings include: On 4/4/24 at 3:08 PM and 4/5/24 at 8:40 AM Staff 2 (DNS) and Staff 27 (Staffing Coordinator) were asked to provide evidence of staff competencies for Staff 14 (RN), Staff 22 (LPN), Staff 23 (LPN), Staff 24 (RN) and Staff 25 (RN). On 4/4/24 at 4:40 PM and 4/5/24 at 2:38 PM Staff 2 provided an incomplete competency review for Staff 14. Staff 1 (Administrator) and Staff 27 stated they did not have the requested competencies for Staff 22, Staff 23, Staff 24 and Staff 25. Refer to F880

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 8, 17, 18 and 19) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 4/5/24 with Staff 27 (Staffing Coordinator) indicated the following employees had not received their annual performance evaluations: -Staff 8 (CNA), adjusted seniority date 10/4/08: no annual performance review was completed. -Staff 17 (CNA), adjusted seniority date 11/22/22: no annual performance review was completed. -Staff 18 (CNA), adjusted seniority date 1/21/20: no annual performance review was completed. -Staff 19 (CNA), adjusted seniority date 10/9/21; no annual performance review was completed. On 4/5/24 at 11:52 AM Staff 27 confirmed annual performance reviews for Staff 8, Staff 17, Staff 18 and Staff 19 were not completed. On 4/8/24 at 10:33 AM Staff 2 (DNS) reported she was aware many CNA staff did not have their annual performance reviews completed…

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 appropriate infection control practices for 3 of 11 sampled staff (#s 8, 14 and 15) observed during medication administration and dining. This placed residents at risk for the spread of infection. Findings include: 1. The CDC website, section titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers (a device used to measure blood sugar levels) when shared. Using a glucometer for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). Glucometers should be cleaned and disinfected after every use. The facility's 7/2023 Glucometer Disinfection Policy & Procedure specified glucometers were disinfected after each use with an EPA-registered disinfectant that was effective against viruses. The disinfecting procedure directed staff to wash hands before and after 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 CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 16, 17, 18, and 19) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 4/5/24 at 1:00 PM Staff 2 (DNS) provided a list of training hours for the sampled staff and confirmed the following: -Staff 16 (CNA): 8.6 annual training hours; -Staff 17 (CNA): 0 annual training hours; -Staff 18 (CNA): 9.10 annual training hours and -Staff 19 (CNA): 4 annual training hours. On 4/5/24 at 1:00 PM and 4/8/24 at 10:33 AM Staff 2 confirmed Staff 16, Staff 17, Staff 18 and Staff 19 did not complete the required 12 hours of annual in-service trainings. Staff 2 stated she was aware CNA trainings were not being completed.

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity related to dining needs for 1 of 2 sampled dining rooms reviewed for dining. This placed residents at risk for lack of a dignity. Findings include: The facility's 3/2022 Assistance with Meals Policy indicated residents would receive assistance with meals in a manner that met the individual needs of each resident. Residents unable to feed themselves would be fed with attention to safety, comfort and dignity including not standing over residents while assisting them with meals. On 4/2/24 between the hours of 11:55 AM and 12:30 PM, during the lunch meal in the East dining room, the following observations were made: -The East dining room consisted of four tables with two to three residents placed at each table, one resident placed at a bedside table and another resident sitting in a wheelchair. -Staff 8 (CNA) provided assisted with the lunch meal at a table with three males, standing over one resident as she provided eating assistance. While Staff 8…

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 consent was obtained prior to administering psychotropic and antiviral medications to 2 of 5 sampled residents (#s 12 and 29) reviewed for medications. This placed residents at risk for being uninformed about their medications. Findings include: 1. Resident 29 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease. Resident 29's Profile Information Sheet indicated the resident's spouse was the resident's responsible party. Resident 29's 12/2023, 1/2024, 2/2024, 3/2024 and 4/2024 Physician Orders included mirtazapine (antidepressant) and quetiapine (antipsychotic). Resident 29's 12/2023, 1/2024, 2/2024, 3/2024 and 4/2024 MARs revealed the resident received mirtazapine 15 mg daily and quetiapine 25 mg - 50 mg daily. Review of Resident 29's health record revealed no documentation to indicate the resident or her/his representative was informed of the risks, benefits and potential side effects of mirtazapine and quetiapine and no evidence the resident consented to receive…

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 reasonable accommodations for 1 of 1 sampled resident (#37) reviewed for wheelchair accommodations. This placed residents at risk for unmet needs. Findings include: Resident 37 admitted to the facility in 4/2021 with diagnoses including Parkinson's disease (a disorder affecting movements). Observation on 4/3/24 at 12:21 PM revealed Resident 37 was sitting in her/his wheelchair with her/his calves pressed against the back of exposed metal on her/his chair and the left arm rest pad was missing, leaving a metal bar exposed for her/his arm to rest on. On 4/5/24 at 10:08 AM Resident 37 stated the back of her/his legs hurt. On 4/5/24 at 10:34 AM Staff 10 (CNA) stated she reported the missing arm rest pad to maintenance a while ago. On 4/5/24 at 11:22 AM Staff 3 (LPN Resident Care Manager) stated she was not aware of Resident 37's missing arm rest pad or and that her/his legs were resting against exposed metal. Staff 3 observed the back of Resident 37's calves and stated there were bad…

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 protect the resident's right to be free from physical abuse by a resident for 1 of 4 sampled residents (#5) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 5 was admitted to the facility in 2/2024 with diagnoses including post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Resident 5's 3/5/24 admission MDS indicated the resident was moderately cognitively impaired. Resident 4 was admitted to the facility in 3/2024 with diagnoses including alcohol-induced dementia. Resident 4's 3/22/24 admission MDS indicated the resident was moderately cognitively impaired. Resident 4's 5/16/24 Care Plan revealed the following: -The resident was involved in an incident which involved physical aggression on 5/8/24 with another resident and on 5/14/24 with a staff member. -The resident's behaviors included wandering, exit-seeking, verbal aggression and physical aggression. A 5/21/24…

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

Based on observation, interview and record review it was determined the facility failed to obtain consent, assess, monitor and reevaluate for use of a restraint for 1 of 1 sampled resident (#5) reviewed for restraints. This placed residents at risk for inappropriate use of a restraint. Findings include: The facility's 4/2017 Use of Restraints Policy stated the following: -Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. -Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. - Resident and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. Resident 5 was admitted to the facility in 8/2007 with diagnoses including schizophrenia and dementia with behavioral disturbances. A 7/12/23 Annual MDS…

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

Based on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 1 of 2 sampled residents (#8) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 8 was admitted to the facility in 12/2023 with diagnoses including schizoaffective disorder (a mental health condition), bipolar disorder (a mental health condition) and stroke. Resident 8's current care plan indicated the following: -Resident 8 required extensive assistance of one person for toileting. -Resident 8 required extensive assistance of one person for dressing and personal hygiene. -Resident 8 required extensive assistance of one person for ambulation while using a front wheeled walker. -Resident 8 required extensive assistance of one person for bed mobility and transfers. Multiple observations from 4/2/24 through 4/8/24 between the hours of 8:00 AM and 3:30 PM revealed Resident 8 independently moved in her/his bed, transferred from the bed to standing and/or to her/his wheelchair…

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 a discharge summary for 1 of 1 sampled resident (#53) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 53 was admitted to the facility in 10/2023 with diagnoses including normal pressure hydrocephalus (abnormal buildup of fluid in the brain). The resident was discharged from the facility on 1/14/24 as a resident initiated discharge. A review of Resident 53's health record indicated there was no discharge summary documentation. On 4/8/24 at 10:55 AM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 53.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 8 and 19) reviewed for edema and hospice services. This placed residents at risk for unmet care needs. Findings include: 1. The undated Hospice and Nursing Facility Services Agreement specified the facility shall provide in a timely manner, those drugs related to the management of the terminal illness. Resident 19 was admitted to the facility in 4/2018 with diagnoses including Huntington's disease (a degenerative disease which affects movement and cognitive functions). Resident 19's 2/8/24 Significant Change MDS indicated the resident received Hospice services. On 4/2/24 at 10:58 AM Witness 1 (Hospice RN) stated an order for glycopyrrolate 1 mg, prescribed to control Resident 19's oral secretions, was faxed to the facility on 3/29/24. Review of Resident 19's health record revealed the glycopyrrolate was not implemented and administered to Resident 19 until 4/3/24, five days after the medication was prescribed. On 4/4/24 at 4:14 PM 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 ensure residents were not prescribed unnecessary medications for 1 of 5 sampled residents (#29) reviewed for medications. This placed residents at risk for experiencing adverse medication effects. Findings include: Resident 29 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease. A 1/11/24 Physician Order included acyclovir (anitviral medication used to treat herpes simplex viral infections), 800 mg, take one half tablet twice a day for prophylaxis (action taken to prevent disease). The order did not specify which disease the medication was prophylactically prescribed and no further information or rationale for the medication was included in the order. Resident 29's 1/2024, 2/2024, 3/2024 and 4/2024 MARs revealed the resident received acyclovir daily beginning 1/12/24. On 4/5/24 at 1:00 PM Staff 12 (LPN Resident Care Manager) was asked about the indication for use of acyclovir. Staff 12 stated today she asked Staff 35 (Physician) for clarification regarding the use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 4/2/24 through 4/8/24 identified the following issues: -room [ROOM NUMBER] had a section of missing cove base behind the door, scrapes of missing paint along the wall under the window, gouges of missing wood on the window sill and the bedside table base was covered with paint chips. -Floor mats in multiple resident rooms were torn and tattered. -West hall sitting area across from the DNS office had an approximate 12 inch piece of wall covering peeling from underneath the window sill, a long crack in the wall with missing paint above the hand hygiene dispenser, and four large screws sticking out of the wall below the flag quilt. -The west dining room had an area on the north wall with missing paint 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 report an incident of suspected abuse in a timely manner for 2 of 4 sampled residents (#s 3 and 18) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 3 was admitted to the facility in 12/2020 with diagnoses including dementia with agitation. Resident 18 was admitted to the facility in 12/2020 with diagnoses including dementia with behavior disturbance and delusional disorder. On 7/25/22 at 11:53 AM a FRI was submitted which indicated on 7/22/22 at 6:17 PM Resident 18 and Resident 3 were overheard yelling at each other and then observed hitting each other. On 4/5/24 at 1:36 PM Staff 1 (Administrator) confirmed the incident of abuse between Resident 3 and Resident 18 occurred and there was a delay in reporting the incident within the required two hour reporting timeframe.

Based on interview and record review it was determined the facility failed to assess a pressure ulcer for 1 of 3 sampled residents (#3) reviewed for skin impairment. This placed residents at risk for worsening pressure ulcers and delayed healing. Findings include: CMS Appendix PP dated 2/3/23 defined the following: Stage 1 Pressure Injury (PI): Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Resident 3 was admitted to the facility in 2021 with diagnoses including partial paralysis. A Progress Note dated 7/12/22 indicated a Red patch of skin smaller than a dime was found on resident's upper buttocks, close to the left cheek. An order was entered for a sacrum (tail bone) dressing to be changed daily and monitor for increased redness. (The note failed to…

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

Based on interview and record review it was determined the facility to ensure safe transfers were performed for 1 of 3 sampled residents (#4) reviewed for transfer safety. This placed residents at risk for accidents and falls. Findings include: Resident 4 was admitted to the facility in 2017 with diagnoses including Alzheimer's. The facility's Using a Mechanical Lifting Machine policy from 4/2017 stated, at least two nursing assistants are needed to safely move a resident with a mechanical lift. Resident 4's 2/2023 Care Plan stated all transfers were to be performed with a sit to stand mechanical lift. A 5/17/23 Incident Review reported Resident 4 experienced 2 lacerations on her/his head which were determined to be as a result of injury from an unsafe transfer using a sit to stand mechanical lift with the assistance of only one CNA. On 9/19/23 at 9:26 AM Staff 15 stated Resident 4 required the use of a sit to stand mechanical lift which always required two trained nurses to safely use. Staff 15 stated she observed Staff 16 assisting Resident 4 with ADLs on the morning of 5/17/23…

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

Based on interview and record review it was determined the facility failed to provide timely lab services for 1 of 3 sampled residents (#1) reviewed for change in condition. This placed residents at risk for delayed treatment. Findings include: Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. Resident 1's Progress Notes revealed the following: - On 6/6/23 at 2:49 PM: The resident's spouse notified the facility the resident's hands and feet were twitching which the spouse thought might be related to a UTI. The resident's provider was notified and a urine sample would be collected. - On 6/6/23 at 8:35 PM: A urine sample was obtained from a urinal. - On 6/7/23 at 2:15 PM: The urine sample was collected. - On 6/9/23 at 9:06 PM: The lab was called to make sure a urine sample could be collected on the weekend before a sample was obtained. No notes were found to indicate why a second urine sample was needed. - On 6/11/23 at 6:41 AM: A urine sample was obtained by straight catheter. - On 6/16/23 at 7:09 AM: A lab report dated 6/14/23 revealed no…

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

Based on observation and interview it was determined the Dietary Manager (DM) did not obtain the required certification to provide dietary management services for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: Observations from 1/9/23 through 1/19/23 from 8:30 AM to 4:30 PM revealed Staff 6 (Dietary Manager) functioned in the capacity of the facility's Dietary Manager. On 1/13/23 at 10:18 AM Staff 6 stated he had been the Dietary Manager since 4/2022 and did not complete the required certification for the position as Dietary Manager. Staff 6 stated it would be approximately nine months until he finished the course. On 1/19/23 at 11:28 AM Staff 2 (DNS) confirmed Staff 6 did not have the required certification for the Dietary Manager position.

Based on interview and record review it was determined the facility failed to designate a qualified and trained Infection Preventionist for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate care related to infection control. Findings include: On 1/8/23 at 12:40 PM Staff 5 (RN/IP) stated he began working as the facility's Infection Preventionist in 9/2022 and he did not complete the CDC Infection Preventionist training by the time he assumed the position. A review of training certificates provided by Staff 5 revealed Staff 5 completed seven of the 23 modules and submodules included in the training. On 1/12/23 at 2:05 PM Staff 5 stated he planned to complete the remaining modules and submodules of the CDC Infection Preventionist training by the end of February 2023. On 1/19/23 at 1:40 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility lacked a certified infection preventionist.

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day 7 days per week for 9 out of 100 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 8/31/22 and 12/1/22 through 1/8/23 revealed on 7/3, 7/10, 7/11, 8/12, 8/13, 8/14, 12/15, 12/26 and 1/2 there was no RN coverage for eight consecutive hours. On 1/17/23 at 8:41 AM Staff 2 (DNS) acknowledged the facility lacked RN coverage on the identified days.

Based on observation, interview and record review it was determined the facility failed to ensure dignity for 1 of 3 sampled residents (#59) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: The facility's Quality of Life - Dignity policy revised 3/11/22 revealed: -Residents shall be treated with dignity and respect at all times and -Demeaning practices and standards of care that compromise dignity are prohibited. Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 admission MDS indicated the resident was cognitively intact. Multiple random observations from 1/8/23 through 1/17/23 between the hours of 8:00 AM and 11:50 PM revealed food and cups of liquid were frequently observed on the bedside table near Resident 59's urinal. On 1/13/23 at 11:47 AM Staff 3 (RNCM) and surveyor were with Resident 59 when Staff 31 (CNA) brought Resident 59's lunch into her/his room. Staff 31 removed…

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 a resident's representative in a timely manner regarding a resident-to-resident incident for 1 of 3 sampled residents (# 32) reviewed for accidents. This placed residents and responsible parties at risk for lack of timely notification. Findings include: Resident 32 was admitted to the facility in 4/2018 with diagnoses including Huntington's disease (a progressive brain disorder) and a mental health disorder. Resident 32's admission Record indicated: Witness 1 (Complainant) was Guardian, Care Conference Person, Emergency Contact #1, and Next of Kin. A FRI revealed on 10/14/22 Resident 32 was involved in an incident with Resident 31. It was reported Resident 31 stood behind Resident 32 and grasped and shook Resident 32's head. The facility Alleged Abuse Checklist form dated 10/14/22 revealed Witness 1 (Complainant) was notified of the incident on 10/17/22, three days after the incident occurred. On 1/8/22 at 6:25 PM Witness 1 stated the facility did not notify her until 72 hours after the incident. 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 the facility failed to ensure a personalized, homelike environment for 1 of 1 sampled resident (#41) reviewed for personal property. This placed residents at risk for living in an unhomelike environment. Findings include: Resident 41 was admitted to the facility in 6/2018 with diagnoses including frontotemporal dementia (a type of dementia characterized by changes in emotions, behavior, personality and language). A review of Resident 41's clinical record revealed the resident moved into a new room on 11/2/22. Observations of Resident 41's room from 1/8/23 to 1/12/23 between the hours of 8:10 AM to 3:20 PM revealed the resident's room to have blank walls except for one picture that did not belong to the resident. On 1/8/23 at 2:04 PM Witness 8 (Family Member) stated Resident 41 moved into her/his current room a few months ago. She stated the resident's previous room had numerous family photos and personalized pictures hanging on the walls. Witness 8 stated she requested the photos and pictures be moved to the resident's current room…

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

Based on observation, interview and record review it was determined the facility failed to obtain consent, assess, monitor and reevaluate for use of a restraint for 3 of 4 sampled residents (#s 22, 41 and 50) reviewed for restraints. This placed residents at risk for inappropriate use of a restraint. Findings include: 1. Resident 22 was admitted to the facility in 9/2021 with diagnoses including schizophrenia. Resident 22's 12/15/21 Quarterly MDS indicated the resident had two or more falls and used a chair alarm daily. Resident 22's 3/16/22 Quarterly MDS, 6/15/22 Quarterly MDS, 9/14/22 Annual MDS and 12/14/22 Quarterly MDS assessments indicated the resident had no falls and used a chair alarm daily. Resident 22's 9/14/22 Fall CAA revealed the following: - [Resident] actually takes the device with [her/him] to bed to remind [her/himself] to wait for help to get up. If [she/he] turns in bed and activates device accidentally, [she/he] deactivates device by replacing magnet to reset the device. The CAA lacked comprehensive assessment components such as justification for the ongoing use…

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 and implement a comprehensive person-centered care plan for 1 of 2 sampled residents (#59) reviewed for aspiration precautions (practices to help prevent food or fluids from entering the lungs). This placed residents at risk for choking or developing lung infections. Findings include: Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 admission MDS indicated the resident was cognitively intact. Resident 59's current Care Plan located in the resident's clinical record indicated Resident 59 was on a modified diet consisting of minced and moist diet textures (diet textures requiring little chewing and are finely chopped, grated, ground or mashed) and mildly thick liquids (liquids thickened to nectar consistency). The following aspiration precautions were in place: -Small bites, chew food completely; -Small sips of fluids…

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 care plans were revised to accurately reflect the resident needs for 2 of 9 sampled residents (#s 26 and 41) reviewed for ADLs and accidents. This placed residents at risk for unmet needs. Findings include: 1. Resident 26 was admitted to the facility in 3/2020 with diagnoses including stroke. Resident 26's 11/9/22 Quarterly MDS indicated the resident was not on Hospice. Resident 26's undated CNA Care Plan Reference Sheet indicated the resident was on Hospice. On 1/12/23 at 1:39 PM Staff 4 (RNCM) stated the CNA Care Plan Reference Sheet was designed to be used by staff, such as new CNAs and agency CNAs, who were unfamiliar with the resident. Staff 4 stated the reference sheet served as a quick reference with information about the resident and the type of care needed. Staff 4 reviewed Resident 26's CNA Care Plan Reference Sheet, stated Resident 26 was discharged from Hospice in 8/2022 and acknowledged the Care Plan was inaccurate. On 1/18/23 at 10:57 AM Staff 2 (DNS) stated she expected 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 provide necessary care and services related to bathing/showering and nail care for 1 of 6 sampled residents (#59) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 admission MDS indicated the resident had intact cognition and required extensive assistance of one person for bathing/showering and personal hygiene. Resident 59's 12/13/22 through 1/13/23 bathing/showering task logs indicated the resident received showers on Tuesday and Friday evening shift. Resident 59's bathing/showering task logs revealed the following: -12/13 not applicable; -12/16 not applicable; -12/20 not applicable; -12/23 not applicable; -12/27 not applicable; -12/30 shower completed; -1/3 shower completed; -1/6 not applicable; -1/10 not applicable and -1/13 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 3 of 4 sampled residents (#s 22, 28 and 50) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: 1. Resident 22 was admitted to the facility in 9/2021 with diagnoses including schizophrenia. Resident 22's 9/14/22 Annual MDS indicated the resident's cognition was moderately impaired, her/his vision and hearing were adequate and she/he preferred to read books, newspapers and magazines and liked to listen to music. The Activities CAA indicated Resident 22 liked magazines with news articles and the news was important to her/him. Resident 22's Care Plan included the following activity goals and interventions: - 10/13/22 Goal: provide activities that match resident's preference, ability, skill set and participation level. - Interventions: activities very important to [resident]:…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents received care and services related to the use of an indwelling catheter for 1 of 1 sampled resident (#15) reviewed for catheter care. This placed residents at risk for unmet catheter needs. Findings include: Resident 15 was admitted to the facility in 2022 with diagnoses including stroke, urinary tract infection (infection in the bladder, kidneys or urethra) and urinary incontinence. The facility policy, Urinary Incontinence-Clinical Protocol, dated 3/11/22 indicated the following: -The staff and physician will monitor the individual for complications of an indwelling catheter such as symptomatic urinary infection, urosepsis, or urethral erosion or pain and for complications of medications used to treat urinary incontinence. -Upon admission or re-admission, residents will be assessed for a catheter in place and will ensure MD (Medical Doctor) order, care plan and TAR are in place. Resident 15's Progress Notes indicated on 12/15/22, Resident 15 was sent to the emergency room…

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

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 2 of 5 sampled residents (#s12 and 32) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 32 was admitted to the facility in 4/2018 with diagnoses including Huntington's disease. Resident 32's 12/2022 physician orders included Senna Plus tablet (a laxative and stool softener) 8.6-50 MG, two tablets by mouth twice a day related to constipation, HOLD for loose stools. Resident 32's 1/2023 MAR revealed Senna Plus was administered twice a day from 1/1/2023 through 1/18/23. Resident 32's 1/2023 Bowel Elimination Flowsheet revealed the resident had loose/diarrhea stools on the following days: - 1/1/23 - 1/3/23 - 1/5/23, two episodes of loose/diarrhea stools - 1/7/23 - 1/11/23 - 1/13/23, two episodes of loose/diarrhea stools - 1/14/23, two episodes of loose/diarrhea stools On 1/17/23 at 1:09 PM and 1:32 PM Staff 13 (CNA) and Staff 14 (CNA) stated they were responsible for…

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

Based on observation, interview and record review it was determined the facility failed to ensure a medication pass error rate of less than 5%. There were six errors in 33 opportunities resulting in an 18.18% error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 16 was admitted to the facility in 4/2018 with diagnoses including stroke. Resident 16's 12/2022 physician orders included the following medications: - Senna 8.6 mg (laxative) 1 tab, hold for loose stool; - DSS (stool softener) 250 mg, hold for loose stool; - Protonix (medication for stomach problems) 20 mg, give before breakfast. On 1/12/23 at 7:36 AM Staff 16 (LPN) was observed for Resident 16's medication administration. Staff 16 prepared the Senna, DSS and Protonix and other medications ordered for Resident 16's high blood pressure and entered the resident's room. Resident 16 was eating her/his breakfast and asked Staff 16 to wait a minute so she/he could eat the last two bites of her/his egg. After Resident 16 finished eating, the resident told Staff 16 she/he had…

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

Based on interview and record review it was determined the facility failed to ensure provision of education related to risks and benefits, informed consent and the opportunity to receive administration of pneumococcal immunizations for 1 of 5 sampled residents (#55) reviewed for immunizations. This placed residents at risk for being uninformed of their healthcare options and for contracting infectious diseases. Findings include: Resident 55 was admitted to the facility in 2/2022 with diagnoses including calculus of bile duct with acute cholecystitis without obstruction (a condition characterized by stones in the pathway between the liver with the small intestine). No evidence was found in Resident 55's clinical record to indicate she/he was screened for appropriateness to receive a pneumococcal immunization, provided information related to the risks and benefits or provided the opportunity to consent to or decline the immunization. On 1/19/23 at 12:23 PM Staff 5 (RN/IP) confirmed the resident was not screened, provided education about the immunization, or provided the opportunity 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.