Saint Helens Post Acute

Based on observation, interview and record review it was determined the facility failed to provide appropriate wheelchair positioning and head/neck support for 1 of 1 sampled resident (#50) reviewed for mobility and positioning. This placed residents at risk for decreased range of motion and pain. Findings include: Resident 50 was re-admitted to the facility in 10/2025 with diagnoses including anoxic brain injury (damage to the brain due to a lack of oxygen) and right femur fracture (thighbone fracture).Resident 50's 12/25/25 Annual and 3/24/26 MDS revealed the resident had a BIMS score of zero, which indicated she/he was severely cognitively impaired, and did not talk. The resident required substantial/maximal assistance and dependence for bed mobility ADLs. The Pressure Ulcer/Injury and Pain CAA identified Resident 50 to have impaired mobility and had chronic pain.Review of the 3/5/26 Nursing Assessment revealed Resident 50 was completely immobile without assistance and maintained good positioning in the chair and bed.Between 4/19/26 through 4/22/26 between the hours of 8:00 AM…

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

Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to smoking safety and liquid modifications for 2 of 2 sampled residents (#s 9 and 67) reviewed for smoking and dietary modifications. This placed residents at risk for injury. Findings include:1. The facility's 8/2022 Smoking Policy indicated the following:-Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. -Resident smoking status is evaluated upon admission and reevaluated quarterly, upon a significant change and as determined by staff.-Any smoking-related privileges, restrictions and concerns are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. -The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. -Residents without independent smoking privileges…

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

Based on interview and record review it was determine the facility failed to ensure residents received appropriate pain management for 1 of 2 sampled residents (#94) reviewed for pain. This placed residents at risk for increased pain. Findings include:Resident 94 was admitted to the facility in 2/2026 with diagnoses including spinal stenosis (a narrowing of spaces within the spine leading to pain), dorsalgia (back pain), anxiety disorder, panic disorder, and opioid dependence. Resident 94's 2/28/26 admission MDS indicated the resident was cognitively intact. Resident 94's 2/24/26 admission orders included the following:Hydrocodone-acetaminophen (an opioid pain reliever) 10 mg - 325 mg oral tablet, give 1 tabs every four hours as needed for pain.Resident 94's 2/2026 MAR indicated the following medication was ordered on 2/24/26 at 10:26 AM:- Hydrocodone-acetaminophen 10 mg - 325 mg oral tablet, give 1 tablet every four hours as needed for pain.- Hydrocodone-acetaminophen 10 mg - 325 mg oral tablet was first administered to the resident on 2/25/36 at 4:25 AM.On 4/21/26 at 1:01 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 observation, interview and record review it was determined the facility failed to ensure appropriate provisions for dialysis care were implemented and timely post-dialysis assessments were completed for 1 of 1 sampled resident (#7) reviewed for dialysis. This placed residents at risk for delayed treatment. Findings include:The facility's 2/2023 Hemodialysis Catheters (a flexible, plastic tube inserted into a large vein, typically in the neck, chest or groin used to provide access for filtering blood in patients with kidney failure) - Access and Care of Policy revealed the following:a. Care immediately following dialysis treatment:-The dressing change is done in the dialysis center post-treatment.-If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. -Mild bleeding from the access site can be expected. Apply pressure to the site and contact the dialysis center for instructions.-If there is major bleeding from the site, apply pressure to access site and contact emergency services and dialysis center. b.…

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 who were trauma survivors received trauma-informed care for 3 of 3 sampled residents (#s 8, 41 and 49) reviewed for trauma-informed care. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include:The facility's 8/2022 Trauma-Informed and Culturally Competent Care Policy revealed the following: -Universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events will be performed.-The initial screening will be utilized to identify the need for further assessment and care. -Assessment involves an in-depth process of evaluation of the presence of symptoms, their relationship to trauma, as well as the identification of triggers. -Individualized care plans will be developed that address past trauma in collaboration with the resident and family as appropriate. 1. Resident 8 was admitted to the facility in 2/2026 with diagnoses including PTSD (post-traumatic stress…

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 identify and ensure a resident with a diagnosed substance use disorder and/or mental health disorder received necessary behavioral health care and services for 2 of 2 sampled residents (#s 9 and 49) reviewed for smoking and dementia care. This placed residents at risk for unaddressed behavioral and emotional needs and a decrease in their quality of life. Findings include: 1. Resident 9 was admitted to the facility in 3/2026 with diagnoses including psychoactive substance dependence (a chronic condition where an individual requires a substance, such as alcohol, nicotine or drugs to function normally), other stimulant use (the consumption of illicit, prescription or over-the-counter substances that increase alertness and energy) and sedative, hypnotic or anxiolytic abuse (the misuse of central nervous system depressants for euphoric effects or beyond their prescribed purpose, leading to addiction, coma or death).Resident 9's 3/10/26 Hospital History & Physical revealed the resident had a…

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

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent during medication administration for 2 of 10 sampled residents (#s 74 and 82) reviewed for medication administration. The facility's medication administration error rate was 11.11%. This place residents at risk for subtherapeutic dosing and uncontrolled blood sugars. Findings include: The 2016 insulin aspart (NovoLog) FlexPen manufacturer Guide to Using Your NovoLog FlexPen indicated the insulin pens should be primed with two units of insulin prior to each administration to ensure the correct dose was delivered. 1.Resident 74 was admitted to the facility in 2/2022 with diagnoses including type 2 diabetes mellitus (a chronic condition affecting the body's ability to control blood sugar levels).Resident 74's 6/2024 Physician Orders included the following:- insulin aspart (a rapid acting insulin) 100 unit/ml - give 7 units with meals for type 2 diabetes mellitusOn 4/21/26 at 7:08 AM Staff 31 (LPN) was observed to administer insulin aspart…

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

Based on observation and interview it was determined the facility failed to ensure a functional and comfortable environment for 1 of 1 resident rooms reviewed for lighting. This placed residents at risk for diminished quality of life and quality of care. Findings include:The facility's 2/2021 Homelike Environment Policy revealed comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes sufficient general lighting in resident-use areas, task lighting as needed and night lighting to promote safety and independence. Resident 9 was admitted to the facility in 3/2026 with diagnoses including quadriplegia (paralysis affecting all four limbs and the torso). Resident 9's 3/24/26 admission MDS revealed the resident was cognitively intact. On 4/23/26 at 7:32 AM, Resident 9 was observed in bed in the room she/he shared with two additional residents. A curtain was pulled to the left of the resident's bed and another one at the foot of the bed to divide the room space and to allow 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 record review and interview the facility failed to report an allegation of abuse and neglect within the required time frame to the State Agency for 2 of 2 sampled residents (#4 and #7) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include1. Resident 7 was admitted to the facility in 2/2013 with diagnoses including anoxic brain injury (a critical condition that resulted in a lack of oxygen to the brain). Resident 7's 1/12/25 Care Plan indicated the resident had a history of impaired cognitive function with poor impulse control, difficulty in expressing general awareness, decision making, self-expression and mental status. Resident 7's 3/31/25 MDS identified resident with a BIMS score of 0 out 0 which indicated severe cognitive impairment. A 10/23/25 Facility Investigation Report indicated Resident 7 had swelling and bruising on her/his right knee on 10/11/25. An x-ray was ordered on 10/13/25, which identified Resident 7 had a right knee fracture. The facility concluded that the injuries were likely a result of a self-initiated injury from…

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

Based on interview and record review it was determined the facility failed to have evidence a thorough investigation was completed to prevent potential abuse for 1 of 2 sampled residents (#7). This placed residents at risk for abuse. Findings include: Resident 7 was admitted to the facility in 2/2013 with diagnoses including anoxic brain injury (a critical condition that resulted in a lack of oxygen to the brain).Resident 7's 1/12/25 Care Plan revealed the resident had a history of impaired cognitive function with poor impulse control, difficulty in expressing general awareness, decision making, self-expression and mental status. Resident 7's 3/31/25 MDS identified resident with a BIMS score of 0 out 0 which indicated severe cognitive impairment.A 10/23/25 Facility Investigation Report indicated on Resident 7 had swelling and bruising on her/his right knee on 10/11/25. An x-ray was ordered on 10/13/25, which identified Resident 7 had a right knee fracture. The facility concluded that the injuries were likely a result of a self-initiated injury from kicking the footboard of the bed.…

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

Based on interview and record review it was determined the facility failed to follow physician's orders for medication administration for 1 of 3 sampled residents (#1) reviewed for quality of care. This placed residents at risk for unmet medication needs. Findings include:Resident 1 was admitted to the facility in 12/2024 with diagnoses including polyneuropathy (widespread malfunction of multiple peripheral nerves throughout the body), inflammatory spondylosis-cervical region (chronic, inflammatory, and degenerative disorders affecting the neck vertebrae) and hypothyroidism (abnormally low activity of the thyroid gland). Resident 1's Physician Order dated 1/4/2025 directed that Resident 1 receive Thyroid Oral 90 mg daily by mouth for treatment of hypothyroidism. Resident 1's 1/2025 MAR indicated Thyroid Oral 90 mg was not administered on 1/19/25, 1/20/25, 1/22/25, 1/23/25, and 1/24/25, with instructions to see nurses notes. Resident 1's Nursing Progress notes dated 1/19/25 and 1/20/25 indicated the Thyroid Oral 90 mg medication was on order. Resident 1's Nursing Progress notes dated…

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 implement airborne precautions for 1 of 3 sampled residents (#1) reviewed for infection control. This placed residents at risk for exposure to infection. Findings include:Resident 1 was admitted to the facility in 11/2025 with diagnoses including cerebral infarction (blockage of blood flow to the brain).On 11/12/25 at 2:48 PM a physician order indicated to test Resident 1 for the presence of tuberculosis (TB).Review of the 11/2025 TAR revealed Resident 1 received a TB test on 11/13/25 at 3:31 AM.An 11/14/25 cognitive assessment determined Resident 1 had normal cognitive function.An 11/15/25 at 7:24 AM progress note from Staff 10 (LPN) reported a chest x-ray was ordered for Resident 1 to rule out TB.A 11/15/25 physician order indicated Resident 1 was to be placed on airborne precautions.On 11/15/25 at 3:54 PM an orders - administration note from Staff 9 (LPN) stated Resident 1's TB test site showed an abnormality and an x-ray was ordered. The note also stated N95 masks were recommended to be…

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

Based on interview and record review it was determined the facility failed to ensure resident records were accurate for 1 of 3 sampled residents (# 5) reviewed for medical records. This placed residents at risk for inaccurate health records. Findings include: Resident 5 admitted to the facility in 10/2024, with diagnoses including Parkinson's disease. Review of Resident 5's 10/2024 MAR indicated she/he had received one dose of Tramadol (a pain medication) on 10/26/24 and one dose on 10/27/24. The facility's Narcotic logbook indicated Resident 5 had received two doses of Tramadol on 10/26/24 and one dose on 10/27/24. On 3/24/25 at 10:32 AM, Witness 1 (Family Member) indicated she/he was told Resident 5 had received a dose of Tramadol on 10/25/24. On 3/28/25 at 12:07 PM and 1:15 PM, Staff 4 (LPN), Staff 6 (LPN), and Staff 7 (LPN) stated they could not remember any specifics about Resident 5. Staff 4, Staff 6, and Staff 7 agreed accuracy of medication logs were important. On 3/31/25 at 12:00 PM, Staff 2 (DNS) stated he could not recall any specifics about this resident. Staff 2…

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

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day seven days per week for 4 of 68 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: Review of the PBJ (payroll based journal) Staffing Data Report for Quarter 4 (July 1, 2024 - September 30, 2024) revealed the facility reported on 7/7/24, 7/13/24, 7/20/24, 7/28/24, 8/4/24, 9/1/24, and 9/2/24, RN coverage was not available for at least eight consecutive hours per day. Review of the Direct Care Staff Daily Reports from 12/13/24 through 1/13/25 revealed on 12/22/24, RN coverage was not available for at least eight consecutive hours per day. On 1/16/25 at 11:41 AM Staff 23 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days on the PBJ and Direct Care Staff Daily Reports. On 1/17/25 at 8:48 AM Staff 1 (Executive Director) acknowledged the facility's failure to meet RN coverage for eight consecutive hours per day on the dates provided.…

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

Based on interview and record review the facility failed to implement a Quality Assessment and Performance Improvement (QAPI) program which identified quality deficiencies, developed and implemented action plans to correct identified quality of care deficiencies. The facility failed to initiate a QAPI review related to abuse, investigations, timely reporting and immunizations. This placed residents at risk of not receiving care and services for optimal resident outcomes. Findings include: The facility's QAPI policy and procedure, created in 4/2021 and reviewed 5/2023, stated the facility's QAPI is a data driven and proactive approach to quality improvement. continuously identifying opportunities for improvement. Gaps in systems are addressed through planned interventions with goal of improving the overall quality of life and quality of care and services delivered to nursing home residents. The Executive Director will ensure that the QAPI plan is reviewed minimally on an annual basis by the QAA (quality assessment and assurance) committee. On 1/21/25 at 2:32 PM Staff 2 (DNS) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure effective systems were in place to identify problems, and take action to improve and monitor its performance for 1 of 1 facility reviewed for quality assessment and assurance. This failure placed residents at risk for worsening care. Findings include: On 1/21/25 at 2:15 PM the facility's undated 2024 Quality Assurance and Performance Improvement (QAPI) Plan for [NAME] Care (Meadow Park Care facility) included oversight of Administration, Clinical Care Services, Nutrition Services, Pharmacy Services, Quality of Life and Engagement, Maintenance Services, Housekeeping, and Training And Orientation. The plan included use of a QAPI Committee, Analytics, Core Processes, and Medical Oversight for purposes of Performance Improvement Projects, Systematic Analysis, Communication, QAPI Self-Assessment, as well as Feedback and Data Monitoring. A review of the facility's Quality Assessment and Assurance (QAA) 2024 records 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 observations and interviews the facility failed to ensure the state survey inspection results were readily accessible for 1 of 1 facility reviewed for resident council. This placed residents and the public at risk of not being informed of the facility's survey history. Findings include: On 1/14/25, 1/15/25 and 1/16/25 a notice of survey results was observed located near the front entrance on the wall approximately five feet high up on the wall. The notice indicated the state survey binder was in the basket below the notice. The basket was dark in color and angled in a way that protruded from the wall at the top. There was no state survey binder in the basket. The notice was not visible to someone in a wheelchair. During a resident council interview on 1/15/25 at 3:11 PM, seven resident attendees indicated they did not know where to find the state survey inspection results in the facility. On 1/16/25 at 8:49 AM Staff 1 (Executive Director) stated the state survey books were located at the nurses station. She was observed to pull two four-inch binders off of a shelf, which…

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 interviews and record review it was determined the facility failed to implement written policies and procedures to thoroughly investigate all alleged violations, retain documents showing that all alleged violations were thoroughly investigated, to further prevent abuse and failed to establish coordination with the QAPI program regarding alleged staff and resident abuse for 3 of 7 sampled residents (#s 19, 23 and 202) reviewed for abuse. This placed residents at risk for verbal and physical abuse by staff. Findings include: The facility's 8/2022 Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injures of Unknown Source and Misappropriation of Resident Property policy revealed the following: - Thoroughly investigate all alleged violations and retain documents showing that all alleged violations are thoroughly investigated. - Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress . - Coordination with QAPI: Coordination of allegations of abuse will be completed monthly by the QAPI committee, 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 interviews and record review it was determined the facility failed to report allegations of verbal and physical abuse within the mandated timeframe for 3 of 7 sampled residents (#s 19, 23, and 202) reviewed for abuse. This placed residents at risk for verbal and physical abuse from staff. Findings include: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses including cirrhosis of the liver (chronic liver damage), mild cognitive impairment and obesity. The facility's 11/15/24 Verbal Aggression Received investigation revealed Resident 19 arrived at the facility for admission by private vehicle on 11/15/24 at 4:30 PM. The investigation alleged Staff 33 (CNA) verbally abused Resident 19 by yelling at her/him while Staff 33 assisted Resident 19 out of the vehicle. Staff 30 (CNA) witnessed the event and reported it to Staff 31 (LPN). A FRI for the 11/15/24 alleged verbal abuse from Staff 33 to Resident 19 was submitted to the state agency on 11/18/24 (three days after the alleged verbal abuse…

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 interviews and record review it was determined the facility failed to thoroughly investigate alleged physical and verbal abuse from staff for 3 of 7 sampled residents (#s 16, 19 and 202) reviewed for abuse. This placed residents at risk for physical and verbal abuse from staff. Findings include: The facility's 8/2022 Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injures of Unknown Source and Misappropriation of Resident Property policy revealed the following: - Thoroughly investigate all alleged violations and retain documents showing that all alleged violations are thoroughly investigated. 1. Resident 19 was admitted to the facility on [DATE] by a family member in a private vehicle, with diagnoses including cirrhosis of the liver (chronic liver damage), mild cognitive impairment and obesity. The facility's 11/15/24 Verbal Aggression Received investigation revealed Resident 19 arrived at the facility for admission with family by private vehicle on 11/15/24 at 4:30 PM. 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 2. A facility Wound Documentation-Wound Rounds Policy dated 9/2023 indicated at the time of a new admission or readmission the resident would have a head-to-toe skin assessment by the wound nurse, charge nurse or designee within eight hours of admission. If a skin issue was noted the area would be entered in wound rounds which includes, but is not limited to, measurements, drainage and wound descriptors. The nurse's note was completed to document findings and summarize the initial assessment or findings. A care plan would be initiated. Skin check frequency would be indicated on the TAR weekly and was to be completed by a licensed staff. If skin issues were noted, orders would be written and transferred to the TAR as appropriate. Resident 100 was admitted to the facility in 1/2025 with diagnoses including disorder of circulatory system and chronic total occlusion (blockage or closing of an opening, blood vessel or hollow organ) of an artery of the extremities. A review of signed admission orders dated 1/8/25…

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

Based on observation and interview it was determined the facility failed to ensure expired medications were removed from 1 of 1 medication storage rooms and 3 of 4 medication carts reviewed for medication storage. This put residents at risk for reduced efficacy of medications. Findings include: During a review of the medication storage room on 1/14/25 at 9:38 AM Staff 26 (CMA) verified the following expired medications were found: - one bottle of Latanoprost eyedrops (eye pressure relief drops) with an expiration date of 12/2024 - one bottle of Zioptan eyedrops (eye pressure relief drops) with an expiration date of 8/2024 - 10 vials of powdered Cephazolin (an antibiotic medication) with an expiration date of 10/2024 On 1/14/25 at 9:53 AM Staff 26 stated the expectation for expired medications was for them to be removed per the facility policy. The facility Storage and Expiration Dating of Medications, Biologicals Policy, with revision date 7/21/22, stated the facility should ensure all expired medications and biologicals were stored separately from other medications until destroyed…

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, interviews and record review it was determined the facility failed to ensure dishwasher temperatures were monitored daily to ensure the dishwasher functioned properly during an influenza outbreak for 1 of 1 dishwasher reviewed for the kitchen. This placed residents at risk for communicable diseases, un-sanitized dishware and utensils. Findings include: On 1/12/25 at 10:20 AM the facility was observed to have one low temperature dishwasher in the kitchen. A dishwasher temperature log was observed to have blanks for the month and year and the spaces to fill in temperatures for three cycles of washes were blank for the following dates: - 1/3/25 last cycle wash, rinse, parts per million (PPM) (a unit of measurement used to express very small concentrations of a solute within a solvent) and initials - 1/4/25 first and second cycles wash, rinse, PPM and initials - 1/8/25 through 1/12/25 all three cycles wash, rinse, PPM and initials On 1/12/25 at 10:20 AM Staff 39 (Cook) confirmed the facility was in an influenza outbreak and the dishwasher temperature logs were to…

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

Based on interview and record review it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and reduced quality of life. Findings include: On 1/21/25 at 3:16 PM Staff 3 (Regional Director of Clinical Operations) provided a copy of the facility's assessment. The assessment lacked evaluation and information for the following areas: -Listing of contracts, memorandums of understanding and other agreements with third parties who provide services or equipment to the facility during both normal operations and emergencies. -A facility-based and community-based risk assessment was not identified in the plan and there was no assessment or plan to address continuity of care during an emergency. -The care required by the resident population, using evidence-based, data-driven methods that considered the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that were present within…

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 understood the meaning of an arbitration agreement (disputes are resolved with a neutral party and not in court) for 3 of 3 sampled residents (#s 44, 201, 300) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights. Findings include: 1. Resident 44 admitted to the facility in 12/2024 with diagnoses including Fibromyalgia and asthma. Review of a 1/10/25 admission MDS indicated Resident 44 was cognitively intact. Resident 44's chart revealed she/he signed a facility Voluntary Arbitration Agreement form on 12/16/24. On 1/16/25 at 1:49 PM Resident 44 stated she/he knew what arbitration meant and remembered signing a lot of paperwork on admission but did not remember signing a facility Voluntary Arbitration Agreement form. On 1/16/25 at 5:18 PM Staff 25 (Business Office Manager) stated the facility Voluntary Arbitration Agreement form was explained to residents and signed by residents on admission. She stated a paper copy of all signed paperwork was…

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

Based on interview and record review it was determined the facility failed to ensure vaccines were offered for 2 of 5 sampled residents (#s 8 and 301) reviewed for immunizations. This placed residents at risk for respiratory infections. Findings include: A review of the facility's Influenza Vaccine Policy Statement revised in 2019 indicated all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the risks and benefits of vaccines to residents or their legal representatives. 1. Resident 8 was admitted in 7/2014 with diagnoses including traumatic brain injury and contractures of the left and right ankles. A Pneumococcal, COVID-19 and Annual Influenza Vaccine Information and Request form indicated on 9/25/23 Resident 8's representative consented to request influenza vaccine annually. No additional documentation was found in Resident 8's clinical record annual influenza vaccine was offered…

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

Based on interview and record review it was determined the facility failed to ensure residents received risk and benefit of the COVID-19 vaccine information for 2 of 5 sampled residents (#s 8, and 301) reviewed for immunizations. This placed residents at risk for lack of information regarding vaccines. Findings include: A review of the facility policy COVID-19 Policy and Procedure revised 12/2022 revealed all residents would be offered COVID-19 vaccines to aid in preventing COVID-19 and COVID like illness. Prior to, or upon admission, residents would be assessed for eligibility to receive the COVID-19 vaccine series, and when indicated, would be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident was already vaccinated. Assessments of the COVID-19 vaccination status would be conducted within five working days of the resident's admission if not conducted prior to admission. Residents should receive the risks and benefits and have the right to refuse the vaccination. If refused, staff would reapproach 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.

Based on observation and interview it was determined the facility failed to ensure a functional and comfortable environment for 1 of 3 shower rooms reviewed for environment. This placed residents at risk for an uncomfortable bathing experience. Findings include: On 1/12/25 at 2:31 PM a resident stated the ambient air in the shower room near resident room one was cold when she/he bathed and the heater in there could not be used. On 1/15/25 at 1:42 PM the State surveyor stood in the shower room between rooms one and two for about 10 minutes. The surveyors' fingertips became cold. A DO NOT turn heater on! fire hazard!! handwritten sign was observed posted in the shower room. On 1/17/25 at 8:03 AM Staff 1 (Executive Director) was aware of the lack of a heat source in the shower room. Staff 1 confirmed the shower room heater between rooms one and two was an issue and needed to be replaced.

Based on interview and record review, it was determined the facility failed to provide documentation that Notification of Medicare Non-Coverage (NOMNC) letters were provided in a timely manner for 1 of 3 sampled residents (# 205) reviewed for liability and appeal notices. This placed residents at risk of being uninformed of their right to appeal. Findings include: Resident 205's NOMNC letter indicated services were scheduled to end on 8/9/24. There was no documented evidence the resident was notified of her/his services ending. On 1/16/25 at 5:20 PM, Staff 1 (Executive Director) verified there was no documentation that Resident 205 was informed of her/his services ending. On 1/17/25 at 8:14 AM, Staff 5 (Social Services Director) confirmed there was no documentation that Resident 205 was informed of her/his services ending.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation for 1 of 1 resident (#50) reviewed for misappropriation. This placed residents at risk for lack of medication efficacy and loss of property. Findings include: Resident 50 was admitted to the facility in 1/2024 with diagnoses including arthritis and stroke. A 1/4/24 signed admission physician orders instructed staff to administer Oxycodone (to treat pain) one to two tablets every six hours as needed for moderate pain. Sixty tablets were physician ordered with no refills. The admission MDS with an assessment review date of 1/11/24, revealed Resident 50 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident 50 had frequent pain and received PRN pain medications. A 1/18/24 signed physician order instructed staff to administer Oxycodone one to two tablets by mouth every six hours as needed for pain with a quantity of 56 tables ordered. A review of Resident 50's 1/2024 MAR instructed staff to administer Resident 50 the following…

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, interviews and record review it was determined the facility failed to ensure a comprehensive care plan addressed dental needs for 1 of 1 sampled resident (#28) reviewed for dental. This placed residents at risk for unmet dental needs. Findings include: Resident 28 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease) and dental caries (permanently damaged areas in teeth). The 1/23/24 Food Preference Record revealed Resident 28 had .all broken teeth no dentures can't chew most or all foods, NSM (Nutrition Services Manager) will continue to monitor & follow up as needed. The 1/29/24 admission MDS Assessment revealed Resident 28 had a BIMS of 14 (cognitively intact) and had dental caries. An 8/27/24 Nutrition/Therapy Communication revealed the resident's diet was downgraded to mechanical soft. The 10/28/24 Nutrition Evaluation revealed Resident 28 had missing, broken teeth with dental caries and she/he required a soft diet. There…

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 treatment and services to prevent further decreases in range of motion for 1 of 1 sampled resident (# 37) reviewed for rehab and restorative services. This placed residents at risk for decreased range of motion and a decreased physical condition. Findings include: Resident 37 admitted to the facility in 9/2024 with a diagnosis of lupus (immune system attacks own organs), depression and obesity. Resident 37's 1/8/25 Quarterly MDS indicated she/he was cognitively intact and she/he received zero hours or days of active or passive RA services. On 1/12/25 at 3:04 PM Resident 37 stated she/he does not get the opportunity to do any exercises and she/he would like to exercise to gain strength to be able to discharge from the facility. Resident 37 was observed in her/his bed with no exercise equipment available for use in the room. Record review of Resident 37's health records provided no indication she/he received RA services. On 1/16/25 at 11:37 AM Staff 24 (CNA) stated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide adequate incontinence care for 1 of 1 sampled resident (#8) reviewed for incontinence care. This placed residents at risk for unmet incontinence needs. Resident 8 was admitted to the facility in 7/2014 with diagnoses including traumatic brain injury and contractures of the left and right ankles. Resident 8's care plan revised on 12/9/21 indicated the resident had an ADL self-care performance deficit and needed frequent checks. Resident 8 had an alteration in bowel elimination and incontinence. Resident 8 needed to be checked every two hours and provided with peri care after each incontinent episode. Resident 8's Annual MDS dated [DATE] identified the resident was always incontinent of both bowel and bladder and required staff assistance with toileting. Resident 8 was rarely to never understood when communicating. The 12/31/24 Urinary Incontinence CAA identified the type of incontinence as functional, meaning the resident could…

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, interviews and record review it was determined the facility failed to ensure prompt routine and emergency dental services were obtained for 1 of 1 sampled resident (#28) reviewed for dental. This placed residents at risk for unmet dental needs. Findings include: Resident 28 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease) and dental caries (permanently damaged areas in teeth). The 1/23/24 Food Preference Record revealed Resident 28 had .all broken teeth no dentures can't chew most or all foods, NSM (Nutrition Services Manager) will continue to monitor & follow up as needed. The 1/29/24 admission MDS Assessment revealed Resident 28 had a BIMS of 14 (cognitively intact) and had dental caries. The 5/16/24 Social Services Quarterly Evaluation revealed Dental will be at the facility on May 30th. There was no additional documentation or evidence in Resident 28's electronic health record she/he was seen by the dentist on 5/30/24.…

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

Based on interview and record review it was determined the facility failed to provide a written discharge notice to the resident and failed to notify the resident's representative of a discharge for 1 of 1 sampled resident (#2) reviewed for discharge. This placed residents at risk for lack of information regarding discharge and for their representatives being notified. Findings include: Resident 2 was admitted to the facility in 9/2024, with diagnoses including encephalopathy (a condition that affects the brain) and dementia. A review of Resident 2's clinical record revealed Resident 2 was not provided a written notice to the resident or the resident's representative regarding discharge from the facility on 10/26/24. On 10/30/24 at 1:23 PM, Staff 6 (LPN) stated Resident 2 was not provided a written discharge notification prior to discharge. On 10/30/24 at 3:23 PM, Witness 1 (Resident Representative) stated she/he was not notified or provided with written documentation of Resident 2's 10/26/24 discharge. On 11/4/24 at 1:31 PM, Staff 2 (DNS) confirmed the findings and stated 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 residents received adequate supervision to prevent an elopement for 1 of 3 sampled residents (#2) reviewed for accidents. This placed residents at risk for elopement from the facility. Findings include: Resident 2 was admitted to the facility in 9/2024, with diagnoses including encephalopathy (a condition that affects the brain) and dementia. Resident 2's 9/5/24 Care Plan revealed the resident as a fall risk due to visual and sensory communication issues including the inability to see at night, hearing loss due to a history of tinnitus, and vertigo. Facility interventions included monitoring and reporting any changes in Resident 2's cognition, decision making abilities, recall, and awareness of her/his surroundings. On 10/30/24 at 1:13 PM, Staff 4 (CNA) stated she and Staff 5 (CNA) identified Resident 2 was missing from the building and located Resident 2 approximately one mile away from the facility. On 10/30/24 at 1:25 PM, Staff 6 (LPN) confirmed Resident 2 had eloped from the facility without…

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 risk & benefit information for psychotropic medications for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for being uninformed of medications. Findings include: Resident 1 was admitted to the facility in 9/2023 with diagnoses including metabolic encephalopathy (a chemical imbalance that effects the brain). A 9/20/23 Physicians Order revealed Resident 1 received Olanzapine (antipsychotic) daily for agitation. A review of Resident 1's medical record revealed Resident 1 received six doses of Olanzapine (9/20/23 - 9/26/23) without obtaining consent from the resident or the resident's representative. On 2/5/2024 at 12:35 PM Staff 2 (DNS) stated the risk and benefit information for the Olanzapine was not reviewed with Resident 1 or her/his representative at the time of admission. Staff 2 acknowledged that Resident 1 was administered six doses of Olanzapine prior to obtaining consent.

Based on interview and record review, it was determined the facility failed to thoroughly investigate for potential injuries of unknown cause and failed to rule out potential abuse or neglect without adequate documentation for 1of 3 sampled residents (#1) reviewed for abuse and accidents. This placed residents at risk for abuse and neglect. Findings include: Resident 1 was admitted to the facility in 9/2023 with diagnoses including metabolic encephalopathy (a chemical imbalance that effects the brain). A 9/29/23 admission Assessment identified Resident 1 had a severe cognitive impairment. A 9/29/23 Alert Note indicated during rounds, Resident 1 became physically aggressive and agitated towards residents and staff. Resident 1 was sent to the hospital due to a confrontation with staff. A 9/29/23 Facilty Incident Report indicated Emergency Medical Services and Law Enforcement were called to the facility due Resident 1's confrontation with staff. No witnesses were noted and there was no documentation of any staff interviews or evaluation of the resident for potential injuries of unknown…

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 provide sufficient nursing staff to ensure residents attained and maintained their highest practicable mental, physical and psychosocial well-being for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. A 9/2/23 Progress Note for each of the following residents revealed they were on alert for missed medications: - Residents 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 17, 20, 22, 31, 33, 40, 97, 98 and 196. - Four additional residents who were discharged at the time of this investigation. On 9/6/23 at 4:02 PM Staff 11 (LPN) stated she worked as the day shift charge nurse on 9/2/23 and over 20 residents did not receive their medications during the preceeding night shift. Staff 11 stated a CMA was not scheduled to work on this particular night shift which made it very difficult for the nurse to administer medications and complete resident treatments. Staff 11 further stated the facility did not have a CMA scheduled to work the evening shift approximately four…

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 fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed regarding their legal rights. Findings include: On 9/5/23 at 9:23 AM Staff 1 (Executive Director) stated the facility offered a Voluntary Binding Arbitration Agreement to residents upon admission. Staff 1 stated he and Staff 29 (Business Office Manager) were responsible for the process of explaining the agreement to residents upon admission. On 9/11/23 at 12:11 PM Staff 29 stated she was not responsible to provide residents with information related the facility's Voluntary Arbitration Agreement. Staff 29 stated she believed it was provided to residents by Staff 13 (Medical Records) upon admission. On 9/11/23 at 1:44 PM Staff 13 stated the admitting nurse was responsible to provide residents with the facility's admission Agreement and she did not know if the arbitration agreement was included in that process.…

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 systematically identify and correct deficiencies in the areas of smoking, assessments, care plans, quality of care, accidents and staffing. This placed residents at risk for accidents, injuries and unmet care needs. Findings include: 1. The facility failed to identify and establish priorities for its improvement activities related to smoking, which resulted in an immediate jeopardy situation: - The need to educate staff regarding the facility's smoking policies. - The need to educate residents regarding the facility's smoking policies. - The need to complete smoking assessments to ensure residents who smoke can independently follow safe smoking practices and comply with the facility smoking policy. - The need to secure all smoking materials at the nursing station or in a lockbox in the resident room. - The need for staff to monitor residents while they smoked. On 9/12/23 at 11:55 AM Staff 1 (Executive Director) acknowledged the deficient practices related…

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 for 6 of 12 sampled residents (#s 1, 15, 17, 25, 30 and 33) reviewed for position and mobility, bowel care, activities, edema and unnecessary medications. This placed residents at risk for worsening medical conditions and hospitalization. Findings include: 1. Resident 1 was admitted to the facility in 1/2021 with diagnoses including cerebral palsy. A 6/2/23 Physician Order instructed staff to assist Resident 1 to wear a hand splint on her/his left hand at bedtime daily for eight hours. Resident 1's 8/7/23 Quarterly MDS indicated she/he wore a splint or brace five of the past seven lookback days. Record review of Resident 1's TAR from 8/1/23 to 9/7/23 revealed no documentation to indicate the splint was provided on 8/4/23, 8/13/23, 8/16/23, 8/17/23, 8/22/23, 8/30/23, 9/1/23 and 9/7/23. On 9/8/23 at 11:14 AM Staff 2 (DNS) confirmed the days with lack of documentation for the hand splint in Resident 1's 8/2023 and 9/2023 TAR. Staff 2 confirmed if the space was empty it…

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 it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 sampled CNAs (#s 18, 23, 28 and 30) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 9/8/23 at 12:09 PM Staff 2 (DNS) stated she started working for the facility nine months ago and had not completed annual performance reviews for CNAs. Staff 2 further stated she was unsure the last time annual performance reviews were completed. On 9/8/23 from 1:35 PM to 2:30 PM Staff 18 (CNA), Staff 23 (CNA), Staff 28 (CNA/CMA) and Staff 30 (CNA) stated they had not received a performance review in over a year. On 9/12/23 at 10:43 AM Staff 1 (Executive Director) stated he expected CNA performance evaluations to be completed annually. Staff 1 confirmed he did not have any record of completed performance evaluations for Staff 18, Staff 23, Staff 28 and Staff 30.

Based on interview and record review it was determined the facility failed to ensure consultations from a qualified dietitian or other clinically qualified nutrition professional for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: On 9/7/23 at 11:36 AM Staff 4 (Dietary Manager) stated she had not worked with an RD for a very long time. On 9/8/23 at 11:12 AM Staff 2 (DNS) stated she was unaware if an RD worked in the facility over the past year. Staff 2 stated the facility hired an RD several weeks ago and the RD was to work with Staff 2, and Staff 2 was to make resident diet recommendation changes. Staff 2 stated the new RD would not work on site to assist the dietary staff with recommendations. On 9/8/23 at 11:49 AM Staff 4 confirmed she had not worked with an RD consultant in the past year for any recommendations with the kitchen or staff. Staff 4 stated the facility hired a new RD, but she had not met her and understood the RD would only work remotely and not make recommendations for the kitchen or…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated in a dignified manner for 3 of 3 sampled residents (#s 1, 15 and 96) reviewed for dignity. This placed residents at risk for a decreased quality of life. Findings include: 1. Resident 15 was admitted to the facility in 8/2023 with diagnoses including spinal fracture. On 9/5/23 at 11:27 AM the State Surveyor was in Resident 15's room with the door closed. Staff 12 (RN) opened the door and entered Resident 15's room without knocking. Staff 12 approached Resident 15 with medications without announcing or introducing himself, indicated he needed to go back to crush the resident's medications and left the room. Resident 15 stated she/he did not know who that staff member was or why that person was in her/his room. On 9/7/23 at 8:34 AM Staff 23 (CNA) stated staff were supposed to knock and announce themselves before entering a resident's room. On 9/07/23 at 10:07 AM Staff 2 (DNS) was notified about the observation when Staff 12 did not knock, announce or introduce…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#96) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 96 was admitted to the facility in 8/2023 with diagnoses including anxiety and sleep apnea. Resident 96's 8/2023 Physician Order included an order for Albuterol Sulfate inhaler solution (breathing medication) every four hours as needed for shortness of breath and wheezing. On 9/5/23 at 12:45 PM Resident 96 stated the staff left the medication with her/him and no assessment was completed to ensure she/he was able to use the medication correctly. On 9/6/23 at 9:23 AM and 4:03 PM and 9/7/23 at 3:08 PM Resident 96 was lying in her/his bed with an overbed table within reach. An Albuterol Sulfate inhaler was observed on Resident 96's overbed table, and no nursing staff were present in the room. A review of Resident 96's health record 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 interview and record review it was determined the facility failed to ensure a resident request for a medical appointment was honored for 1 of 2 sampled residents (#33) reviewed for choices. This placed residents at risk for unmet medical needs. Findings include: Resident 33 was admitted to the facility in 9/2022 with diagnoses including drug-induced movement (tremors). Resident 33's 7/2/23 Quarterly MDS indicated the resident had no cognitive or memory impairment. A 4/4/23 Care Conference Note written by Staff 3 (Social Services Director) indicated Resident 33 would like to have a [neurology] appointment. Will follow up to schedule the appointment. On 9/5/23 at 10:10 AM Resident 33 stated she/he requested to see a neurologist, staff did not follow up on her/his request and she/he has not had a neurology appointment. On 9/8/23 at 2:04 PM Staff 3 reviewed the 4/4/23 Care Conference Note and stated she recalled Resident 33's request to see a neurologist. Staff 3 stated she was unsure of the outcome of the resident's request. Staff 3 stated she and Staff 13 (Medical Records)…

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

Based on interview and record review it was determined the facility failed to obtain copies of advance directives for 2 of 4 sampled residents (#s 27 and 40) reviewed for advance directives. This placed residents at risk of not having their health care decisions honored. Findings include: 1. Resident 27 was admitted to the facility in 7/2023 with diagnoses including displaced subtrochanteric fracture of right femur (a leg fracture near the hip). Resident 27's 7/25/23 admission MDS indicated the resident was cognitively intact. Resident 27's 7/19/23 Social Services Admission/Discharge Evaluation revealed she/he was her/his own person and did not have an advance directive. Resident 27's 7/25/23 Care Plan indicated the resident was her/his own decision maker with a goal to continue to make choices related to her/his end of life concerns or advance directive topics. On 9/8/23 at 11:07 AM Resident 27 reported she/he had an advance directive but did not know if the facility had a copy of it. No evidence was found in Resident 27's health record to indicate the facility had a copy 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 comfortable homelike environment for 1 of 3 sampled residents (#96) reviewed for dignity. This placed residents at risk for an unkempt environment. Findings include: Resident 96 was admitted to the facility in 8/2023 with diagnoses including a leg fracture. Resident 96's 8/31/23 admission Nursing Evaluation indicated she/he was cognitively intact. On 9/5/23 at 12:45 PM Resident 96, in room [ROOM NUMBER], stated she/he stopped using the bathroom in her/his room due to the dirty floors. She/he thought it seemed unsanitary. The Surveyor observed the bathroom floor which appeared dirty, with water-stained lines on the edges of the floor and under the toilet which went out and under the bathroom door. A large crack in the flooring was about three feet long in front and to the right of the toilet. When the Surveyor attempted to remove the water-stained lines, no substance came off the floor and there was no change in the appearance…

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 potential abuse to the State Agency within the required timeframe for 2 of 7 sampled residents (#s 1 and 17) reviewed for accidents. This placed residents at risk for abuse. Findings include: The facility's 2/2023 Accidents and Incidents policy outlined the following: - All unusual occurrences will be reported immediately to the Manager/Supervisor on call and an electronic accident/incident report shall be completed. - Notify the Executive Director and Director of Nursing immediately if alleged abuse, neglect, mistreatment, injuries of unknown source and/or misappropriation and immediately complete the required reporting to the applicable State and other agencies. 1. Resident 1 was admitted to the facility in 1/2021 with diagnoses including cerebral palsy. Resident 1's 8/29/23 Progress Note indicated she/he experienced an unwitnessed fall out of bed, sustained a head and wrist injury. No evidence of a completed FRI form was found for the 8/29/23 fall. On 9/8/23 at 11:16 AM Staff 2…

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 thoroughly investigate the contributing factors of a fall for 1 of 7 sampled residents (#1) reviewed for accidents. This placed residents at risk for abuse and further injury. Findings include: Resident 1 was admitted to the facility in 1/2021 with diagnoses including cerebral palsy. Resident 1's 8/29/23 Progress Note indicated she/he experienced an unwitnessed fall out of bed, sustained a head and wrist injury. No evidence of a completed investigation was found for the 8/29/23 fall. On 9/8/23 at 11:16 AM Staff 2 (DNS) acknowledged the incident on 8/29/23 and stated she had not completed an investigation. No further information was provided.

Based on interview and record review it was determined the facility failed to comprehensively assess cognition, mood, activities and discharge for 2 of 3 sampled residents (#s 25 and 30) reviewed for activities and care planning. This placed residents at risk for unassessed needs. Findings include: 1. Resident 25 was admitted to the facility in 9/2023 with diagnoses including seizures. A review of Resident 25's 6/9/23 Significant Change MDS revealed the following: - All questions on the BIMS were marked as not assessed. - All questions on the Resident Mood Interview were marked as not assessed. - Section F: Preferences for Routine & Activities were not marked as assessed. On 9/8/23 at 8:51 AM Staff 3 (Social Services Director) stated she was responsible for completing the mental status, mood and discharge interviews with residents. Staff 3 stated she sent her completed interviews to an off-site staff person in the corporate office who was responsible for inputting the responses from these interviews into the MDS. On 9/8/23 at 11:21 AM Staff 2 (DNS) acknowledged resident assessments…

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 accurate assessments for 1 of 2 sampled residents (#15) reviewed for food. This placed residents at risk for inaccurate assessments. Findings include: Resident 15 was admitted to the facility in 8/2023 with diagnoses including spine fracture. Resident 15's 8/9/23 admission MDS indicated the resident was edentulous (no natural teeth). On 9/5/23 at 11:16 AM Resident 15 was observed to have his/her own natural teeth. On 9/7/23 at 8:34 AM Staff 23 (CNA) stated Resident 15 had her/his own teeth. On 9/7/23 at 8:50 AM Staff 2 (DNS) was notified Resident 15's admission MDS indicated she/he had no teeth and observations of the resident revealed she/he had her/his own teeth. Staff 2 stated Resident 15's admission MDS was completed by a former MDS coordinator and acknowledged it was assessed inaccurately.

Based on observation, interview and record review it was determined the facility failed to implement care plan interventions in the area of ADLs for 1 of 2 sampled residents (#11) who were reviewed for position and mobility. This placed residents at risk for potential injury. Findings include: Resident 11 was admitted to the facility in 7/2014 with diagnoses including traumatic brain injury. Resident 11's 6/30/23 Quarterly MDS revealed the resident was severely cognitively impaired and required extensive assistance from two or more staff with dressing. Resident 11's 12/2021 ADL Self Care Performance Deficit Care Plan directed the following: - Provide long sleeves and/or geri sleeves (used to protect skin from tears and abrasions) to protect arms. - Put knee socks on only. Observations of Resident 11 on 9/5/23 at 12:23 PM and on 9/6/23 at 10:27 AM revealed the resident in her/his wheelchair wearing ankle-high fleece socks and a short-sleeved shirt. On 9/7/23 at 3:34 PM Staff 11 (LPN) stated she was unsure what type of socks Resident 11 wore and the resident usually wore fleece socks.…

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 care needs for 2 of 8 sampled resident (#s 11 and 15) reviewed for unnecessary medications, pressure ulcers and position and mobility. This placed residents at risk for incorrect care and unmet needs. Findings include: 1. Resident 15 was admitted to the facility in 8/2023 with diagnoses including spinal fracture. Resident 15's 8/9/23 admission MDS indicated the resident had unhealed pressure ulcers and injuries. Resident 15's 8/4/23 Care Plan revealed the resident had community acquired pressure ulcers and injuries related to the clamshell brace (full torso brace) worn at all times except when showering. Resident 15's current Kardex revealed the resident must be up in her/his wheelchair prior to having the clamshell brace removed. An 8/31/23 Skin/Wound Note revealed Resident 15 no longer had to wear the clamshell brace which was the cause of the [pressure ulcers and injuries]. On 9/7/23 at 8:34 AM Staff 23 (CNA) stated she used Resident 15's…

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

Based on observation, interview and record review it was determined the facility failed to provide the necessary services to maintain grooming assistance and hand hygiene for 2 of 5 sampled residents (#s 25 and 40) reviewed for ADLs. This placed residents at risk of unmet grooming and hygiene needs. Findings include: 1. Resident 25 was admitted to the facility in 4/2023 with diagnoses including seizures. Resident 25's 6/9/23 Significant Change MDS indicated she/he required extensive assistance from two people with personal hygiene. The current 6/13/23 Care Plan revealed Resident 25 was totally dependent on staff for daily personal hygiene. On 9/5/23 at 10:30 AM Resident 25 was observed lying in bed with 10 to 15 two-inch long chin hairs and messy hair. Resident 25 stated it was very important to her/him to not have chin hair and to have her/his hair look nice. On 9/6/23 at 9:42 AM and 3:31 PM Resident 25 was observed with 10 to 15 two-inch long chin hairs. On 9/7/23 at 1:41 PM Staff 30 (CNA) stated she received information to care for residents from the care plan, which included…

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

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 2 of 2 sampled residents (#s 11 and 25) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's 7/2016 Life Enrichment Manual outlined the following: - The center involves the resident in an ongoing program of activities that is designed to appeal to his or her interests and to enhance the resident's highest practicable level of physical, mental and psychosocial well-being. - For the resident who prefers to stay in her/his own room or is unable to leave her/his room: in-room visits by staff/other residents/volunteers with similar interests/hobbies, touch and sensory activities such as massage or aroma therapy, access to art/craft materials, cards, games, reading materials, access to technology of interest and/or visits from spiritual counselors. - For the resident with cognitive impairment: smaller groups without interruption 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 provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include: On 9/11/23 at 10:07 AM Staff 5 (Life Enrichment Assistant) stated the facility's Activity Director was out since the last week of 5/2023 and she was the replacement since this time. Staff 5 stated she did not have the certification, experience or training required for the position. On 9/12/23 at 10:01 AM Staff 1 (Executive Director) stated Staff 5 stepped in to cover activities two to three months ago. Staff 1 acknowledged Staff 5 lacked the required certification, experience or training required for the Activity Director position.

Based on observation, interview and record review it was determined the facility failed to manage pain for 1 of 1 sampled resident (#27) reviewed for pain management. This placed residents at risk of increased pain. Findings include: Resident 27 was admitted to the facility in 7/2023 with diagnoses including displaced subtrochanteric fracture of right femur (a leg fracture near the hip). The 7/25/23 admission MDS indicated Resident 27 was cognitively intact. A review of Resident 27's 7/21/23 Nursing admission Pain Evaluation revealed her/his hip and knee pain limited her/his ability to move and participate in activities. Resident 27's 8/30/23 Care Plan specified staff were to anticipate her/his need for pain relief and respond to any complaints of pain. A review of Resident 27's 7/18/23 Physician Orders revealed she/he was to receive hydromorphone HCI Oral Tablet 2 MG every three hours as needed for excessive pain. A Progress Note dated 8/25/23 at 6:49 PM revealed Resident 27 reported 10 out of 10 pain to nursing staff. At 7:40 PM on the same evening a Progress Note indicated out 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.

2. Resident 17 was admitted to the facility in 10/2021 with diagnoses including depression. A 4/15/23 Pharmacy Recommendation revealed the following: - Resident 17 received bupropion (an antidepressant medication) 150mg daily for depression and duloxetine (an antidepressant medication) 60mg daily for depression. - Resident 17 received these antidepressants since 10/24/21. - Consider a dose reduction of one of the medications unless contraindicated to reduce either at this time. - If dual therapy was to continue, the prescriber should document an assessment of risk versus benefit, indicating that the medications continue to be valid therapeutic interventions. No pharmacy recommendations were made for Resident 17 in 6/2023, 7/2023 or 8/2023. Resident 17's 8/2023 Physician Orders included an order for bupropion 150mg daily for depression and duloxetine 30mg daily for depression. No evidence was found in Resident 17's clinical record to indicate any additional dose reductions were attempted prior to the 4/2023 reduction of the duloxetine or physician documentation demonstrating why a…

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

Based on observation, interview and record review it was determined the facility failed to provide adaptive equipment for 1 of 2 sampled residents (#30) reviewed for nutrition. This placed residents at risk for decreased independence and weight loss. Findings include: Resident 30 was admitted to the facility in 10/2021 with diagnoses including stroke. Resident 30's 5/21/23 Quarterly MDS revealed the resident was cognitively intact and ate independently with set-up assistance only. Resident 30's 8/12/23 ADL Care Plan revealed the resident used adaptive utensils and a wrist weight when eating due to tremors. Resident 30's 9/2023 Physician Orders indicated the resident needed weighted utensils. On 9/5/23 at 10:44 AM Resident 30 stated she/he was supposed to have weighted silverware at mealtimes but she/he was only ever provided with built-up silverware. Resident 30's breakfast tray was observed at this time which revealed silverware with built-up handles. On 9/7/23 at 12:36 PM observations of Resident 30's lunch tray revealed a fork and knife with built-up handles. The diet ticket 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 and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 1 kitchen reviewed. This placed residents at risk for foodborne illnesses. Findings include: 1. On 9/5/23 at 9:13 AM the refrigerator and freezer in the facility's kitchen were observed to contain the following stored items: -open bag of grated cheese (undated without a discard date); -plastic sandwich bag of cooked bacon (undated and without a discard date); -small bowl of salad (uncovered, undated and without a discard date); -plastic bag of unknown, possible red pasta (unlabeled, undated and without a discard date); -tartar sauce in paper cups (uncovered, undated and without a discard date); -unknown food in a plastic container (unlabeled, undated and without a discard date); -meat was stored in an uncovered plastic bin container on a shelf above the butter; -frozen bag of possible chicken nuggets (unlabeled, undated and without a discard date); -frozen box of meat patties (undated in an opened cardboard box without a discard date); -frozen bag of…

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

Based on interview and record review it was determined the facility failed to ensure resident care equipment was maintained in proper operating condition for 1 of 6 sampled residents (#196) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: Resident 196 was admitted to the facility in 8/2023 with diagnoses including aftercare following joint replacement surgery. A review of the 9/7/23 admission MDS revealed Resident 196 was cognitively intact. On 9/5/23 at 10:23 AM Resident 196 stated she/he had to use a bedside commode. She/he stated the commode had the wrong size bucket, fell out and tipped over onto the floor at least daily since she/he was admited. She/he stated staff were aware of the problem but did not fix it. On 9/6/23 at 3:19 PM Resident 196 reported she/he experienced the same issue with the commode on the previous night. She/he said the bucket fell out of position while she/he used it which resulted in the resident, the CNA who was assisting her/him and the adjacent floor and wall to be splattered with the resident's…

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