Rivers Edge Rehabilitation And Care

Based on observation, interview, and record review it was determined the facility had a medication error rate of greater than 5%. The facility error rate was with 32 percent with 8 errors in 25 opportunities. This placed resident at risk for adverse medication regimen. Findings include: Resident 16 was admitted to the facility in 4/2026 with a diagnosis including diabetes. Resident 16's 4/27/26 admission MDS revealed she/he was cognitively intact On 6/2/26 at 8:56 AM Staff 19 (CMA) was observed to prepare Resident 16's medications, enter Resident 16's room, place her/his medicine cup with the prepared medications on her/his computer table, then Staff 19 exited her/his room. The medications which were left on the bedside table included: -amlodipine (treats high blood pressure)-atorvastatin (anti-lipid)-disulfiram (treats alcohol use disorder)-Biktarvy (anti-viral medication)-vitamin B12 (Supplement)-Farxiga (treats heart failure)-metformin (treats diabetes)-multvitamin (supplement)-Omeprozole (treats reflux disease)After Staff 19 left the room, this surveyor asked if Resident 16 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 observation, interview, and record review it was determined the facility failed to ensure resident equipment, resident windows, walls, and bathroom lighting were in good working order and water was hot for 4 of 8 sampled residents (#s 6, 13, 22, and 26) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: 1. Resident 6 was admitted to the facility in 12/2024 with diagnoses including dementia. On 2/26/25 at 12:00 PM, Resident 6's bathroom was observed to be dim with the light on. On 3/3/25 at 10:23 AM, Resident 6's bathroom was observed to be dark with the lights on. On 3/3/25 at 10:25 AM, Staff 13 (CNA) stated Resident 6 used the bathroom. Staff 13 stated the light had been dim for at least a week. On 3/3/25 at 10:38 AM Staff 5 (Maintenance Director) confirmed the bathroom light was dim and it was unsafe for a resident to go in there with the dim light. On 3/3/25 at 12:28 PM Resident 6 stated she/he took her/himself to the bathroom and had a difficult time seeing her/his way around in the bathroom. 2. Resident 13 admitted…

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 food in a sanitary manner for 1 of 1 resident refrigerator reviewed for food safety. This placed residents at risk for foodborne illnesses. Findings include: On 2/27/25 at 12:53 PM, a resident room refrigerator was observed with Staff 12 (Food Service Director) and observed the following: -An undated plate of meatballs. -An undated, uncovered bowel of pears. -A container of cottage cheese dated 2/12/25. -A sandwich dated 2/21/25. -An undated desert. -Two partial gallons chocolate milk with an expiration date of 2/7/25. -A jar of salsa with an expiration date of 2/20/25. -An open container of hot dogs with an expiration date of 1/16/25. -An open container of cole slaw with an expiration date of 2/20/25. -An open container of bologna with an expiration date of 2/18/25. -A green canister dated 11/14/23 with an unknown powder in it. -An undated pitcher with blue liquid in it labeled bowel prep with a resident's name on it. Staff 12 stated anything provided by the kitchen was dated and should be thrown out…

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 offered pneumonia vaccines for 5 of 5 sampled residents (#s 19, 22, 26, 38, and 39) reviewed for vaccines. This places residents at risk for pneumonia. Findings include: 1. Resident 19 was admitted to the facility in 9/2022 with a diagnosis of Parkinson's disease. Resident 19's clinical record revealed she/he was eligible for, but was not offered a pneumonia vaccine. On 2/27/25 at 11:02 AM and at 11:26 AM, Staff 2 (DNS) verified resident 19 was eligible to receive a pneumonia vaccine. A request was made for Staff 2 to provide documentation a pneumonia vaccine was offered to Resident 19. No additional information was provided. 2. Resident 22 was admitted to the facility in 12/2024 with a diagnosis of diabetes. Resident 22's clinical record revealed she/he was eligible for, but was not offered a pneumonia vaccine. On 2/27/25 at 11:02 AM and at 11:26 AM, Staff 2 (DNS) verified Resident 22 was eligible to receive a pneumonia vaccine. A request was made for Staff 2 to provide documentation…

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 dementia training for 5 of 5 sampled staff (#s 4, 9, 21, 22, and 23) reviewed for dementia training. This placed residents with dementia at risk of not receiving appropriate care and services to attain or maintain their highest practicable self. Findings include: A review of the facility's in-service records revealed dementia training was not completed by Staff 4 (CNA), Staff 9 (CNA), Staff 21 (CNA), Staff 22 (CNA), and Staff 23 (CNA) within the last 12 months. On 3/3/25 at 1:59 PM, Staff 1 (Administrator) confirmed the reviewed staff did not complete dementia training within the last 12 months.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review it was determined the facility failed to follow resident rights for 2 of 2 sampled residents (#s 13 and 26) reviewed for resident rights and incontinence care. This placed residents at risk for lack of dignity. Findings include: 1. Resident 13 admitted to facility in 11/2023, with diagnoses including congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles). A 12/2024 Annual MDS assessment revealed Resident 13 had a BIMS of 15 (cognitively intact). A review of Resident Council notes from 7/2024 revealed Resident 13's concerns about leaking briefs had been discussed at Resident Council and the facility response recorded was they would work to ensure the most appropriate product was used and supply an incontinence pad for Resident 13's wheelchair. A review of Resident 13's 8/2024 care plan revealed no changes were made related to incontinence. On [DATE] at 10:05 AM, Resident 13 stated her/his brief leaked when she/he…

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 or resident's representative was provided the risk and benefits information for psychotropic medications prior to administration for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 9 was admitted to the facility in 6/2022 with a diagnosis of depression. A 1/17/25 hospice Certification and Plan of Care revealed Resident 9 was admitted to hospice services on 1/17/25. Orders indicated Abilify (an antipsychotic medication) was to be administered daily, Cymbalta (an antidepressant medication) was to be administered daily, and lorazepam (an antianxiety medication) was to be administered PRN for restlessness. Review of Resident 9's clinical record revealed no evidence of consent forms for the administration of Abilify, Cymbalta, or lorazepam. On 2/27/25 at 9:18 AM, Staff 8 (LPN) stated consents for psychotropic medications were to be obtained from residents prior to medication administration. 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 interview and record review it was determined the facility failed to follow up on grievances for 1 of 4 sampled residents (# 26) reviewed for staffing. This placed residents at risk for not having their needs addressed. Findings include: Resident 26 admitted to the facility in 12/2023 with diagnoses including heart failure. A 12/23/24 Annual MDS revealed Resident 26 had a BIMS of 15 which indicated she/he was cognitively intact. A 5/14/24 progress note revealed Resident 26 complained to Staff 7 (Social Services Director) about long call light times. Staff 7 told Resident 26 she would address the issue. A 5/24/24 progress note revealed Resident 26 complained to Staff 7 about long call light times and her/his room not being clean. Staff 7 told Resident 26 she would report the concerns to the appropriate people. A 5/29/24 progress note revealed Resident 26 complained to Staff 7 about food issues and long call light times. Staff 7 told Resident 26 she would report the concerns to the appropriate department. A 6/3/24 progress note revealed Resident 26 complained to Staff 7 about…

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

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 sampled residents (#39) reviewed for abuse. This placed residents at risk for injury related to abuse. Findings include: Resident 39 was admitted to the facility in 9/2024 with diagnoses including post traumatic stress disorder (PTSD). Resident 20 was admitted to the facility in 11/2024 with diagnoses including PTSD. On 1/18/25 a Facility Reported Incident (FRI) was received by the State Survey Agency, which alleged Resident 20 hit Resident 39 on the head several times. Resident 39's 1/18/25 Progress Note indicated she/he reported to the nurse she/he was hit by Resident 20 on the top of the head several times. The facility's investigation dated 1/20/25, revealed Resident 39 and Resident 20 were in the dining room. Resident 39 was on her/his phone when Resident 20 asked Resident 39 to turn her/his phone down. Resident 39 stated she/he did turn her/his phone down, Resident 20 stated Resident 39 refused to turn her/his…

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

Based on interview and record review it was determined the facility failed to provide bowel care and failed to follow physician orders for medication parameters for 3 of 5 sampled residents (#s 9, 22, and 24) reviewed for medications. This placed residents at risk for constipation and adverse medication regimen. Findings include: 1. Resident 9 was admitted to the facility in 6/2022, with a diagnosis of dementia. A bowel record dated 1/29/25 through 2/27/25 revealed Resident 9 had a bowel movement on 2/1/25 and did not have another bowel movement until 2/7/25. A 2/2025 MAR revealed Senna (laxative) was administered on 2/4/25 and the results of the administration were unknown. Progress Notes from 1/29/25 through 2/7/25 did not include an assessment related to Resident 9's lack of bowel movement. On 2/27/25 at 9:18 AM, Staff 10 (CMA) stated every day a bowel sheet was printed for all residents. If a resident did not have a bowel movement for three days, bowel care was initiated. On 2/27/25 at 9:18 AM, Staff 8 (LPN) stated if a resident refused bowel care the nurse was to document in…

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

Based on observation, interview, and record review it was determined the facility failed to ensure cigarette lighters were not stored in resident rooms for 1 of 3 sampled residents (#5) reviewed for smoking. This placed residents at risk for burns. Findings include: Resident 5 was admitted to the facility in 10/2022 with a diagnoses of seizures and heart disease. The facility's undated Smoking Policy for Residents revealed smoking was only permitted in designated smoking areas and all cigarettes and lighters were to be kept locked at the nurse's station. A 12/30/24 Smoking Assessment indicated Resident 5 was a supervised smoker due to noncompliance with the smoking policy including sharing cigarettes with nonsmoking residents. On 2/26/25 at 2:06 PM, Resident 5 was observed by the back door, in a nonsmoking area, in her/his wheelchair, and was smoking a cigarette. Staff were not with the resident. On 2/26/25 at 2:11 PM, with Witness 4 (State Fire Marshall) Resident 5 stated she/he kept her/his cigarette lighter in a box in her/his coat pocket. Resident 5 pulled the box from her/his…

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

Based on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was maintained for 1 of 1 sampled resident (#13) reviewed for respiratory care. This placed residents at risk for increased risk for respiratory concerns. Findings include: Resident 13 admitted to the facility in 11/2023, with diagnoses including congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles). A 12/2024 Annual MDS assessment revealed Resident 13 had a BIMS of 15 (cognitively intact). Review of Resident 13's 8/2024 and 2/2025 TARS revealed an order for PRN oxygen, but no instruction for the resident's oxygen concentrator to be cleaned. On 2/24/25 at 10:05 AM, Resident 13 stated the facility had not cleaned her/his oxygen concentrator and it was filthy the last time they cleaned it. The facility's Departmental Respiratory Therapy policy revealed oxygen cannula and tubing were to be changed every seven days and filters were to be washed every seven days. On 3/3/25 at 12:22 PM, Staff 3 (LPN/Resident Care Manager)…

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 care and services related to dialysis for 1 of 1 sampled resident (#22) reviewed for dialysis. This placed residents at risk for dialysis access complications. Findings include: Resident 22 was admitted to the facility in 12/2023, with a diagnosis of kidney failure. The facilities Dialysis Access and Care Policy revised on 2/2023 revealed: -Do no use the access site arm to take blood samples, or give injections. -Do not use the access arm to take blood pressure. -Document in the resident's medical record every shift the location, condition of dressing, if dialysis was done, report from dialysis, and observations post-dialysis. A 12/18/24 Annual MDS revealed Resident 22 received dialysis and was cognitively intact. A care plan initiated 12/12/23 revealed Resident 22 had scheduled dialysis on Monday, Wednesday, and Fridays. Staff were to monitor her/his dialysis site upon return from dialysis. Staff were to send the dialysis communication book with the resident to dialysis. Resident 22's care plan…

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

Based on interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 3 sampled resident (#12) reviewed for abuse. This placed residents at risk for unmet trauma needs and a decrease in their quality of life. Findings include: Resident 12 was admitted to the facility in 7/2022, with diagnoses including post-traumatic stress disorder (PTSD). A 1/22/25 MDS indicated Resident 12 was cognitively intact. On 2/24/25 at 12:03 PM, Resident 12 stated about a month ago she/he was coming out of the shower room and another male resident was in the hall. Resident 12 stated the other resident looked her/him up and down and stated he wanted to shower with Resident 12. Resident 12 stated this made her/him uncomfortable and triggered her/his PTSD. A 2/24/25 review of Resident 12's care plan revealed no evidence of a PTSD care plan. On 2/27/25 at 10:17 AM, Staff 2 (DNS) stated Resident 12 had a PTSD care plan initiated on 2/26/25. A 2/28/25 investigation for a 1/14/25 resident-to-resident incident involving…

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 each CNA received annual performance reviews for 2 of 5 sampled CNAs (#s Staff 21 and Staff 23) reviewed for in-service education. This placed residents at risk for lack of care by competent staff. Findings include: On 3/3/25 at 12:31 PM and 1:17 PM, annual performance reviews of Staff 21 (CNA) and Staff 23 (CNA) were requested from Staff 1 (Administrator). Staff 1 was unable to provide the performance reviews and confirmed Staff 21 and Staff 23 did not have their annual performance reviews completed within the last 12 months.

Based on interview and record review it was determined the facility failed to provide medically-related social services for arranging mental health services for 2 of 2 sampled residents (#s 20 and 39) reviewed for abuse and unnecessary medications. This placed residents at risk for unmet behavioral health needs and a decrease in their quality of life. Findings include: 1. Resident 20 was admitted to the facility in 11/2024, with diagnoses including schizoaffective disorder, bipolar disorder, post-traumatic stress disorder, and borderline personality disorder. Resident 20's 1/18/25 Progress Note indicated he hit another resident several times on top of the head. The facility's investigation dated 1/20/25 noted Resident 20 was to follow up with mental health due to hitting another resident. A review of Resident 20's medical record on 2/28/25 revealed no evidence Resident 20 was seen by mental health provider after 1/20/25. On 2/28/25 at 2:22 PM, Staff 1 (Administrator) stated the facility did not have a mental health provider who visited the facility. Staff 1 stated the facility 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 act upon pharmacist recommendations for 1 of 5 sampled residents (# 32) reviewed for unnecessary medications. This placed residents at risk for a decrease in their quality of life. Findings include: Resident 32 was admitted to the facility in 5/2023, with diagnoses including depression, schizoaffective disorder, and anxiety. A review of Resident 32's Physician Orders revealed a 7/29/24 order for aripiprazole (an antipsychotic medication) for schizoaffective disorder, a 7/30/24 order for duloxetine (an antidepressant medication) for depression, and a 7/29/24 order for depakote (a mood stabilizing medication) for schizoaffective disorder. Resident 32's 1/10/25 Pharmacist's Recommendation to Prescriber noted a gradual dose reduction (GDR) for the resident's psychotropic medications (ariprazole, duloxetine, or depakote). The resident's recommendation was signed by her/his provider on 1/28/25, with an order for a psychiatric consult to discuss if a GDR was appropriate. A review of Resident 32's medical record…

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 rationale for PRN psychotropic medication and develop a care plan related to antianxiety medication side effects for 1 of 5 sampled residents (#9) reviewed for unnecessary medications. This placed residents at risk for sedation. Findings including: Resident 9 was admitted to the facility in 6/2022, with a diagnosis of depression. Resident 9's hospice Certification and Plan of Care revealed Resident 9 was admitted to hospice services on 1/17/25, with orders for lorazepam (an antianxiety medication) was to be administered PRN for restlessness. A care plan revised 1/28/25 revealed Resident 9 had ineffective coping and anxious behavior. Interventions included to give reassurance, report delusions to the nurse, and to See Psychotropic medication plan of care. Resident 9's care plan did not address the resident's psychotropic medication use, side effects of the lorazepam, or nonpharmacological interventions to be used prior to administration of the lorazepam. Resident 9's 2/2024 MAR revealed lorazepam…

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 therapy evaluation was obtained for 1 of 2 sampled residents (#38) reviewed for discharge. This placed residents at risk for weakness. Findings include: Resident 38 was admitted to the facility in 8/2024 with a diagnosis of a stroke. Resident 38's 8/29/24 hospital admission orders revealed admit to skilled. There were no orders for PT, OT, or SLP. A 9/3/24 Physician Encounter Note revealed Resident 38 was to continue skilled PT, SLP, and OT at the facility until the resident had enough strength and function to return to her/his previous living situation safety and successfully. Review of Resident 38's record revealed there were no therapy services provided. On 2/27/25 at 11:50 AM and 2/28/25 at 8:46 AM, Staff 3 (LPN/Resident Care Manager) stated Resident 38 required little assistance from the facility and could be at a lower level of care. Staff 3 stated Resident 38 was never a skilled resident. Staff 3 reviewed the 9/3/24 Physician Encounter Note and stated therapy got missed. Staff 2 stated she…

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

Based on interview and record review the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 3 sampled resident (# 12) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed regarding their legal rights. Findings include: Resident 12 admitted to the facility in 11/2022, with diagnoses including quadriplegia (paralysis affecting all of a person's limbs). On 9/20/23 Resident 12 signed an Arbitration Agreement with the new owner of the facility. On 2/27/25 at 2:20 PM, Resident 12 stated she/he did not know what a binding arbitration agreement was. Resident 12 stated she/he never would have signed a document giving up the right to sue the facility in court if she/he had known that was what she/he was signing. In interviews on 2/28/25 at 11:55 AM and 12:26 PM, Staff 7 (Social Services Director) stated she left the form with Resident 12 at her/his request then returned after a few days and asked for the form. Staff 7 stated she would discuss the form with residents when requested, and 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 offer Covid-19 vaccines for 3 of 5 sampled residents (#s 19, 38 and 39) reviewed for vaccines. This placed residents at risk for respiratory illness. findings include: 1. Resident 19 was admitted to the facility in 9/2022, with a diagnosis of Parkinson's disease. Resident 19's clinical record revealed she/he was eligible but not offered the Covid vaccine. On 2/27/25 at 11:02 AM and at 11:26 AM, Staff 2 (DNS) verified Resident 19 was eligible to receive a Covid-19 vaccine. A request was made for Staff 2 to provide documentation a Covid-19 vaccine was offered to Resident 19. No additional information was provided. 2. Resident 38 was admitted to the facility in 8/2024, with a diagnosis of a stroke. Resident 38's clinical record revealed she/he was eligible for, but was not offered a Covid-19 vaccine. On 2/27/25 at 11:02 AM and at 11:26 AM, Staff 2 (DNS) verified Resident 38 was eligible to receive a Covid-19 vaccine. A request was made to Staff 2 to provide documentation a Covid-19 vaccine was offered to…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 2 sampled residents (#13) reviewed for dignity. This placed residents at risk for lack of privacy and dignity. Findings include: Resident 13 was admitted to the facility in 2020 with diagnoses including chronic heart failure and diabetes. The facility's 2/2021 Dignity Policy indicated staff were to protect resident's privacy, including bodily privacy during assistance with personal care. Resident 13's 4/6/23 ADL Functional Status CAA indicated the resident was non-ambulatory and occasionally needed staff assistance with toilet hygiene following a bowel movement. On 10/3/23 at 12:43 PM Resident 13 was observed from the hallway sitting on a toilet in the bathroom located across the hall from her/his room. The door to the bathroom was open and the resident's electric wheelchair was in the doorway. The hallway had a strong fecal odor. Staff members were observed walking past the bathroom and did not offer privacy to the resident. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure resident bathrooms were clean and kept in good repair for 1 of 2 sampled resident rooms (#26) reviewed for environment. This placed residents at risk for living in an unhomelike environment. Findings include: Multiple observations between 10/2/23 and 10/4/23 revealed the bathroom in the following condition: The bathroom was observed to have one of two light bulbs not working, the bathroom fan had a thick layer of fuzz/lint build up (approximately half an inch) and the toilet ran continuously. The base around the toilet was black in color and the floor around the toilet had a rust/brown color that extended approximately 5 inches in width on both sides. The floor on the back side of the toilet had a crack approximately 10 inches in length that extended to the wall. An uneven bulge on the floor located on the right side of the toilet was present. On 10/02/23 at 2:19 PM the resident in room [ROOM NUMBER] stated the bathroom needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to transmit Discharge MDS Assessments and Quarterly MDS Assessments in a timely manner for 2 of 14 sampled residents (#s 32 and 139) reviewed for MDS completion. This placed residents at risk for untimely, inaccurate records and unmet needs. Findings include: 1. Resident 32 admitted to the facility on [DATE] and discharged on 7/13/23. A review of Resident 32's health record revealed no evidence a 7/13/23 Discharge MDS was transmitted. On 10/6/23 at 11:10 AM Staff 2 (DNS) acknowledged Resident 32's Discharge MDS was not transmitted timely. 2. Resident 139 admitted to the facility on [DATE] and she/he passed away in the facility on 11/22/22. A review of Resident 139's health record revealed her/his Discharge MDS was not transmitted. On 10/6/23 at 11:10 AM Staff 2 (DNS) acknowledged Resident 139's 11/22/22 Discharge MDS was not transmitted timely.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide a restorative program to prevent further decline in range of motion for 3 of 3 sampled residents (#s 5, 14 and 17) who were reviewed for mobility. This placed residents at risk for a decline in their range of motion abilities. Findings include: 1. Resident 5 admitted to the facility in 5/2016 with diagnoses including traumatic brain injury, stroke and abnormal gait. A 3/25/22 Restorative Therapy Plan indicated Resident 5 was to receive restorative therapy three to five times a week and staff were to assist Resident 5 with ambulation 50 to 70 feet with SBA (stand by assist), shoes, gait belt, and FWW (front wheeled walker) once daily. Restorative Therapy records from 9/1/23 through 10/5/23 (35 opportunities) indicated Resident 5 only received five days of her/his restorative therapy sessions. On 10/2/23 at 12:22 PM Resident 5 stated staff were to assist her/him with ambulation with a walker for exercise. Resident 5…

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. There were three errors in 27 opportunities resulting in an 11.11% error rate. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 2 was admitted to the facility in 2021 with diagnoses including bone density disorder. Resident 2's 9/11/23 physician's orders included alendronate sodium (medication to treat brittle bones) weekly with directions to give the medication on an empty stomach with six to eight ounces of water. On 10/4/23 at 4:07 AM Staff 11 (LPN) was observed to administer the alendronate sodium medication to Resident 2. Resident 2 took the medication with two sips of water from her/his personal cup. Staff 11 did not provide the resident with six to eight ounces of water or encourage Resident 2 to consume additional water with the medication. On 10/5/23 at 1:01 PM Staff 11 stated she did not know Resident 2 was to receive six to eight ounces of water with the alendronate medication…

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.