French Prairie Nursing & Rehabilitation Center

Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a significant change of condition for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for their responsible party not being informed of the resident's status. Findings include:Resident 3 admitted to the facility in 2025 with diagnoses including epilepsy and dementia. Resident 3's emergency contact was listed as Witness 7 (Family Member). The 9/14/25 12:01 AM Progress Note by Staff 15 (LPN) indicated Patient found having active seizure. Called 911, resident left facility 00:01 [12:01 AM]. Notified on call. Left message on administrators phone.There was no indication in the clinical record to indicate Witness 7 was notified of Resident 3's change of condition and hospitalization. On 9/23/25 at 2:23 PM Witness 7 stated she was unaware of Resident 3's seizure or hospitalization until the hospital staff called and told her. On 9/25/25 at 12:55 PM Staff 2 (DNS) acknowledged Resident 3's emergency contact was Witness 7 and she was not…

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

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for reduced efficacy of medications. Findings include:Resident 3 admitted to the facility in 7/2025 with diagnoses including epilepsy (a neurological disorder characterized by unprovoked seizures) and dementia. The 8/20/25 physician order indicated Resident 3 was to receive the following medications twice daily for epilepsy:-levetiracetam (antiepileptic drug) 750 mg 3 tablets;-lamotrigine (anticonvulsant medication used to prevent or control seizures) 200 mg 2 tablets;-zonisamide (anticonvulsant medication used to prevent or control seizures) 100 mg 3 tablets. The 9/2025 MAR indicated the following:-Resident 3 was to receive levetiracetam, lamotrigine and zonisamide at 8:00 AM and 8:00 PM.-On 9/13/25 Staff 15 (LPN) administered levetiracetam, lamotrigine and zonisamide to Resident 3 at 11:47 PM (three hours and 47 minutes late). On 9/24/25 at 9:55 AM Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 3 of 3 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 4/23/25 the facility provided a list of residents who: -Required assistance with mechanical lifts: 18 -Required two person assistance with ADLs: 4 -Required assistance with eating: 5 -Had behaviors: 10 The 3/24/25 Facility Assessment indicated to continue to analyze and review specific times and circumstances where additional or directed staffing needed. Admin and/or DNS assure appropriate staffing levels for compliance. a. A review of the Direct Care Staff Daily Reports from 8/1/24 through 8/31/24 revealed the facility had insufficient CNA staff, per state minimum requirements, for one or more shifts on the following dates: -8/3/24 -8/9/24 -8/14/24 A review of the Direct Care Staff Daily Reports from 3/20/25 through 4/20/2025 revealed the…

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

Based on interview and record review it was determined the facility failed to ensure a registered nurse was available for at least eight consecutive hours, seven days a week for 13 of 91 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including nursing assessments. Findings include: A review of the Direct Care Staff Daily Reports from 8/1/24 through 8/31/24, 9/1/24 through 9/30/24, and 3/20/25 through 4/20/2025 revealed the following dates with no RN coverage: -8/4/24 -8/9/24 -8/10/24 -8/13/24 -8/16/24 -8/17/24 -8/20/24 -8/22/24 -8/25/24 -8/28/24 -9/4/24 -9/6/24 -9/8/24 On 4/28/25 at 2:35 PM Staff 1 (Administrator) acknowledged the identified dates without the required RN coverage.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 22, 28, 29, and 30) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: Annual performance reviews and hire dates were requested on 4/25/25 and 4/28/25 from Staff 1 (Administrator) and Staff 4 (Regional RN) for the following staff: -Staff 22 (CNA), hired on 8/4/21. -Staff 28 (CNA), hired on 9/20/22. -Staff 29 (CNA), hired on 3/22/22. -Staff 30 (CNA), hired on 9/26/12. On 4/28/25 at 1:39 PM Staff 4 stated they were unable to find annual performance reviews for the four identified staff.

Based on interview and record review it was determined the facility failed to obtain informed consent prior to administration of a psychotropic medication for 1 of 5 sampled residents (#34) reviewed for unnecessary medications. This placed residents at risk for being uninformed of the risks and benefits of their medications. Findings include: Resident 34 was admitted to the facility in 4/2025 with diagnoses including major depressive disorder. A 4/3/25 physician order included bupropion 300mg (used to treat depression) and desvenlafaxine 100mg (used to treat depression) one time daily. Resident 34's 4/2025 MARs revealed the resident received bupropion and desvenlafaxine daily since 4/3/25. Resident 34's medical record revealed the signed consent related to the risks and benefits of bupropion was obtained on 4/23/25 and the signed consent related to the risks and benefits of desvenlafaxine was obtained on 4/24/25. On 4/28/25 at 10:10 AM Staff 2 (DNS) acknowledged the consents were obtained after the medications were administered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self-administration of medications for 1 of 1 sampled resident (#104) reviewed for medication self-administration. This placed residents at risk for adverse outcomes related to unsafe self-administration of medication. Findings include: The facility's 3/2023 Right to Self-Administer Medication outlined the following criteria for a resident to self-administer medications: 1. If a resident has requested to self-administer medications, it is the responsibility of the interdisciplinary team to determine it is safe before the resident exercises the right. A resident may self-administer medications after the interdisciplinary team has determined which medication may be self-administered. 2. Considerations in determining of the resident is clinically appropriate to self-administer include: a. Which medications are appropriate and safe for self-administration. b. The resident's physical capacity…

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

Based on interview and record review it was determined the facility failed to administer bowel care medication and ensure physician orders related to bowel care were followed for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for adverse outcomes related to constipation. Findings include: A review of the facility's undated constipation protocol revealed to administer the following orders: -milk of magnesia 30mL PO PRN daily. -MiraLAX 17 grams mix with four-eight oz of fluid PO PRN daily OR Senna-Colace 8.6mg/50mg two tablets PRN daily. -Bisacodyl five-10 mg extended-release tablets PRN daily. -Bisacodyl 10mg PRN daily. -Then add Fleet Enema PRN daily. -Notify physician if >4 days since last BM. Resident 4 was admitted to the facility in 5/2022 with diagnoses including dementia and multiple sclerosis. The 2/22/25 Quarterly MDS indicated Resident 4's cognition was severely impaired. The 12/12/24 care plan indicated Resident 4 was to be monitored for side effects of constipation and to keep the physician informed of any problems. 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 interview and record review it was determined the facility failed to ensure residents received vision treatment and services for 1 of 2 sampled residents (#27) reviewed for vision. This placed residents at risk for vision loss. Findings include: Resident 27 was admitted to facility on 4/2021 with diagnoses including diabetes. A 12/17/24 Eye Exam Summary indicated a diagnosis of combined forms of age-related cataract - bilateral: Planning on cataract surgery. The summary instructed to hold off on glasses until after cataract surgery. No additional documentation was found to indicate the facility followed up on the recommendation for cataract surgery. A 3/21/25 Significant Change MDS documented a BIMS score of 14, indicating Resident 27 was cognitively intact. On 4/21/25 at 11:14 AM and on 4/21/25 at 12:40 PM Resident 27 stated her/his vision was not good. and was supposed to have her/his cataracts removed. Resident 27 said it was a while ago and no one talked to her/him about the surgery since then. On 4/23/25 at 2:14 PM Staff 13 (Social Services Director) stated she talked…

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 required dialysis care including post-dialysis assessments for 1 of 1 sampled resident (#28) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 28 was admitted to the facility in 10/2023 with diagnoses including end-stage renal disease and dependence on dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly). Resident 28's 11/1/24 Annual MDS indicated the resident was cognitively intact and received dialysis. A review of the 3/20/25 physician order indicated the resident received dialysis on Mondays, Wednesdays, and Friday's. The physician order also indicated a post-dialysis assessment was to be completed when the resident returned to the facility from dialysis. A review of Resident 28's medical record revealed the last completed post-dialysis assessment evaluation was on 3/24/25. There was no indication the resident was assessed post-dialysis on 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 interview and record review it was determined the facility failed to provide timely pharmaceutical services for 1 of 2 sampled residents (#102) reviewed for pain. This placed residents at risk for untreated medical needs. Findings include: Resident 102 admitted to the facility on [DATE] with diagnoses including right ankle fracture and candidal stomatitis (oral thrush). A review of Resident 102's 4/10/25 admission orders revealed an order for Magic Mouthwash - lidocaine/Maalox/Diphenhydramine Liquid to be given four times a day for throat pain. A review of Resident 102's April MAR indicated the Magic Mouthwash was marked not available from 4/10/25 to 4/23/25. On 4/23/25 at 1:35 PM Resident 102 stated she/he did not recall receiving the Magic Mouthwash. On 4/23/25 at 8:19 PM Staff 21 (Agency LPN) stated she contacted the pharmacy and notified the provider the medication was not available on 4/14/25 and again on 4/15/25, the days she worked. On 4/25/25 at 11:34 AM Staff 8 (Pharmacist) stated the pharmacy…

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 2 errors out of 26 medication administration opportunities resulting in a 7.69% error rate. This placed residents at risk for reduced medication efficacy and feeding tube complications. Findings include: The facility's Pharmacy Services Medication Administration dated 3/2023 specified crushed medications will not be combined to give multiple medications at once, whether administered orally or via a feeding tube. Resident 47 was admitted to the facility in 3/2025 with diagnoses including an inability to swallow following a stroke. Resident 47's 4/2025 Physician Orders included the following: -metoprolol tartrate (medication for high blood pressure) 25 mg, give one tablet via PEG-Tube two times a day -atorvastatin calcium (medication for high cholesterol) 40 mg, give one tablet via PEG-Tube one time a day On 4/24/25 at 9:52 AM Staff 10 (LPN) administered medications to Resident 47 via feeding tube. Staff 10 crushed one tablet…

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 lab samples for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This placed residents at risk for lack of treatment. Findings include: Resident 21 was admitted to the facility in 9/2022 with diagnoses including multiple sclerosis and slow transit constipation. A review of Resident 21's 4/2025 Physician Orders revealed an order to collect stool sample and complete IFOBT test - screening for colo-rectal cancer-Optum to provide the kit with an order start date of 11/19/24. On 4/23/25 at 12:43 PM Staff 18 (CNA) stated Resident 21 was incontinent of bowels and needed bowel care routinely during the day and/or evening shift. Staff 18 stated the charge nurse alerted CNAs if the resident was the bowel list or needed a stool sample for collection. Staff 18 stated she did not recall Resident 21 needing her/his stool sample to be collected. On 4/24/25 at 2:48 PM Staff 10 (LPN) stated it was difficult to collect a stool sample from Resident 21 due to the test requiring three stool samples…

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

Based on interview and record review it was determined the facility failed to notify a resident's responsible party in writing prior to a change in room of the reason for the room change for 1 of 3 sampled residents (#4) reviewed for resident rights. This placed residents at risk for potential adjustment difficulties and delayed responsible party notification related to changes in room location. Findings include: The facility's undated Room Move Notification policy indicated the following: - The resident and the representative would be notified of a potential room move, providing as much advance notice as possible. -When the resident was being moved by the facility's request, the resident and/or resident representative must receive an explanation in writing of why the move was being requested. - The Social Service Director/designee was to ensure the resident and/or resident representative agreed to the potential move before the room move occurred. Resident 4 admitted to the facility in 2024 with diagnoses including dementia. Resident 4's admission Record indicated 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.

Based on interviews and record review, the facility failed to protect the resident's right to be free from deprivation of goods and services for 2 of 3 sampled residents (#s 17 and 18) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include: 1. Resident 17 was admitted to the facility in 2024, with diagnoses including a fractured femur (leg bone), dementia, and a history of falling. A Facility Reported Incident dated 8/7/24, indicated on the morning of 8/7/24 the in-coming day shift staff reported to administration Resident 17 was found on the floor of her/his room naked and covered in urine and feces. The facility's investigation dated 8/7/24, indicated Resident 17 was left on the floor of her/his room for an extended period by Staff 7 (CNA) and Staff 8 (LPN) because the resident was repeatedly climbing out of bed. The two staff members did not attempt to engage with the resident but left her/him naked on the floor. The resident urinated and defecated and crawled around in the mess on the floor during the night. In the early morning 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 interview and record review it was determined the facility failed to ensure Staff 8 (LPN) adhered to professional standards of practice related to deprivation of goods and services for 2 of 3 sampled residents (#s 17 and 18) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include: 1. Resident 17 was admitted to the facility in 2024, with diagnoses including a fractured femur (leg bone), dementia, and a history of falling. A Facility Reported Incident dated 8/7/24, indicated on the morning of 8/7/24 the in-coming day shift staff reported to administration Resident 17 was found on the floor of her/his room naked and covered in urine and feces. The facility's investigation dated 8/7/24, indicated Resident 17 was left on the floor of her/his room for an extended period by Staff 7 (CNA) and Staff 8 (LPN) because the resident was repeatedly climbing out of bed. The two staff members did not attempt to engage with the resident but left her/him naked on the floor. The resident urinated, defecated, and crawled through the mess on the floor during…

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 assess and monitor pressure ulcers for 3 of 6 sampled residents (#s 13, 15 and 22) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include: 1. Resident 22 re-admitted to the facility in 9/2024, with diagnoses including diabetes and dementia. The 9/5/24 Nursing readmission Evaluation revealed an unstageable coccyx wound and no other pressure injuries. The Skin and Wound Evaluations revealed the following: -9/6/24: Deep Tissue Injury (persistent non-blanchable deep red, maroon or purple discoloration) to the rear, distal right malleolus. There was no assessment completed for the resident's right heel. -9/6/24: Coccyx wound stalled, approximately one month old. The wound assessment did not include measurements or description of the resident's wound. -10/11/24: Coccyx wound. The wound assessment did not have any measurements or description of the resident's wound. The 10/29/24 Hospital Records revealed Resident 22 had the following wounds: -Foot Anterior, Right,…

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

Based on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to ensure residents attained their highest practicable psychosocial well-being for 3 of 3 halls reviewed for staffing. This placed residents at risk for delayed care and unmet needs. Findings include: On 2/7/24 the facility provided lists of residents who: -Required assistance with eating: 14 -Required assistance with dressing: 46 -Required assistance with bathing: 49 -Required assistance with toileting: 41 -Required two-person assistance with transfers: 20 -Required mechanical lift transfers: 23 -Required incontinence care: 45 -Had wandering behaviors: 3 -Had behavioral healthcare needs: 3 A review of the facility Direct Care Staff Daily Reports for 5/2023, 6/2023, 11/2023, 12/2023, 1/2024 and 2/1/24 through 2/5/24 revealed the facility had insufficient CNA staff for one or more shifts to meet the state minimum staffing requirement on the following dates: 5/2023: 12 days 6/2023: 2 days 11/2023: 6 days 12/2023: 7 days 1/2024: 11 days 2/2024: 2 days Observations…

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 use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 10 of 97 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: A review of the Direct Care Staff Daily Reports from 11/2023 through 2/5/24 revealed the following days with no RN coverage for eight consecutive hours: -November: 10 and 20. -December: 4, 21, 24, and 25. -January: 9 and 15. -February: 1 and 2. On 2/12/24 at 12:54 PM Staff 1 (Regional Director of Operations), Staff 2 (Assistant Administrator) and Staff 5 (DNS) acknowledged the facility lacked RN coverage on the identified dates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined Staff 28 (Former DNS) falsified resident records for 20 of 20 sampled residents (#s 1, 7, 15, 21, 22, 23, 24, 26, 30, 31, 36, 40, 51, 57, 59, 60, 61, 62, 198 and 202) reviewed for false documentation. This placed residents at risk for inaccurate medical records, missed medications and a delay in treatment. Findings include: On 12/20/23 a public complaint was received which alleged Staff 28 falsified multiple resident records related to medication and treatment administration on 11/20/23 and skilled nursing assessments from 12/3/23 through 12/5/23. The (undated) facility investigation revealed the following information regarding missed medication and treatment administrations on 11/20/23 and how they were falsely documented by Staff 28: -Resident 1: Two medications signed as held. -Resident 7: Three medications signed as administered, refused or held and two treatments completed. -Resident 15: 13 medications signed as administered, refused or held. -Resident…

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

Based on observation, interview and record review it was determined the facility failed to provide ADL care to 4 of 4 sampled residents (#s 11, 27, 33 and 41) reviewed for ADLs. This placed residents at risk for unmet needs and loss of dignity. Findings include: 1. Resident 33 admitted to the facility in 12/2023 with diagnoses including osteoarthritis (breakdown of cartilage) of the right knee. Resident 33's care plan initiated on 12/18/23 revealed she/he required the assistance of staff with bathing, dressing and toilet use. On 1/23/24 a concern was reported which alleged on 1/20/24, Resident 33 was observed to have on a soiled brief and feces were observed to be on her/his back and legs. On 2/8/24 at 2:18 PM, Staff 13 (CNA) stated staff were supposed to provide incontinence care every two hours but sometimes were short staffed and the CNAs did the best they could. On 2/12/24 at 11:43 AM, Witness 5 (Complainant) stated she visited Resident 33 many times since she/he was admitted . On 1/20/24 Witness 5 arrived before lunch. She confirmed Resident 33's brief was soiled, she observed…

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 assess and treat skin conditions and administer medications as ordered for 8 of 12 sampled residents (#s 4, 9, 11, 25, 41, 43 and 54) reviewed for skin and medications. This placed residents at risk for worsening skin conditions, adverse medication side effects, constipation. Findings include: 1. Resident 9 admitted to the facility on [DATE] with diagnoses of left sided hemiplegia (paralysis) and a history of deep vein thrombosis (DVT/clots) and COPD (chronic obstructive pulmonary disease). a. The 12/2/23 Nursing admission Evaluation indicated Resident 9 had a hematoma wound on the right leg. A wound assessment was not completed. The 12/3/23 Skin and Wound Assessments did not assess the right leg wound. The 12/3/23, 12/4/23 and 12/5/23 Skilled Nursing Notes indicated the resident had no skin or wound concerns. The 12/6/23 Wound Care Assessment revealed a full skin assessment of Resident 9's right lower leg wound. [This was the initial…

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. Resident 15 admitted to the facility in 5/2023 with diagnoses including neuromuscular dysfunction of the bladder. The 5/17/23 Urinary Care Plan revealed the resident had a history of urine retention and frequent UTIs. Staff were to check the tubing for kinks every shift. The current Kardex (CNA care plan) instructed staff to check tubing for kinks every shift. The Point of Care documentation revealed staff documented the resident utilized a urinary catheter and recorded how much urine output there was each shift. The November 2023 TARs revealed an order to change the urinary catheter monthly. Review of Resident 15's medical record revealed no evidence catheter care (cleansing of the area) was completed. On 2/9/24 at 10:40 AM Staff 31 (CNA) stated the med tech (CMA) provided care for Resident 15's catheter and he only checked for tubing kinks or leakage, and reported to the nurse if needed. On 2/6/24 at 12:48 PM Staff 6 (LPN Unit Manager) stated the standard of care for indwelling catheters was every shift…

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

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily reports were accurate for 36 of 41 days reviewed for staffing. This placed residents at risk for inaccurate staffing information. Findings include: A review of Direct Care Staff Daily Reports and nursing staff time sheets from 5/22/23 through 5/31/23 and 1/2024 revealed the Direct Care Staff Daily Reports were inaccurate for the number of staff on duty and the hours staff worked for the following dates: - 5/22/23 through 5/31/23 - 1/2/24 through 1/8/24 - 1/10/24 through 1/25/24 - 1/27/24 - 1/30/24 - 1/31/24 On 2/12/24 at 12:54 PM Staff 1 (Regional Director of Operations), Staff 2 (Assistant Administrator) and Staff 5 (DNS) acknowledged the inaccuracies for the identified dates and no further information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 1 of 3 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: The facility's Medication Storage Policy revised in 1/2023 indicated medications which required refrigeration were to be kept between 36-46 degrees and temperatures were to be recorded on the refrigerator temperature log. On 2/7/24 at 8:03 AM refrigerator #2 in the medication storage room was observed with Staff 9 (LPN). Review of the refrigerator temperature log showed temperatures were to be recorded twice daily and maintained between 36-46 degrees. The 2/2024 refrigerator log from 2/1/24 through 2/7/24 revealed ten instances when the temperature of the refrigerator was 33 degrees. The medication refrigerator contained an emergency kit, insulin, IV (intravenous) medication, and eye drops. On 2/8/24 at 9:22 AM Staff 5 (DNS) acknowledged the…

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

Based on observation and interview it was determined the facility failed to provide palatable and appealing food for 4 of 5 sampled residents (#s 16, 18, 20 and 247) reviewed for food. This placed residents at risk for weight loss. Findings include: Interview with residents from 2/5/25 through 2/6/24 indicated the following food concerns: - Resident 16 stated the flavor of the food sometimes tasted like crap. - Resident 18 stated some days the food was not good. Resident 18 stated the food's flavor was not very good. - Resident 20 stated the facility's food was horrible, overcooked and the vegetables were mush. - Resident 247 stated the food did not taste like anything, had no resemblance of what was being eaten and was just lumps of brown and white something. On 2/7/24 at 12:55 PM a test tray was sampled by the survey team. The meal consisted of mashed potatoes, seasoned green beans and a boneless pork chop on top of a slice of bread with brown gravy. The mashed potatoes were bland and tasteless. The pork chop was tough and difficult to cut with the utensils provided. The green…

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 accurately documented for 20 of 20 sampled residents (#s 1, 7, 15, 21, 22, 23, 24, 26, 30, 31, 36, 40, 51, 57, 59, 60, 61, 62, 198 and 202) reviewed for false documentation. This placed residents at risk for inaccurate medical records. Findings include: The (undated) facility investigation revealed the following missed medication and treatment administrations on 11/20/23 and how they were falsely documented by Staff 28: -Resident 1: Two medications signed as held. -Resident 7: Three medications signed as administered, refused or held and two treatments completed. -Resident 15: 13 medications signed as administered, refused or held. -Resident 21: Seven medications signed as administered, refused or held. One nutritional supplement signed as given. -Resident 22: Six medications signed as administered, refused or held. -Resident 23: Three medications signed as held and one treatment as completed. -Resident 24: One medication signed as held. -Resident 26: One medication signed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to complete a Baseline Care Plan within 48 hours of admission for 3 of 9 sampled residents (#s 41, 43 and 199) reviewed for medications, catheter care and hospice. This placed residents at risk for a lack of care and services. Findings include: 1. Resident 43 was admitted to the facility on [DATE] with diagnoses including intraspinal abscess and pathological (no force) right femur fracture. The 12/7/23 Care Conference documentation indicated it was the initial care plan and welcome meeting. Resident 43's Care Plan revealed the first care area initiated was on 12/5/23. On 2/6/24 at 1:24 PM Staff 6 (LPN Unit Manager) verified the Baseline Care Plan was not completed within the required 48 hours after admission. 2. Resident 199 admitted to the facility on hospice status on 1/12/24 with diagnoses including dementia. Review of Resident 199's baseline care plan indicated it was not initiated until 1/16/24 (4 days after admission). The Care Plan…

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

Based on interview and record review it was determined the facility failed to complete a comprehensive recapitulation of stay and a final summary of the resident's status upon discharge for 1 of 2 sampled residents (#55) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: Resident 55 was admitted to the facility in 9/2022 with diagnoses including dementia. Resident 55 was discharged from the facility in 11/2023. Review of a Discharge Planning Review form dated 10/18/23 revealed the resident was discharged to an adult foster care home (AFC). The recapitulation of stay indicated the resident was transferred to the facility from another facility, was dependent on staff for care and a family member was the resident's decision maker. The recapitulation of stay did not include the resident diagnoses, course of treatment/illness, therapy, pertinent labs, radiology and consultations. The discharge form also did not include a final summary of the resident's status at the time of discharge compared to the resident's most recent comprehensive…

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 the care plan which resulted in a fall for 1 of 1 sampled resident (#55) reviewed for falls. This placed residents at risk for falls. Findings include: Resident 55 was admitted to the facility in 9/2022 with diagnoses including dementia. Review of a care plan initiated 9/13/22 revealed the resident had an ADL self performance deficit. Interventions included assistance with transfers which included the help of two staff and a Hoyer/mechanical lift initiated on 5/31/23. Review of an incident report dated 8/14/23 revealed the resident was found on the floor next to her/his wheelchair and a CNA standing next to the resident. The report indicated the resident was transferred from the wheelchair to the bed using a Hoyer. As the resident was lifted the resident slipped out of the Hoyer sling and was assisted to the floor by CNAs. No injuries were noted. The report failed to indicate if the care plan was followed and possible neglect was ruled out. A statement by Witness 8 (CNA) dated 8/14/23 indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide care and services for a central venous port for 1 of 1 sampled resident reviewed for IV (Intravenous) medications. This placed residents at risk for worsening infections and hospitalization. Findings include: The 2011 CDC (Centers for Disease Control) guidelines on how to handle and maintain central lines indicated dressings were to immediately be replaced when they were wet, soiled or dislodged and to perform routine dressing changes every two to seven days depending on the supplies used. Resident 43 admitted to the facility on [DATE] with diagnoses including an intraspinal abscess and diabetes. The 12/1/23 Hospital admission Orders and Discharge Summary revealed Resident 43 discharged to the facility with a right internal jugular port-a-cath (central venous IV port). The dressing was last changed on 11/30/23. The 12/3/23 Progress Note indicated Resident 43 was transferred to the hospital due to not having the resident's IV…

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 follow physician orders related to oxygen administration and maintain oxygen concentrators for 2 of 2 sampled residents (#s 9 and 20) reviewed for oxygen therapy. This placed residents at risk for difficulty breathing. Findings include: 1. Resident 9 admitted to the facility on [DATE] with diagnoses of left sided hemiplegia (paralysis) and a history of deep vein thrombosis (DVT/clots) and COPD (chronic obstructive pulmonary disease.) The 12/2/23 Hospital admission Orders revealed an order for oxygen (O2) up to 2L/NC (two liters per minute/nasal cannula) as needed (PRN) to keep the oxygen saturation (O2 Sat) level over 93%. Contact the physician if unable to achieve. The December 2023 TARs revealed no indication O2 was administered and no indication the resident's O2 SAT was assessed from 12/2/23 through 12/19/23. The 12/6/23 Skilled Nursing Note completed at 2:31 PM revealed the resident's O2 Sat was 90% at 9:31 AM on an undocumented…

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 dialysis treatment and care was in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#18) reviewed for dialysis (a procedure to remove waste products from the blood when the kidneys stop working.) This placed residents at risk for dialysis complications. Findings include: Resident 18 admitted to the facility in 2020 with diagnoses including stroke and chronic kidney disease. a. The facility's Dialysis Policy revised in 3/2023 indicated: - The medical record was to contain communication between the facility and the dialysis center. - Facility staff were to monitor and document the status of the resident's dialysis access site for complications. Resident 18's Care Plan initiated on 12/12/23 revealed the resident received dialysis three times a week at a clinic outside the facility. Resident 18's 12/17/23 Physician's Orders included an order for staff to complete both pre and post dialysis assessments three times a week on the resident's dialysis days.…

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 obtain medications timely to ensure the provision of routine medications for 2 of 6 sampled residents (#s 247 and 347) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include. 1. Resident 347 admitted to the facility on [DATE] with diagnoses including chronic kidney disease and edema. The 1/18/24 physician order indicated Resident 347 was to receive torsemide (diuretic medication) once daily. The 1/2024 MARs indicated Resident 347 did not receive torsemide on the following dates: -1/20/24 -1/22/24 -1/24/24 -1/29/24 -1/30/24 -1/31/24 Progress Notes and Order Administration Notes indicated the following: - 1/20/24 torsemide was not available. -1/22/24 torsemide do not have. - 1/24/24 torsemide was not available. -1/25/24 torsemide not available, will call pharmacy. This was crossed out and indicated declined order. -1/29/24 torsemide was not available, will follow up with 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 respond to pharmacy recommendations in a timely manner for 1 of 2 sampled residents (#21) reviewed for medications. This placed residents at risk for potential adverse consequences related to medications. Findings include: Resident 21 was admitted to the facility in 9/2022 with diagnoses including vascular dementia. An 11/7/23, 12/6/23 and 1/10/24 pharmacy recommendation indicated Resident 21 received Quetiapine (antipsychotic), Duloxetine (antidepressant) and Lamictal (anticonvulsant) medications and to consider a Gradual Dose Reduction (GDR) for all three medications. Records revealed no indication the physician was notified regarding a Gradual Dose Reduction for Quetiapine, Duloxetine or Lamictal. On 2/9/24 at 12:35 PM Staff 6 (LPN Unit Manager) stated the first Tuesday of every month the pharmacist conducted medication reviews and within 48 hours the list of pharmacy recommendations ready for the physician to review. The list of recommendations provided to the facility and sent to the physician for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure a risk versus benefits for the use of the psychotropic medication in the form of a signed informed consent was obtained for 1 of 5 sampled residents (#397) reviewed for unnecessary psychotropic medications. This placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings include: Resident 397 admitted to the facility on [DATE] with diagnoses including adjustment disorder with mixed anxiety and depression. The 1/24/24 hospital discharge orders indicated Resident 397 received Lorazepam (antianxiety medication) and Aripiprazole (antipsychotic) for adjustment disorder. Review of Resident 397's medical record revealed no indication the risks and benefits of the medications were reviewed with the resident. On 2/8/24 at 10:26 AM Resident 397 stated both the Lorazepam and Aripiprazole medications were new for her/him. Resident 397 stated she/he did not recall going over the risks and benefits of 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 follow physician orders for 1 of 1 sampled resident (#52) reviewed for medication and medication treatments. This placed residents at risk for medical complications. Findings include: Resident 52 was admitted to the facility in 7/2023 with diagnoses including a femur fracture (a large bone in the leg). Review of a physician's order dated 7/28/23 revealed the resident was to receive Enoxaparin (anticoagulant) injection once a day for blood clot prevention post surgery. Review of a July 2023 MAR revealed the resident was not administered Enoxaparin on 7/29/23, 7/30/23 and 7/31/23. Review of a progress note dated 7/31/23 at 4:41 PM revealed the resident was noted to have a physician order for Lovenox (Enoxaparin) on 7/29/23 and was not administered the medication for two days. The note indicated the resident's physician was notified and a physician order was sent to the facility to restart the medication on 8/1/23. In an interview on 2/7/23 at 9:35 AM Staff 2 (Assistant Administrator) acknowledged physician…

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

Based on interview and record review it was determined the facility failed to complete laboratory testing as ordered for 1 of 1 sampled resident (#25) reviewed for lab orders. This placed residents at risk for worsening conditions. Findings include: Resident 25 admitted to the facility in 2017 with diagnoses including stroke and diabetes. On 12/13/23 the facility's pharmacist recommended Resident 25 have HbA1c (measures average blood sugar level over past three months) and a Lipid panel (cholesterol) labs drawn. On 12/14/23 the physician ordered the HbA1c and Lipid panel labs. On 2/8/23 the facility was asked to provide documentation the labs were completed. On 2/8/23 at 11:02 AM Staff 5 (DNS) stated the ordered labs were not completed and they reached out to the physician. On 2/9/24 at 1:45 PM Staff 5 (DNS) verified the physician ordered labs were not completed and she expected lab orders to be followed and completed.

Based on interview and record review it was determined the facility failed to comprehensively investigate resident-to-resident verbal and aggressive incidents for 3 of 3 sampled residents (#s 3, 4 and 7) who were reviewed for abuse. This placed residents at risk for continued abuse. Findings include: On 8/4/23 the facility's Freedom From Abuse, Neglect and Exploitation was provided by Staff 2 (DNS). Review of the facility's abuse policy did not reveal information regarding the requirements to ensure thorough investigations were completed for alleged abuse violations. Facility records included documentation of the following resident-to-resident incidents during 7/2023: 1. Resident 7 was admitted to the facility 7/2022 with diagnoses including Parkinson's disease (nervous system disease) and diabetes. Resident 7's 6/14/23 quarterly MDS revealed she/he had a BIMS score of 15 (cognitively intact). On 7/2/23 a progress note indicated Resident 7 was observed by staff as she/he yelled out for Resident 6 to go back down the hall, kicked at Resident 6's wheelchair and swung out her/him. 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 ensure the resident received care in accordance with professional standards of practice for 1 of 3 sampled residents (#1) reviewed for safety. This placed residents at risk for unknown injury hazards. Findings include: Resident 1 was admitted to the facility in 2023 with diagnoses including chronic lung disease and diabetes. Resident 1's admission MDS revealed her/his BIMS score was 15 (cognitively intact). On 8/23/23 Witness 1 (Complainant) stated Resident 1 informed her a nurse at the facility gave her/him alcohol wipes to swab inside her/his nose to prevent contracting Covid 19. Resident 1 asked Witness 1 to purchase her/him additional alcohol wipes to have in her/his room. Witness 1 stated she called the facility to talk to Staff 2 (DNS) about the incident with the alcohol wipes and to have someone check on Resident 1. Review of Resident 1's medical record on 8/24/23 revealed no documentation regarding the alcohol wipes or Witness 1 contacting Staff 2 about the issue. On 9/6/23 at 3:10 PM 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 obtain copies of and provide assistance to residents who expressed interest in formulating an advanced directive for 4 of 4 sampled residents (#s 3, 25, 28 and 108) reviewed for advanced directives. This placed residents at risk of not having their healthcare decisions honored. Findings include: Review of advanced directives for Residents 3, 25, 28 and 108 revealed the following: a. Resident 3 was admitted to the facility in 12/2021. Care conference records (dated 1/3/22 and 10/18/22) for Resident 3 indicated the resident was offered and accepted information on advanced directives. On 12/2/22 at 9:50 AM Resident 3 stated she/he was interested in formulating an advanced directive. The resident received advanced directive paperwork at her/his care conference meetings but was not aware of what she/he needed to do. Resident 3 further stated she/he had not received any assistance or follow up by facility staff on how to create an advanced directive. There was no documentation as to the status of assisting…

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

Based on observation, interview and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 6 sampled residents (#50) reviewed for medication administration. This placed residents at risk for unsafe medication administration. Findings include: The facility's Right to Self-Administer Medication policy last revised on 7/2018, indicated the following: - A resident may self-administer medications after the interdisciplinary team has determined which medications may be self-administered. - Appropriate documentation of the determinations will be documented in the resident's medical record and care plan. Resident 50 was admitted to the facility in 2022 with diagnoses including kidney failure. Resident 50's current physician's orders included the following medications: - Arginaid (used for wound healing) - Lokelma (potassium binder) - sevelamer carbonate (phosphate binder) On 12/2/22 at 8:14 AM Staff 10 (LPN) was observed to leave three cups at Resident 50's bedside containing 8 ounces of water, each cup mixed with one 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 interview and record review it was determined the facility failed to provide care and services in relation to bathing for 2 of 4 sampled resident (#s 25 and 33) reviewed for ADLs and choices. This placed residents at risk for unmet needs. Findings include: 1. Resident 33 was admitted in 5/2022 with diagnoses including End Stage Renal Disease (ESRD) with dialysis status, diabetic foot wounds requiring amputation of the right leg below the knee and functional incontinence of bowel/bladder. Resident 33's care plan dated 8/25/22 and updated 11/29/22 revealed she/he was functionally incontinent of bowel/bladder and at continued risk for skin integrity compromise with increased dependence on others for ADL support. Staff were to check for hygiene needs even if the resident was not voiding. Resident 33 was identified with an ADL self-care performance deficit related to weakness, deconditioning and cognitive impairment. Bathing/showering was limited to the extensive assistance of one person and the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to initiate treatment and monitoring when an area of skin impairment was identified for 1 of 1 sampled resident (#108) reviewed for non-pressure skin conditions. This placed residents at risk for lack of treatment and worsening of wounds. Findings include: Resident 108 was admitted to the facility on [DATE] with diagnoses including diabetes and CVA (stroke). On 11/30/22 at 11:14 AM Resident 108 was observed with an adhesive bandage on her/his outer left ankle. Resident 108 stated she/he needed to have the bandage replaced and it covered an injury sustained from a wheelchair. The bandage did not appear to be new and a small amount of dark drainage was visible on the outer surface of the bandage which was peeling up on the edge. According to the Nursing Admission/readmission Evaluation dated 11/14/22, the resident had a scab on left outer heel. There was no treatment order found on the 11/2022 or 12/2022 TARs for 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.

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 necessary treatment and services to prevent the development of an avoidable pressure ulcer for 1 of 3 sampled residents (#50) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include: Resident 50 was admitted to the facility in 9/2022 with diagnoses including diabetes, congestive heart failure, kidney failure and malnutrition. The resident's admission MDS dated [DATE] indicated the resident did not have any pressure ulcers at the time of admission and was assessed to be at risk for developing pressure ulcers. The MDS identified the resident required limited assistance of one staff person for bed mobility, toileting and personal hygiene. Facility Skin Wound photos for Resident 50 from 9/29/22 revealed the resident had MASD (moisture-associated skin damage) to her/his sacrum present on admission from the hospital. Documentation with the photo indicated the facility would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to identify the need for diabetic foot care for 2 of 2 sampled residents (#s 50 and 108) reviewed for foot care. This placed residents at risk for complications associated with diabetes. Findings include: The facility Clinical Services Policy and Guidelines for Foot Care indicated the need for foot care, including treatment to prevent complications from diabetes, peripheral vascular disease or immobility by providing care and treatment to maintain good foot health. Residents with complicating disease processes will be referred to qualified professionals for foot care. 1. Resident 50 was admitted to the facility in 9/2022 with diagnoses including diabetes, congestive heart failure, kidney failure and malnutrition. On 12/1/22 at 8:15 AM Resident 50 was observed in bed with both feet exposed. The resident's toenails were observed to be long, curling over the end of her/his toes and some were thickened with jagged edges. 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 ensure a medicated powder was not left at the bedside of a cognitively impaired resident for 1 of 4 sampled residents (#34) reviewed for accidents. This placed residents at risk for the inappropriate consumption of an antifungal powder medication not meant to be orally ingested. Findings include: Resident 34 was admitted in 11/2022 with diagnoses including vascular dementia without behavioral disturbances and right-side hemiplegia (paralysis of one side of the body). The 11/8/22 admission MDS identified Resident 34's cognition as being moderately impaired. On 11/24/22 Resident 34 was reported to have ingested an antifungal powder that was left on her/his bedside table. According to the incident report, Staff 9 (LPN) gave Staff 24 (CNA) the antifungal powder in a medicine cup and asked her to put it on the resident when Staff 24 was getting the resident dressed. Staff 24 left the antifungal powder on Resident 34's bedside table. Staff 20 (Director of Rehab) informed Staff 9 it appeared the resident consumed…

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. The facility's medication administration error rate was 7%. This placed residents at risk for adverse medication consequences. Findings include: Resident 47 was admitted to the facility in 2022 with diagnoses including stroke and seizures. Resident 47's current physician's orders as of 11/2022 included the following medications which were scheduled on the MAR to be administered at 8:00 AM daily: - acetaminophen (pain reliever) - Dilantin (anticonvulsant) On 12/1/22 at 10:40 AM Staff 8 (LPN) was observed to administer Resident 47's acetaminophen and Dilantin. On 12/6/22 at 1:55 PM Staff 8 verified Resident 47's acetaminophen and Dilantin medications were not given within one hour of their ordered administration time. On 12/7/22 at 1:45 PM Staff 2 (Interim DNS) was made aware of these findings. No additional information was added.