Canterbury Place

Based on review of job descriptions, facility and clinical records, and staff interviews it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that the facility provide a fully functioning call bell system for one resident resulting in an immediate jeopardy situation for one of three residents (Resident R1).Findings include: The job description for the NHA specified that the job scope is to oversee the overall operations of the Community and is responsible for resident care, customer service, and the welfare and safety of residents. The job description for the DON specified that the job scope is to plan, organize, develop, and direct the overall operation of the Nursing services department. Facilitates the coordination of nursing services and other departments to maintain quality of care for residents. Based on the findings of this report that identified that the facility failed to provide a fully functioning call bell system for on resident resulting in an immediate jeopardy situation.…

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 review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents' care plans were updated and revised to reflect the resident's specific care needs for three of six residents (Resident R22, R29, and R31).Findings include: Review of the facility policy Goals and Objectives, Care Plans dated 12/9/25, indicated care plan goals and objectives are defined as the desired outcomes for a specific resident problem. Care plans will be modified accordingly. Review of clinical record indicated Resident R29 was admitted to the facility on [DATE], with diagnoses that included pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), glaucoma and dysphagia (difficulty swallowing). Review of Resident R29's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 11/6/25, indicated the diagnoses remain current.…

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 review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide an Assessment Involuntary Movement Scale (AIMS- a widely used tool designed to measure the severity of tardive dyskinesia (TD- a disorder characterized by involuntary movements that can occur as a side effect of long term use of antipsychotic medication) assessment at least quarterly for three of five residents (Resident R30, R36, R102).Findings include: Review of the facility policy Assessment Involuntary Movement Scale last reviewed 12/9/25, indicated to ensure early identification, monitoring, and appropriate clinical response to involuntary movements particularly those associated with antipsychotic medication use, through consistent use of the AIMIS scale for residents receiving nursing services. AIMS must be completed prior to initiation of any antipsychotic medication, must be completed every three months (quarterly) for all residents receiving antipsychotic medications. Review 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 a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for five of seven residents (Resident R21, R30, R33, R36, and R50) and failed to have a current hospice agreement that included the vendors name.Findings include: Review of the facility Hospice Program last reviewed 12/9/25, indicated Hospice services are available to residents at the end of life. Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. Hospice providers who contract with this facility must have a written agreement with the facility outlining the responsibilities of the facility and the hospice agency. It is the responsibility of the hospice to manage the residents' care as it relates to terminal illness and related conditions including…

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 facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of five residents (Resident R64). Findings include:Review of facility policy Dignity dated 12/9/25, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered.Review of the clinical record indicated Resident R64 was admitted to the facility on [DATE].Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/28/25, indicated diagnoses of benign prostatic hyperplasia (BPH- a common enlargement of the prostate gland in aging men that squeezes the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for one of four residents reviewed (Resident R48).Findings include:Review of the facility policy Advanced Directives dated 12/9/25, indicated prior to or upon admission of a resident, the social services director or designee inquires of his/her family members and/or their legal representative, about the existence of any written advanced directives. If the resident indicates that they have not established an advanced directive the facility staff will offer assistance in establishing advanced directives. Staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.Review of the admission record indicated…

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 review of clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of five residents (Resident R41). Findings include: Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE], with diagnoses that included polyneuropathy (nerve disease caused by damage to many nerves), edema and obesity. Review of Resident 's Medicare 5-day MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 12/29/25, indicated the diagnosis remained current. Review of Resident R41's physician orders dated 12/29/25 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 140 = 0 units; 141 - 180 = 1 unit; 181 - 220 = 2 units; 221 - 260 = 3 units; 261 - 300 = 4 units; 301 - 340 = 5 units; 341 - 1000 = 6 units Call provider if CBG >340, subcutaneously with meals for IDDM Review of blood sugar summary indicated:…

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

Based on observations, resident and staff interviews it was determined that the facility failed to display (for the residents and family members) the required information on the grievance process for the building.Findings include: Review of facility policy Resident Grievance/Complaint Procedures dated? 12/9/25, indicated: Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at this facility. Grievances also may be voiced or filed regarding care that has not been furnished. Review of facility policy Grievance Program (Concern and Comment) dated 12/9/25, indicated: Purpose: To help guide our communities in the Grievance Process and ensure that a thorough, complete, and accurate investigation has been completed to the best of our knowledge in accordance with F585 483.10 (j)(1)(2)(3) and (4).The facility will post in prominent locations throughout the facility The Right to File Grievances orally (meaning…

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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers/injuries (PU/PI's - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four residents (Resident R11, and R93). Findings include: Review of the facility wound policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 12/9/25, indicated In addition, the nurse shall describe and document/report the following - a full assessment of pressure sore including location, stage, length, width, and depth presence of exudates or necrotic tissue. Review of Resident R11's admission record indicated she was originally admitted on [DATE], and re-admitted on [DATE]. Review of Resident R11's MDS dated [DATE], indicated diagnoses of non-Alzheimer's dementia with behavioral disturbance (brain diseases that mainly affect frontal and temporal lobes of the brain. These areas of the brain are…

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, review of clinical record, review of facility policy, interview with staff and resident, it was determined the facility failed to provide tracheostomy care consistent with professional standards of practice for one of two residents receiving oxygen (Resident R39). Findings include: Review of the facility policy Tracheostomy Care dated 12/9/25, indicated a replacement tracheostomy tube (a hollow tube inserted into a surgical opening in the neck (stoma) directly into the windpipe to provide long-term ventilation) must be available at the bedside at all times. Review of the admission record indicated R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/31/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and Schizophrenia (a disorder that affects 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R36). Findings include: Review of the facility policy Goals and Objectives, Care Plans last reviewed 12/9/25, indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Review of the admission record indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/23/25, indicated the diagnosis of heart failure (heart doesn't pump the way it should), hypertension and dementia. Review of Resident R36's physician progress notes dated 8/19/25, indicated past medical history that included but not inclusive to CAD, hypertension, hyperlipidemia, Post Traumatic…

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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in one of two medication rooms ( Renaissance unit), four of four medication carts (First Floor Carts A and B, and Renaissance Hall front and back), and failed to ensure medication carts were secured when not in presence of the nurse.Findings include: Review of the facility policy Storage of Medications dated 12/9/25, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. During an observation on 1/13/26, at 11:14 a.m. the Renaissance unit medication room refrigeration contained an ice pack. During an interview completed on 1/13/26, at 11:19 a.m. Licensed Practical Nurse (LPN) Employee E10 confirmed the ice pack was stored in the refrigerator and stated, the ice pack is used for the laboratory and should be stored in the laboratory refrigerator. During an observation on 1/13/26, at 1:24 p.m. the First Floor Cart A contained the undated medication of albuterol nebulizers (respiratory…

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 review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarters (January 2025, through March 2025 and July 2025, through September 2025).Findings include: Review of facility policy Quality Assurance and Performance Improvement Program Guidelines last reviewed 12/9/25, indicated the facility shall develop, implement, and maintain an ongoing, facility wide data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Review of the facility policy Quality Assurance and Performance Improvement last reviewed 12/9/25, indicated the following individuals serve on the committee: Administrator, Director of Nursing, Medical Director, Infection Preventionist, Pharmacy, Social Services, Activity Service, Environmental Services, Human Resources, Medical Records and Diagnostics. A review of the QAPI Committee meeting sign-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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to manage airborne isolation for Covid positive infections in one of seven rooms (Resident R37). Findings include: Review of the facility policy Coronavirus Disease (Covid-19) - Identification and Management of Ill Residents dated 12/9/25, indicated newly identified Covid-19 infection in resident; symptomatic residents regardless of vaccination status, are restricted to their rooms and cared for staff using a NIOSH (National Institute for Occupational Safety and Health) approved N95 or equivalent or higher level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and a gown. Review of Resident R37's admission record indicated admission to the facility on 8/11/25. Review of Resident R37's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/25, indicated diagnosis of hypertension (high blood pressure), renal insufficiency (a condition in which the kidneys lose the ability to remove…

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 upon review of clinical and hospital records, interviews with staff, and review of facility submitted documents and policies, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to ensure physician orders were transcribed accurately on admission for two of three records reviewed (Closed Record Resident R1 and Resident R2).Findings include: Review of facility policy Medication and Treatment orders, dated 1/2/25, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Only authorized licensed practioners, or individuals authorized to take verbal orders from practioners, shall be allowed to write orders in the medical chart. Review of clinical record indicated that Closed Record (CR) Resident R1 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 review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings as per order for one out of three residents (Resident R1).Findings include: Review of the facility policy Diabetes - Clinical Protocol dated 1/2/25, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration Record (MAR).Review of the admission record indicated Resident R1 was admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/25, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anemia (the blood doesn't have enough healthy red blood cells), and high blood pressure.Review of Resident R1's physician orders dated 5/25/25, indicated Insulin Lispro (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain residents were free from mental abuse, including abuse facilitated or enabled through the use of technology for one of five residents reviewed (Residents R1). Findings include: Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 1/2/25, indicated to establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Review of admission record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/11/25, indicated the diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), hypertension (the force of the blood against the artery walls is too high), and peripheral vascular disease (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R1 and R2). Findings include: Review of facility policy Respiratory Therapy dated 1/2/25, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. Change the oxygen nasal cannula (a medical device that provides supplemental oxygen to patients through two prongs inserted into the nostrils) every seven days, or as needed. Store the mask and plastic tubing from the nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) in a plastic bag, marked with date and resident ' s name, between uses. Review of the clinical record indicated Resident R1was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/20/25, indicated…

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 review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to implement their written procedures to prohibit and prevent abuse, neglect, and exploitation of residents by failing to perform criminal history background checks prior to the date of hire for five of six sampled records (Registered Nurse (RN) Employee E2, Nurse Aide (NA) Employee E17, Licensed Practical Nurse (LPN) Employee E18, NA Employee E19, and RN Employee E20). Findings include: The Safety-01 Abuse, Neglect, Exploitation general policy dated 5/1/22, last reviewed 1/3/24, indicated that the facility will obtain criminal and FBI background checks. Prior to the employee's first day of employment, the facility will make reasonable efforts to obtain personal and professional reference information. Documentation will note conducted attempts. Review of Registered Nurse (RN) Employee E2's was hired to the facility on 9/3/24. Review of Registered Nurse (RN) Employee E2's personnel…

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 review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that the physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) included the size of the suprapubic catheter, balloon sizing, and the amount of fluid needed to insert for balloon inflation/securement (the balloon keeps catheter in the bladder) for three out of seven sampled residents (Residents R53, R58, and R316 ) and failed to ensure catheter bags were covered as required for two of seven sampled residents (Residents R58, and R316). Findings include: Review of the facility policy Suprapubic Catheter Replacement dated 1/3/24, indicated verify that there is a physician's order. Review the resident's care plan to assess for any special needs of the resident. Supplies needed indicated catheter of proper size and composition (ordered by the physician). Review of the facility policy Dignity dated 1/3/24, indicated staff are expected to promote dignity…

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 review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for four of five residents (Residents R14, R22, R58, and R314) and failed to maintain an accurate care plan for dialysis access site for two of five (Resident R22, and R314). Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with dated 1/3/24, indicated communication between the dialysis provider and facility staff will occur, and staff will be knowledgeable of the care of grafts and fistulas. The resident's comprehensive care plan will reflect the resident's needs related to End Stage Renal Disease and dialysis care. Review of Resident R14's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/11/24, indicated diagnoses of cerebral infarction (necrotic tissue in the brain…

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 review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of four nurse aide personnel records (Nurse Aide (NA) Employee E10, NA Employee E11, and NA Employee E12). Findings include: Review of CFR (Code of Federal Regulations) §483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). Review of NA Employee E10's personnel record indicated she was hired to the facility on 8/25/14. Review of NA Employee E11's personnel record indicated she was hired to the facility on 3/2/09. Review of NA Employee E12's personnel record indicated he was hired to the facility on [DATE]. Review of personnel records did not include an annual performance evaluations based on the date of hire for NA…

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 review of facility policy, clinical record, and staff interview it was determined that the facility failed to conduct a thorough investigation for one of three residents (Resident R77). Findings include: Review of facility policy Abuse Neglect Exploitation General Policy dated 1/3/25, indicated Investigation - The facility is responsible for investigating and reporting cases of possible abuse, neglect including involuntary seclusion, exploitation, and misappropriation of property to external agencies in accordance with laws and regulations. Review of facility policy Abuse Investigation and Reporting, Protection and Response dated 1/??/25, indicated skilled nursing facilities are responsible for the investigation and reporting of allegation of abuse, neglect, or misappropriation of a resident's property. Review of Resident R77 clinical record was admitted on [DATE]. Review of Resident R77 MDS (minimum data set - a periodic assessment of resident needs) dated 11/26/24, indicated diagnosis of renal…

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 review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for two of seven residents (Residents R8 and R316) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated 1/2/25, indicated the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes measurable objectives and timeframes and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the admission record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/23/24, indicated the diagnoses of heart failure, mild cognitive impairment, and anxiety disorder. Review of Resident R8's physician order dated 11/19/24, indicated FreeStyle…

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 review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings as per order for one out of three residents (Resident R108). Findings include: Review of the facility policy Diabetes - Clinical Protocol dated 1/2/25, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration Record (MAR). Review of the admission record indicated Resident R108 was admitted on [DATE]. Review of Resident R108's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/16/24, indicated the diagnoses of benign prostatic hyperplasia (BPH- age related prostate gland enlargement that can cause urination difficulties), obstructive uropathy (a structural or functional hindrance of normal urine flow), and diabetes (a long-term condition in which the body has trouble controlling…

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 review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers/wounds for two of six residents (Residents R317 and Resident R51). Findings include: Review of the facility policy Prevention of Pressure Injuries dated 1/3/24, indicated review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Use a standardized pressure injury screening tool to determine and document risk factors. Conduct a comprehensive skin assessment. Implement preventative skin care interventions. Select appropriate support surfaces based on the resident's risk factors. Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility policy Care Plans, Comprehensive Person-Centered dated 1/3/24, indicates the facility must develop a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Residents R14). Findings include: Review of facility policy Enteral Nutrition dated 1/2/25, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. The use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policy. Review of Resident R14's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/11/24, indicated diagnoses of cerebral infarction (necrotic…

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 a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of three residents (Resident R59). Findings include: Review of the facility policy Hospice Services dated 1/2/25, indicated that hospice services are available to residents at the end of life. The facility is responsible for collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; obtaining the following information from the hospice: - the most recent hospice plan of care - hospice election form - physician certification and recertification of the terminal illness - names and contact information for hospice personnel involved in hospice care - instruction on how to access the hospice's 24-hour on-call system Coordinated care plan for residents receiving hospice services will include the most recent hospice plan of care 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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for two of seven residents (Residents R22, and R315), failed to have proper interventions carried out by staff for one of two positive Covid residents (Resident R34). Findings include: Review of the facility policy Transmission Based Precautions dated 1/3/24, indicated enhanced barrier precautions (EBP) are in place for residents with an infection or colonization of a multi-drug resistant organism (MDRO), wounds and/or indwelling medical devices, such as an indwelling catheter, trach/vent, central line, and feeding tube. Gowns and gloves are to be on and used when providing high contact care with a resident who is in EBP. Review of the facility policy Covid -19 Identification and Management of Ill Residents dated 1/3/24, indicated newly identified Covid-19 infection in a resident is evaluated as a potential outbreak. Symptomatic residents are…

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 review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for one out of five sampled records (Nurse aide Employee E3). Findings include: The Safety-01 Abuse, Neglect, Exploitation general policy dated 5/1/22, last reviewed 1/3/24, indicated that all employees and contracted staff will be educated upon orientation, annually, and as indicated on topics to include resident rights,privacy and confidentiality , and abuse prevention. Staff will be educated on recognizing the signs of abuse, neglect and exploitation. Review of Nurse aide (NA) Employee E3's personnel record indicated she was hired 10/2/24. Review of nurse deployment documents (form indicating the name and number of nursing staff working a specific date), indicated that Nurse aide (NA) Employee E3 first worked on the floor starting 10/7/24. After her orientation was completed, Nurse aide (NA) Employee E3 worked on 10/13/24 and continued to work at the facility. Review 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 clinical record and interview, it was determined that the facility failed to notify the resident's responsible party of changes in condition for one of six sampled residents (Resident R1). Findings include: Review of the Resident R1 admission record indicates she was admitted on [DATE]. Review of Resident R1 quarterly MDS assessment (MDS-Minimum Data Set Assessment. Periodic assessment of resident care needs) dated 1/5/2024, indicated that the resident current diagnoses were Alzheimers (progressive mental deterioration due to generation of the brain), rheumatoid arthritis, hypertension, and obesity. Review of Resident R1 medical records indicated that in 12/13/2023 a new guardian was appointed for the resident. Review of Resident R1 nurse progress dated 1/31/2024 indicated that a message was left with the POA regarding the physician recommendation. Review of Resident R1 nurse progress dated 2/4/2024 indicated that a message was left with the son regarding a fall the resident sustained. During an…

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 review of facility baseline care plan summary, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan was completed and implemented within 48 hours of admission for four of eight residents (Residents R95, R105, R333, and R262). Findings include: The facility Baseline Care Plan Summary , last reviewed 1/3/24, indicated that all residents will have a Baseline Care Plan Summary completed within 48 hours of admission. A baseline careplan should include the minimum healthcare information necessary to properly care for a resident including physician orders, dietary orders, therapy services, social services, and PASARR recommendation, if applicable. Review of Resident R95's admission record indicated resident was admitted on [DATE]. Review of Resident R95's MDS assessment ( Minimum Data Set Assessment: A periodic assessment of resident care needs ) dated 1/10/24, indicated he was admitted with the following diagnoses , Parkinson's disease…

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 review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs of one of five residents (Resident R69). Findings include: Review of facility policy 2.3 Call Lights dated 1/3/24, indicated all residents have a standard call light or alternative communication device within their reach at all times when unattended. Review of the clinical record indicated Resident R69 was admitted to the facility on [DATE]. Review of Resident R69's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/23/23, indicated diagnoses of hypertension (high blood pressure), depression (a constant feeling of sadness and loss of interest), and osteoarthritis (degeneration of the joints causing pain and stiffness). During an observation on 1/22/24, at 9:29 a.m. Resident R69 was observed lying in bed with his soft touch call light placed on the left top corner of the mattress, completely out of the resident's visual sight and reach. During an…

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 the review of facility policy, clinical records, and staff interviews it was determined that the facility failed to maintain proper Advanced Directives on one of five residents ( Resident R95). Findings include: The facility POLST (Physician's Order for Life Sustaining Treatment) policy, last reviewed 1/3/24, indicated that all residents will have a POLST form completed or reviewed within 14 days of admission, if there is a change in the resident's status, and annually with the annual MDS schedule. In emergency life-saving treatment situations, consent is presumed for full treatment if a decision has not been made and minimum requirements for POLST are not completed. Review of Resident R95's admission record indicated resident was admitted on [DATE]. Review of Resident R95's MDS assessment ( Minimum Data Set Assessment: A periodic assessment of resident care needs ) dated 1/10/24, indicated he was admitted with the following diagnoses Parkinson's disease (neuromuscular disorder causing tremors and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R69). Findings include: Review of facility policy 15.7 Oxygen Therapy Via Nasal Cannula reviewed 1/5/23, and 1/3/24, indicated oxygen therapy via nasal cannula (a lightweight tube placed in the nostrils to provide oxygen) will be administered as ordered by a physician and will include correct flow rate, concentration, mode of delivery, and frequency. Replace cannula every seven days, date, and store in plastic bag when note in use. Review of facility policy SRC-Quality of Care-15.12 Small Volume Nebulizer-Breathing Treatment reviewed 15/23, and 1/3/24, indicated to date connecting tubing, change PRN (as needed) and as indicated. Review of the clinical record indicated Resident R69 was admitted to the facility on [DATE]. Review of Resident R69's Minimum Data Set (MDS - a periodic assessment of care…

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 review of facility policy, observation, and staff interviews, it was determined that the facility failed to label open medications with a date in two of four medication carts (2nd Floor Cart A and 3rd Floor High Side). Findings include: Review of facility policy SRC-Pharmacy-12.21 Medication Storage-AB dated 1/3/24, indicated all medications are maintained under strict conditions according to accepted standards of practice. An observation on 1/24/24, at 9:30 a.m. of the 2nd Floor Cart A medication cart revealed the following medications not dated upon opening: - Resident R69's Humalog pen (prefilled pen to inject rapid acting insulin under the skin). - Resident R85's NovoLog pen (prefilled pen to inject rapid acting insulin under the skin). - Resident R85's Lantus pen (prefilled pen to inject long acting insulin under the skin). During an interview on 1/24/24, at 9:32 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the findings noted above. An observation on 1/24/24, at 9:41 a.m. of the 3rd Floor High Side medication cart revealed the following medications 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 facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for two of four quarterly meeting (February 2023 thru December 2023). Findings Include: The facility Quality assurance and performance improvement (QAPI) policy dated 10/31/21 and last reviewed 1/3/24, indicated that the facility utilizes a quality assurance and performance improvement program. to comprehensively address systems of care and management practices. The administrator and the Medical director of each facility is responsible for implementation of the QAPI program. At minimum, the standing members of this committee are the Administrator, Medical director, Director of Nursing and the clinical staff responsible for infection control. Review of Quality assurance and performance improvement sign in sheets and attendance records from February 13, 2023 through December 14, 2023 did not indicate that the facility…

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.