Vincentian Home

Based on observations, review of facility documentation, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of three crash carts (Second Floor High Side Crash Cart and Second Floor Low Side Crash Cart).Findings include: Review of the facility Emergency Crash Cart policy dated 3/9/26, indicated the facility shall maintain an Emergency/Crash Cart in a readily accessible location to provide emergency equipment and supplies for resident emergencies. Minimum Crash Cart Contents include but are not inclusive of: Portable suction equipment. Weekly Crash Cart Checks: The nursing supervisor or designee shall verify:Crash carts are present and accessibleOxygen tank is adequately filledNo visible missing equipment. Following any emergency the nursing staff or nursing supervisor shall be responsible for re-stocking supplies or used equipment. During an observation completed on 5/27/26, at 11:39 a.m. it was revealed that the Second Floor High Side Crash Cart (a cart maintained with equipment used in cardiac…

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, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation to rule out physical abuse or neglect for one of three residents (discharged Resident R1). Findings include: Review of the facility policy Freedom from Abuse, Neglect, and Exploitation last reviewed 3/23/26, indicated to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident's property. All residents, staff, families, visitors, volunteers and resident representatives are encouraged to report and suspected acts of abuse, neglect, misappropriation of resident property or exploitation. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment:Thoroughly investigate the alleged violationPrevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progressTake appropriate corrective, because of investigation findings.Abuse is the willful infliction of…

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

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents (discharged Resident R1) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (discharged Resident R1, discharged Resident R2 and Resident R3).Findings include: Review of facility policy Resident Notice of Transfer or Discharge last reviewed 3/23/26, indicated before this facility transfers or discharges a resident admission coordinator/designee shall notify the resident/representative of the transfer or discharge and the reason for the move in writing and in the language and manner they understand. Record the reasons for the transfer or discharge in the resident's medical record. Review of the facility policy Notice of Bed Hold and Return last…

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 policies, documents, clinical records, and staff and resident interviews it was determined was determined that the facility failed to protect resident from neglect for one of three residents (Residents R1). Findings include: Review of the facility policy Freedom from Abuse, Neglect, and Exploitation last reviewed 3/19/25, stated it is the policy of the facility to maintain an environment where residents are free from abuse, neglect, and misappropriation of resident property. Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Resident Transfer Protocol last reviewed 3/19/25, stated appropriate transfer techniques shall be used according to each resident's strength, stamina, and ability to assist with the residents. Necessity for the amount and type of assistance shall be assessed upon…

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 policies, clinical records, and staff and resident interviews it was determined the facility failed to report an incident of neglect within 24 hours to the local state field office for one of three residents (Residents R1). Findings include: Review of the facility policy Incident-Clinical Protocol last reviewed 3/19/25, stated anyone who witnesses, discovers or is involved in an incident is responsible for reporting to the Licensed Nurse on the unit as soon as possible, on the day of discovery. In the event, that it was determine the :incident was reportable to the State Agency , it will be done timely and submitted by the Director of Nursing or Designees. Review of the facility policy Freedom from Abuse, Neglect, and Exploitation last reviewed 3/19/25, stated it is the policy of the facility to maintain an environment where residents are free from abuse, neglect, and misappropriation of resident property. Neglect is defined as the failure of the facility, its employees or services…

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 policies, documents, clinical records, and staff and resident interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided to prevent a roll out of bed for one of five residents (Residents R1). Findings include: Review of the facility policy Resident Transfer Protocol last reviewed 3/19/25, stated appropriate transfer techniques shall be used according to each resident's strength, stamina, and ability to assist with the residents. Necessity for the amount and type of assistance shall be assessed upon admission and on an ongoing basis. Review of the facility policy Falls and Falls with Major Injury last reviewed 3/19/25, stated all facility staff is responsible for implementing the intent and directives contained within this policy, and for creating a safe environment of care. It is the facility's policy to minimize the risk of falling, and injuries sustained from falls, without compromising the mobility and functional…

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 that the facility failed to determine it was safe to self-administer medications, did not have a current order or care plan to self-administer medications, or an interdisciplinary assessment for one of five residents (Resident R302). Findings include: Review of the facility policy Self-Administration of Medications by Residents last reviewed 3/19/25, indicated self-administration of medication is the ability of a resident to take medications independently without assistance from another person. The resident shall be assessed for competency using the assessment for self-administration of medications. The results shall be documented in the resident's record and care plan. Specific orders for self-administration of medication shall be documented in the resident's medical record and care plan. Each resident's medication shall be clearly labeled by the prescribing pharmacy. Review of the facility policy Skin and Wound…

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, and interview, it was determined that the facility failed to have physician order specifications relating to the size of indwelling catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R305). Findings include: Review of the facility policy Foley Catheter Care last reviewed 3/19/25, indicates to maintain a closed, sterile drainage system and minimize the risk of infection. Obtain physician order for foley catheter use. Include bulb and catheter size, frequency of catheter changes and catheter care instructions. Review of admission record indicated Resident R305 was admitted to the facility on [DATE], with the diagnosis of dysphagia (difficulty in swallowing), chronic kidney disease (affects the kidneys ability to filter waste), and urinary retention (bladder doesn't completely empty). Review of Resident R305's physician orders…

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 policies, observations, clinical record review, and staff, resident, and family interviews, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Residents R67 and R307). Findings include: Review of the facility policy C-PAP/Bi-PAP Storage dated 3/19/25, indicated it is the policy of the facility to store CPAP (a method of positive pressure ventilation used with patients who are breathing spontaneously) machine in a clean dry environment. When not in use, place clean mask in a plastic bag (not airtight). Review of the facility policy Oxygen Concentrators-Usage and Care last reviewed 3/19/25, indicates Nasal cannulas, masks, tubing and water bottles are to be changed weekly. The water bottle and tubing are to be dated and stored in a plastic bag attached to the concentrator when not in use. Review of the clinical record indicated that Resident R67 was admitted to the facility on [DATE], with diagnoses of anemia (a condition that…

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, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of five residents (Resident R250). Findings include: Review of the facility policy, Pharmacy Requirements last reviewed 3/19/25, indicated regular and reliable pharmaceutical service is available to provide residents with prescriptions and non-prescriptions medications, services, and related equipment and supplies. Pharmacy services will be provided routine and timely. Review of Residents R250's admission record indicated admission to the facility on 4/24/25, with diagnoses of anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), calculus of kidney, and Alzheimer's Disease (a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to carry out daily tasks). Review of Resident R250's physician order dated 4/24/25, indicated to administer two tablets of TheraLith XR (medication…

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

Based on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of four nursing units (Building 2-2) failed to properly store medical supplies in two of five medication carts (County high hall and Country low hall ) and two of four medication rooms (Beach hall high and Country hall high). Findings include: Review of the facility policy Medication Storage last reviewed 3/19/25, indicated medications and biologicals are stored safely, securely, and properly following manufactures recommendations or those of the supplier. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access. Review of the facility policy Medication Administration last reviewed 3/19/25, indicated the individual administering a medication shall be aware of the following information including but not inclusive…

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 interviews, it was determined that that the facility failed to implement a surveillance plan for tracking, and monitoring residents who tested negative for COVID during an outbreak for six of six months (August 2024 to February 2025) and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R67) Review of the Respiratory Virus Outbreak Toolkit dated 11/14/24, indicated a case-line listing is designed to collect information about all ill cases (residents and staff) during an outbreak in a long-term care facility. It was indicated upon identification of an outbreak, use this template to collect and organize information on cases. The type of test ordered and if pathogens were detected must be recorded. A review of the facility policy Skin and Wound Assessment, last reviewed 3/19/25, guidelines for the application of dry, clean dressings indicates step in procedures…

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 review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three out of three residents sampled with facility-initiated transfers (Residents R17, R38, and, R93). Findings include: Review of facility policy Transfers Between Facility and Hospital dated 4/17/24, indicated a resident Transfer and Referral record must be completed in full and sent with the resident. The following information shall be included: the reason for the transfer, the resident's physical status, the resident's psychosocial status, a summary of care, treatment, and services the resident has received, the resident's progress towards goals, a list of community resources or referrals made or provided to the patient, and the resident's normal level of ADL prior to the illness requiring transfer to the acute hospital. The complete medical record shall be sent with the resident, including completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of four residents (Resident R17, R38, and R93). Findings include: Review of Title 42 Code of Federal Regulations §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term…

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 policies, clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for one of five residents (Resident R174), failed to perform weekly skin assessments per physician order for three of ten residents (Resident R50, R382, and R385), and failed to obtain weekly labs for one of six residents (Resident R50). Findings include: Review of facility policy Skin Assessment dated 4/17/24, indicated the facility will assess all resident's skin integrity and identify those at risk for developing pressure ulcers. The nurse will complete a skin assessment upon admission/readmission and weekly times four weeks, minimally. Review of the clinical record revealed that Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 4/4/24, indicated diagnoses of anemia (too little iron in the body causing fatigue), dementia (a group 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 obtain a diagnosis for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of three residents (Resident R17, R53, R62). Findings include: Review of the facility policy Hospice Services dated 4/17/24, indicated that care for the dying resident shall be a collaborative effort between the staff of the designated hospice provider and the staff of the long term care facility. The facility will obtain information from hospice that includes names and contact information for hospice staff involved in the resident's care, and how to access the hospice's 24 hour on-call system. Review of the clinical record revealed that Resident R17 was admitted to the facility on [DATE]. Review of Resident 17's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 3/22/24, 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 policies, clinical records, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of six residents (Resident R114). Findings include: A review of the facility's policy Medication Administration dated 4/17/24, indicated that medications shall be administered only upon the order of physicians. No medication shall be left at the resident's bedside. The nurse administering the medication shall stay with the resident until the medication is taken. If a medication has been opened and is refused by a resident, it shall be destroyed. Review of Resident R114's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident R114's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/20/24, indicated diagnosis of hypertension (high blood pressure in the arteries), osteoporosis (condition when the bones become brittle and fragile), and anxiety. 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 review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to prevent accidents for one of four residents (Resident R13), and ensure that residents received neurological assessments after an incident involving an unwitnessed fall for two of four residents (Residents R54 and R81). Findings include: The facility Falls and Falls with Major Injury policy dated 4/26/23, last reviewed 4/17/24, indicated it is the facility policy to minimize the risk of falling, and injuries sustained from falls, without compromising the mobility and functional independence of residents. It was indicated after a fall, if a resident has just fallen or is found in the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities, and complete neurological checks for 72 hours. It was indicated neurological checks must be performed 4x for 15 minutes, 4x for 30 minutes, 4x for one hour, 4x for four hours, and 4x for four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure a physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) for one of three residents (Resident R385), and failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for two of three residents (Resident R49, and R385). Findings include: Review of the facility policy Indwelling urinary catheter insertion and Maintenance, dated 4/17/24, indicated that a resident should have a physician's order for a catheter that includes the type of catheter and the purpose for the catheter. Change catheters and drainage bags based on physician order. Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident 49's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 4/30/24, indicated diagnoses 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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to identify and address significant weight loss in a timely manner for one out of five residents (Resident R78), failed to obtain daily weights for two out of five residents (Resident R114 and R382), and failed to notify physician of weight gain per physician orders for one out of five residents (R114). Findings include: Review of facility policy Weighing and Measuring the Resident dated 4/17/24, indicated the threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: 1 month - 5% weight loss is significant; greater than 5% is severe 3 months - 7.5% weight loss is significant; greater than 7.5% is severe 6 months - 10% weight loss is significant; greater than 10% is severe Review of the clinical record indicated Resident R78 was admitted to the facility on [DATE]. Review of Resident R78'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 properly secure one of four medications carts reviewed (Building One Second Floor Low Side Med Cart). Findings include: Review of facility policy Drug Acquisition, Storage, Inspection, and Dispensing dated 4/17/24, indicated medications shall be stored in a secure manner. Lockable medication carts shall be used to store unit-of-use medications in the resident medication dose system. These carts shall be locked when not attended. During an observation on 5/28/24, at 10:09 a.m. the Building One Second Floor Low Side Med Cart was observed unlocked and unattended with the top drawer pulled open. During an interview on 5/28/24, at 10:10 a.m. Registered Nurse Employee E2 confirmed that the medication cart was unattended, unlocked, and the top drawer was pulled open. During an interview on 5/28/24, at 1:31 p.m. the Nursing Home Administrator confirmed that the facility failed to properly secure one of four medications carts reviewed (Building One Second Floor Low Side Med…

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, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physicians' orders regarding surgical site care which resulted in a failure of timely care for three of five residents (Residents R1, R2, and Closed Record CR1). Findings Include: A review of the facility policy, Skin Assessment dated 4/26/23, indicated: -Non-pressure related skin conditions include but is not limited to skin tear, arterial ulcer, venous ulcer, foot problem, surgical wound, rash, cut, laceration, open lesion, or burn. -The licensed nurse will complete a head to toe skin assessment within two to six hours of admission/readmission to identify the presence of any skin issue. -If a non-pressure area is identified, will document a complete assessment on the N. Adv Skin Only Evaluation and reassess weekly until healed. -Describe the treatment order and response to treatment. Review of admission…

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 policies, observations and staff interviews it was determined that the facility failed to provide a dignified dining experience to the residents of one of five nursing units/country kitchen (Building Two, Floor Two). Findings include: A review of facility policy Resident Rights dated 10/18/23, indicated that residents of the facility have a right to a dignified existence. During an observation on 10/19/23, at 9:00 a.m., it was revealed that the facility was utilizing disposable styrofoam products to serve the residents their breakfast meal for residents of the Building Two, Floor Two Nursing unit/Country Kitchen. During an interview on 10/19/23, at 9:30 a.m., the Food Service Manager Employee E1 confirmed that the facility's dish machine located at Building Two, Floor Two Nursing unit/Country Kitchen had been non operational for an extended undetermined length of time, Food Service Manager Employee E1 also confirmed that the facility was using disposable styrofoam products to serve residents all of their meals. During an interview on 10/19/23, at 2:30…

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 policies and staff interviews it was determined that the facility failed to maintain equipment vital to the operation of the facility in proper working condition for one of five country kitchens (Building Two, Floor Two). Finding include: A review of the facility's policy Preventative Maintenance of Equipment reviewed on 4/26/23, and 10/18/23, revealed that the facility maintains equipment vital to the operation of the facility in proper working order. During an interview on 10/19/23, at 9:30 am Food Service Manager Employee E1 it was revealed that the dish machine located at Building Two, Floor Two Country kitchen was non operational for an extended period of time. The Food Service Manager Employee E1 further confirmed that the facility does not maintain maintance logs for dietary department equipment. It is the procedure of the facility's dietary department to request repair service from an out side repair company. The dietary department failed to maintain records of these repair requests thus resulting in an uncompleted timeline for the repair 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.