Five Counties Nursing Home

Based on observation, interview, and record review, the provider failed to post the required daily nurse staffing information in a prominent location that was readily accessible to residents and visitors and to include the actual hours worked of nursing staff. Findings include: 1. Observation 3/12/25 at 8:00 a.m. of the posted nurse staffing information revealed: *It was posted on a board near the nurse's station. *It would not be readable to a resident or visitor in a wheelchair at the height it was posted. *There were three categories of staff listed on the sheet: RN (registered nurse), LPN (licensed practical nurse), and CNA (certified nursing assistant). *Under the LPN and CNA category the number of those staff scheduled for the day was listed by shift. *There were no numbers listed under the RN category. *There were no documented actual hours worked on the form for the nursing staff. 2. Interview on 3/12/25 at 8:54 a.m. with director of nursing (DON) B about posting the daily staffing revealed: *CNA/certified medication aide (CMA) K was responsible for developing the schedule.…

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

Based on observation, record review, interview and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential theft) to ensure accurate and complete documentation for those medications related to their receipt, counts, administration details including the dates given and the resident names, and destruction process. Findings include: 1. Observation on 3/10/25 at 2:07 p.m. of the North wing medication cart revealed: *There was a three-ring binder labeled North Narcotic Binder on top of the medication cart that contained: -A March 2025 CONTROLLED DRUG COUNT RECORD. --That form had two columns for nurse initials labeled NURSE ON and NURSE OFF and rows numbered 1 through 31 which indicated days of the month. --There were no nurse initials for two nurses on 3/1/25 and 3/2/25 and only one nurse on 3/4/25. -Multiple forms labeled CONTROLLED DRUG RECORD Individual Patient's Narcotic Record. --Those forms included areas for the resident's name, medication name and strength, directions for administration 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 observation, record review, interview, and policy review, the provider failed to follow standard food safety practices to ensure: *The mechanical dishwashers, refrigerator, and freezer temperatures were monitored and logged according to their policy. *Single-use food containers were not used to store leftover food. *Clean dishes were not stored on frayed cloth towels. Findings include: 1. Observation on 3/9/25 at 1:59 p.m. in the kitchen revealed the posted dishwasher temperature log for March 2025 was not completed for 3/4/25 through 3/7/25 and 3/9/25. *The dishwasher temperature logs for January, February, and March 2025 had no temperatures documented on 36 of 67 days. *The freezer temperature logs for February and March 2025 had no temperatures documented on 15 of 36 days for two of two freezers. *The walk-in cooler temperature logs for February and March 2025 had no documented temperatures on 8 of 36 days. *The satellite kitchen refrigerator/freezer temperature logs for February and March 2025 had no temperatures documented on 7 of 31 days. Interview on 3/11/25 at 4:40…

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

Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered by administrator A, director of nursing (DON) B, and assistant director of nursing (ADON) G, in a manner that ensured quality of life and overall well-being for all 39 residents in the facility. Findings include: 1. Observations, interviews, record reviews, and policy reviews throughout the survey on 3/9/25 from 1:00 p.m. through 6:00 p.m., 3/10/25 from 7:30 a.m. through 6:15 p.m., 3/11/25 from 7:00 a.m. through 6:00 p.m., and 3/12/25 from 7:30 a.m. through 5:30 p.m., revealed administrator A, DON B, and ADON G, had not ensured the management, safety, quality of life, and overall well-being of all the residents who lived in the facility. Those were evidenced by: *A widespread system breakdown to ensure services provided: -Met professional standards as it pertained to: --Medication administration and storage. --Addressing and notifying the physician of the significant weight loss for one resident (36). --Identifying and…

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

Based on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all 39 residents in the facility. Findings include: 1. During the survey on 3/9/25 from 1:00 p.m. through 6:00 p.m., 3/10/25 from 7:30 a.m. through 6:15 p.m., 3/11/25 from 7:00 a.m. through 6:00 p.m., and 3/12/25 from 7:30 a.m. through 5:30 p.m., it was identified that the provider had not operated in a manner to ensure residents received quality care. Administrator A had not been assisted with her duties to ensure she was able to effectively provide guidance to staff to be able to provide quality care. Those were evidenced by: *A widespread system breakdown to ensure services provided: -Met professional standards as it pertained to: --Medication administration and storage. --Addressing and notifying the physician of the significant weight loss for one resident (36). --Identifying and addressing low blood sugars for one diabetic resident (5). -Met the requirements for sufficient…

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 record review, interview, and Arbitration Agreement review, the provider failed to ensure seven of thirteen sampled residents (13, 21, 23, 24, 25, 36, and 142) and three of three recently admitted residents (38, 39, and 142) who had entered into an Arbitration Agreement upon admission to the facility: *Were not required to sign a binding arbitration agreement as a condition of admission to receive care at the facility. *Were explained the arbitration agreement in a form and manner including a language that the resident or his/her representative understood. *Were explicitly granted the right to rescind the agreement within 30 calendar day of signing it. Findings include: 1. Record review on 3/10/25 at 1:00 p.m. of the Resident List Report printed at 12:10 p.m. that day by administrator A revealed: *The report listed forty residents which included thirty-nine residents in the facility and one resident who was hospitalized . *A handwritten note by administrator A that indicated All residents have a signed…

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

Based on interview and Arbitration Agreement review, the provider failed to ensure the provider's Arbitration Agreement: *Included the arbitration organization's name and how to contact that organization. *Provided for the selection of a neutral arbitrator agreed upon by both parties. *Provided for a location that was convenient for both parties for an arbitration dispute. Findings include: 1. Interview and record review of the provider's one-page arbitration agreement on 3/10/25 at 5:43 p.m. with administrator A revealed that the agreement had not included: *The arbitration organization's name and how to contact that organization. *For the provision of the selection of a neutral arbitrator agreed upon by both parties. *For the provision of a location that was convenient for both parties for an arbitration dispute. *Administrator A agreed with those findings above. Interview on 3/11/25 at 1:10 p.m. with administrator A regarding the arbitration agreement revealed: *The provider had no policy regarding arbitration agreements. *She agreed the arbitration agreement was poorly written.

Based on Payroll Based Journal (PBJ) record review, employee timecard review, and interview, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters reviewed Quarter 2, 2024 (January 1 through March 31, 2024); Quarter 3, 2024 (April 1 through June 30, 2024)2024); and Quarter 4, 2024 (July 1 through September 30, 2024). Findings include: 1. Review of the PBJ records submitted to the Center for Medicare and Medicaid Services (CMS) revealed the provider submitted the following for licensed nursing coverage not being covered 24 hours per day for: *Quarter 2, 2024 for 34 days. *Quarter 3, 2024 for 11 days. *Quarter 4, 2024 for 30 days. 2. Review of the PBJ records submitted to CMS revealed the provider submitted the following for RN (registered nurse) coverage for 8 consecutive hours per day for: *Quarter 2, 2024 for 16 days. *Quarter 4, 2024 for 4 days. 3. Review of the provider's employee timecards revealed: *Quarter 2, 2024; 24-hour licensed nursing coverage was verified for 13 of the 34 days that were triggered for no 24-hour licensed nursing…

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

Based on interview, and quality assurance and performance improvement (QAPI) plan policy review, the provider failed to ensure they had identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, or monitored regarding nurse staffing, siderails, medication administration and storage, baseline care plans, and arbitration agreements. Findings include: 1. Interview on 3/12/25 at 11:29 a.m. with administrator A regarding the QAPI program and committee revealed: *She was the QAPI coordinator for the provider and stated each department manager conducted their own audit, discussed that audit with the QAPI committee, and implemented any plan needed for correction. *The provider's QAPI committee was comprised of: -All the department managers. -Administrator A. -Director of nursing (DON) B. -The following committee members attended on a quarterly basis: --The medical director. --The executive director. --The consultant dietitian (by phone). *The QAPI committee was…

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

Based on record review and interview, the provider failed to ensure the proper Medicare Notices were completed accurately for: *Two of two sampled residents (10 and 33) who had remained in the facility following their discharge from Medicare part A skilled services. *One of one sampled resident (41) who had discharged to home following their discharge from Medicare part A skilled services. Findings include: 1. Review of resident 10's electronic medical record (EMR) revealed: *She had a 3/4/25 Brief Interview for Mental Status (BIMS) assessment score of 14, which indicated she was cognitively intact. *Her last covered day of Medicare Part A skilled services was 10/30/24. *The section of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form Beginning on with a blank for the date that her Medicare coverage ended was missing and appeared to have been whited out. *The signature box contained a handwritten note, Phone: [name of family member]/[signature of director of nursing (DON) P]. -There was no documentation of the time of that notification. -There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled resident (9 and 21) privacy had been maintained related to audio or video monitoring devices. The provider had not followed their policy for video monitoring related to: *Ensuring a cognitively intact resident had consented and been aware of the monitoring device in his room. *Staff training and awareness with the devices including which residents had them, when to turn off or block the device to ensure the residents' privacy, the process for consents by the residents and staff, and ensuring a sign was posted to notify others of the video monitoring device. Findings include: 1. Observation on 3/9/25 at 2:36 p.m. of resident 9's room revealed there was a white ball-shaped device on a stand on the dresser with a camera lens that faced resident 9's bed. Observation on 3/10/25 at 1:47 p.m. of resident 9's room revealed: *The above observed device was no longer present. *There was no signage present at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Observation and interview on 3/10/25 at 8:51 a.m. of resident 142 revealed she: *Was seated in a wheelchair by the bathing room. *Stated she was recently admitted for occupational therapy and physical therapy. *Planned to return to her home within the next 30 days. Review of resident 142's EMR revealed: *She was admitted on [DATE]. *Her 3/4/25 BIMS assessment score was a 14, which indicated her cognition was intact. *Her diagnoses included: muscle weakness, Erythema Intertrigo (redness, inflammation, and irritation in the skin folds), lumbar radiculopathy (compressed or irritated nerves in the back that may cause pain and other symptoms), and retention of urine. *Her 3/4/25 baseline care plan included focus areas of: -She did not have a POA (financial and care). -She had the potential of a psychosocial well-being problem related to her major life adjustment of having admitted to the facility and losing her independence. -To ensure on or before admission, and throughout stay, I am reviewed for appropriateness…

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, record review, interview, and policy review, the provider failed to follow professional standards of practice related to: *Physician notification of and implementation of appropriate interventions for one of one sampled resident's (36) significant weight loss as directed in their policy. *Identification and implementation of interventions for one of one sampled resident (5) with low blood sugars. *Holding the administration of insulin for one of one sampled resident (5) with low blood sugars without a physician's order. Findings include: 1.Observation on 3/9/25 at 3:39 p.m. of resident 36 in the hallway revealed she had significant swelling to her ankles. Review of resident 36's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 3/5/25 Brief Interview of Mental Status (BIMS) assessment score was 1, which indicated she had severe cognitive impairment. *Her diagnoses included disorder of electrolyte and fluid balance, heart failure, dehydration, and dementia. *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 observation, interview, record review, and policy review, the provider failed to assess two of two (24 and 36) sampled residents for their need for trauma-informed care. 1. Observation and interview on 3/9/25 at 3:10 p.m. with resident 24 revealed: *Her room had piles of clothing, books, and papers. *She believed someone had taken some of her belongings. *She believed her daughters had been molested by her husband. Review of resident 24's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 1/27/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her diagnoses included anxiety and major depressive disorder. -A copy of resident 24's trauma-informed care assessment was requested from the provider on 3/11/25 at 4:10 p.m. but was not provided for review by the end of the survey. Review of resident 24's 3/10/25 care plan revealed: *She had a focus area of, behavior problem r/t [related to] Depression and Anxiety Disorders.…

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 record review, observation, interview, and policy review, the provider failed to ensure residents who used bed rails/assist bars had: *A signed consent for their use for two of twelve sampled residents (23 and 25). *The medical symptoms for use documented on the Side Rail Assessments for five of twelve sampled residents (6, 9,13, 21, and 36). *Received education on the risks of use versus benefits of use of side rails/assist bars for one of twelve sampled residents (9). *Other attempted interventions documented on the Side Rail Assessment for one of twelve sampled residents (23). Findings include: 1. Review of resident 23's 2/23/25 Side Rail Assessment revealed the area that was to indicate if a consent form had been signed was left blank. 2. Review of resident 25's 1/25/25 Side Rail Assessment revealed the area that was to indicate if a consent form had been signed was left blank. 3. Review of resident 6's 1/12/25 Side Rail Assessment revealed the area that was to have her medical condition/symptoms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to: *Ensure medications were labeled properly for four of four random residents (3, 5, 20, and 32) related to having the pharmacy label remain with the medication and to follow the manufacturers' instructions for use-by dates. *Ensure proper labeling and storage of medication for one of one resident (29) with a medicated ointment stored unsecured in her room. Findings include: 1. Observation on 3/10/25 at 2:32 p.m. of the medication storage room with certified medication aide (CMA) Z revealed: *There were three insulin pens on the top of the treatment cart. -The pens were labeled for residents 3, 5, and 20. *All three insulin pens had the pharmacy label attached to the removable cap. *All three insulin pens were insulin aspart (a fast-acting insulin) and were not labeled with a date to have indicated when the pen was removed from the refrigerator for its first use or when they should have been used by. 2. Interview on 3/10/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to assess side rails on 13 of 13 sampled residents' beds (2, 3, 5, 6, 9, 13, 16, 21, 23, 24, 25, 36, and 142) routinely as a part of a safety and preventative maintenance program to ensure those side rails were in good working order and safe from possible resident entrapment or injury. Findings include: 1. Observation on 3/9/25 at 2:31 p.m. of resident 36 revealed she had two quarter-length side rails in the up position at the head of her bed. 2. Observation on 3/9/25 at 2:32 p.m. of resident 24 revealed she had two quarter-length side rails in the up position at the head of her bed. 3. Observation on 3/9/25 at 2:36 p.m. of resident 9 revealed he had two quarter-length side rails in the up position at the head of his bed. 4. Observation on 3/9/25 at 3:42 p.m. of resident 5 revealed she had two quarter-length side rails in the up position at the head of her bed. 5. Observations on 3/9/25 between 3:48 p.m. and 5:30 p.m. and on 3/10/24 between…

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 record review, interview, and policy review the provider failed to ensure a thorough investigation was completed regarding an allegation of abuse for one of one sampled resident (5). Findings include: 1.Review of a 12/25/24 grievance form completed by registered nurse (RN) Q regarding resident 5 revealed: *The nature of the grievance was Resident reports CNA [certified nursing assistant] R used unnecessary force and maleficence [harmful] while giving cares in changing her brief and providing peri-care during repositioning/turning. *The incident was documented attached to the grievance as happening between 7:30 a.m. and 8:00 a.m. on 12/25/24. *RN Q's documentation attached to the grievance stated, Upon entering [the] resident's room she was visibly upset, looking to me and stating, 'I don't know what else to do. I know I can trust you to make this right.' She then reported the following: - CNA R was in resident 5's room completing morning cares and resident 5 was lying on her right side holding onto 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 observation, record review, interview, and policy review, the provider failed to ensure documentation related to a gradual dose reduction (GDR) had occurred to support the rationale for not completing a GDR for one of one sampled resident (5) who received psychotropic medications (any medication that affects brain activities associated with mental processes and behaviors). Findings include: 1. Observation and interview on 3/9/25 at 3:42 p.m. of resident 5 in her room while she was in bed revealed she had slow slurred speech. 2. Review of resident 5's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 12/26/24 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her diagnoses included schizoaffective disorder (a mental health condition that includes symptoms of both schizophrenia and mood disorder), depression, and anxiety. *She had a physician order to receive mental health services. *She had multiple psychotropic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of SD DOH complaint report submitted on 1/15/25 at 4:53 p.m. revealed: *The complainant wished to remain anonymous. *The complainant reported concerns with the accuracy of resident assessments and timeliness of the documentation of resident assessments at the facility. 3. A review of resident 2's electronic medical record (EMR) revealed: *Her diagnoses included secondary hypertension (high blood pressure from an underlying medical condition), hyperlipidemia (high cholesterol), chronic obstructive pulmonary disease (COPD), anemia, peripheral vascular disease (progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel), and essential hypertension (the most common type of high blood pressure). *Previous vital signs were documented instead of having checked and documented her current vital signs each day. From 10/4/24 to 11/12/24, her: - Blood pressure was checked on 33 out of 41 days. - Pulse was checked on 24 out of 41 days. - Temperature was checked on 25 out of 41 days.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provided failed to ensure the following: *Post-fall monitoring was completed and documented in a timely manner for one of one sampled resident (26) who had fallen. *A physician's order was followed and suprapubic catheter cleaning and care at the insertion site was completed and documented for one of one sampled resident (11). *The use of a chair alarm was monitored and documented for one of one sampled resident (14 ) who required a chair alarm. Findings include: 1. Observation on 12/4/23 at 3:25 p.m. of resident 26 revealed she: *Was asleep on her bed. -Had multiple staples on the crown of her head. Interview on 12/5/23 at 10:00 a.m. with resident 26 revealed she: *Turned wrong and had fallen when she was returning to her bed from the bathroom a few weeks ago. *Was taken to the emergency room (ER) after the fall and required staples to close a cut on the top of her head that occurred as a result of that fall. Review of resident 26's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the provider failed to have an acknowledged and signed code status that was easily accessible for three of three sampled residents (186, 32, and 33). Findings include: 1. Review of resident 186's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *There was no code status documented for the resident on the demographic section at the top of the EMR screen. *There was no physician's order located for a code status. Review of resident 186's care plan revealed: *He had signed an Advanced Directive that was in his EMR. *There was no documentation of his code status. Review of the provider's list of resident code status located at the nurse's station revealed that resident 186 was not on that list. Review of resident 186's paper chart revealed: *There was no indication of his code status on the outside of the paper chart binder. *The advanced directive/code status was not quickly accessible for staff in an emergency situation to find 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 observation, interview, record review, job description review, and policy review, the provider failed to follow a process to thoroughly assess, implement, monitor, and revise interventions for one of one sampled resident (26) who was at nutritional risk. Findings include: 1. Observation on 12/4/23 at 12:30 p.m. of resident 26 in the dining room revealed: *She fed herself the noon meal without observed chewing or swallowing difficulties. *The texture of her food was the consistency of a regular diet. Review of resident 26's electronic medical record (EMR) revealed: *Registered dietician (RD) E's 5/25/23 initial dietary assessment indicated the resident was eating 100% of her meals, her weight was 141 lbs, and her nutritional status was normal. -There were no additional RD assessments or progress notes completed since that initial assessment. *Dietary manager (DM) D completed two progress notes (PN) between 5/17/23 and 12/5/23. -Her 8/17/23 PN: The resident's weight was down 5% over the last 30 days but…

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

Based on record review, interview, and policy review, the provider failed to ensure the bed hold notice was given upon the transfer on three separate dates for one of one sampled resident (10) to the hospital. Findings include: 1. Review of resident 10's electronic medical record (EMR) revealed: *On 3/30/23, he had been transferred to the hospital when staff was unable to keep his oxygen saturation levels above 90% on eight liters of oxygen. *On 4/6/23, he was transferred to the hospital at the request of his family representative when he had lost consciousness while transferring using a mechanical stand lift. *On 11/19/23, he was transferred to the hospital for intravenous (IV) antibiotics to treat cellulitis in his left leg. The bed hold forms were requested on 12/5/23 at 3:15 p.m. for the above three hospital transfers and the facility was not able to produce that documentation. Interview on 12/06/23 at 9:49 a.m. with interim director of nursing B revealed: *Her expectation would have been that all residents who were transferred out of the facility to an acute care provider would…

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

Based on review of the Consultant Pharmacist Review reports for 2023, record review, and interview, the provider failed to ensure a physician's order included a specific duration of time for an as needed (PRN) psychotropic medication for one of one sampled resident (1) who received a PRN psychotropic medication. Findings include: 1. Review of resident 1's electronic medical record (EMR) and paper chart revealed: *Consultant Pharmacist Review 2023 monthly notes completed by pharmacist H regarding his review of the resident's medical record for identification of medication irregularities. *His September 2023 review note was dated 9/30/23: -MD [medical doctor] - Serax (a psychotropic medication) DR [dose reduction] request - now taking prn for insomnia (as of 10/31/23) - no need to send. *His October 2023 note was dated 10/31/23: -No recommendations. *A Fax Communication to Provider form dated 10/31/23: Resident was out of oxazepam [Serax] over the weekend. She reports that she did 'well without it' and is requesting it be changed to PRN. Resident noted to be well and in good spirits…

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.