Grace Pointe Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services.The facility failed to document accurately on Resident #1's EMAR for Acetaminophen with Codeine 300-30 MG tablet, 1 tablet. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.Findings included:Record review of Resident #1's face sheet dated 12/29/25 noted she was a [AGE] year-old female with admission date 08/28/25.Record review of Resident #1's health and physical dated 12/23/25 revealed a medical history of Lupus Erythematosus (an autoimmune disease where the immune system mistakenly attacks the body's own tissues, causing inflammation and tissue damage).Record review of Resident #1's Quarterly MDS dated [DATE] revealed…

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

Based on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 154 beds, failed to employ a qualified social worker on a full-time basis since 08/14/2025. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included:Record review of the facility census dated 09/24/2025 revealed that the facility had a capacity of 154 beds and had a census of fifty-four. During an interview and record review on 09/25/25 at 12:49 PM with the Administrator revealed, the Social Worker had resigned a month ago. He said they hired a social worker on 08/29/25, and she only worked for about a week and resigned for personal reasons. He said they just hired a social worker to start on 10/07/25. He said their company had multiple facilities in town and he had not reached out for help with social services at his facility. He said the potential risk of not having 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 interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for one (Resident #1) of four resident reviewed for grievance resolution. The facility did not issue a written decision to Resident #2 who filed a grievance on 09/05/25 and 09/09/25. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included:Review of the admission Record dated 09/24/25, revealed Resident #2 was admitted on [DATE] from home. Review of History & Physical dated 08/08/25 revealed Resident #2 was a [AGE] year-old female GAD (severe, ongoing anxiety that interferes with daily activities), bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and behavior), DM2 (a chronic metabolic disorder characterized by high blood sugar levels due to insulin deficiency), HTN (is a condition where the force of blood flowing through the arteries is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 10 employees (LVN A) reviewed for annual employee misconduct registry and nurse aide registry screenings, in that: The facility had failed to complete the annual employee misconduct registry and annual nurse aide registry screenings for LVN A. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included:Record review of facility's policy undated on Abuse/Neglect revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Procedure A. Screening: Criminal History and Background Checks All potential employees will be screened for history of abuse, neglect or mistreating of elderly/individuals as defined the applicable requirement of 483.13 (c) (1) (ii) (A) and (B). Employees will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide to send a copy of notice to the Office of the State Long-Term Care Ombudsman at least 30 days prior to the discharge or as soon as possible for 1 (Resident #2) of two residents reviewed for facility-initiated discharges, in that: The facility failed to send a copy of the Discharge Notice at the same time notice was provided to Resident #2 on 09/03/25 to the Local Office of the State-Long Term Care Ombudsman. This failure could place residents at risk of not providing added protection to residents from being inappropriately transferred or discharged and provide residents with access to an advocate who can inform them of their options and rights. Findings included:Review of the admission Record dated 09/24/25, revealed Resident #2 was admitted on [DATE] from home. Review of History & Physical dated 08/08/25 revealed Resident #2 was a [AGE] year-old female GAD (Severe, ongoing anxiety that interferes with daily activities), bipolar disorder (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 interview and record review the facility failed to ensure that information is comprehensive, timely and properly signed for 1 of 9 residents (Resident #3) reviewed for accuracy and completeness. The facility failed to document when Resident #3 complained of pain to the right lower extremity. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in treatment, or a potential decline in the resident's health. Findings included: Record review of closed admission Record dated 07/31/25 for Resident #3, revealed Original admission Date: 03/07/25; re-admission date 03/21/25. Date of discharge: [DATE] at 12:30 PM to hospital. Review of Hospital Operative Record dated 04/17/25 for Resident #3 revealed, Date of Surgery: 04/17/25. Preoperative diagnosis: Right reverse obliquity intertrochanteric femur fracture (is a break in the upper part of the right thigh bone femur, specifically in the area between the two bony bumps) due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan regarding information found in a Social Services Quarterly Assessment that no male CNAs should be in Resident #1's room. This deficient practice could place residents at risk of not receiving the necessary care or services. Findings include: Record review of Resident #1's admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 7 residents (Resident #1) reviewed for accuracy and completeness. The facility failed to document an allegation of sexual abuse was made by Resident #1's. This deficient practice could place residents at risk for abuse, neglect, exploitation. Findings included: Record review of Resident #1's admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes), hypertension (high blood pressure), hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview, and record review the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for 3 of 22 (Residents #17, #34 and #40 ) residents reviewed for telephone use. The facility failed to provide a place for Resident #17, #34, and #40 to make telephone calls without privacy or being overheard. This failure could place all residents that use the telephone at risk of conversations being overheard and privacy rights not being respected . The findings included : Record review of Resident #17's admission Record, dated 12/12/24, reflected [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident # 17's Hospital History and Physical dated 03/31/23, revealed diagnoses of dementia without behavioral disturbance, and Alzheimer's disease. Record review of Resident # 17's Quarterly MDS dated [DATE], revealed a BIMS score of 15 demonstrating he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 22 residents (Resident #39, Resident # 33) reviewed for care plans. 1. The facility failed to implement the resident 's care and Resident #39 was not seen by the podiatrist, and her toenails were long . 2. The facility failed to develop a care plan that addressed Resident #33's wandering behavior. This failure could place residents increased risk of being unable to maintain their highest practicable physical well-being. The findings included: 1. Record review of Resident # 39's admission Record dated 12/12/2024, reflected [AGE] year-old women who was originally admitted into the facility on [DATE], and readmitted on [DATE]. Record review of Resident # 39's Hospital History 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 observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 2 of 22 residents (Resident #39, Resident #62) reviewed for foot care. --The facility failed to provide access to podiatrist for Resident #39. -The facility failed to provide access to podiatrist for Resident #62. This failure could place residents at risk of poor foot hygiene and a decline in residents' physical condition. Findings include: 1. Record review of Resident # 39's admission Record dated 12/12/2024, reflected [AGE] year-old women who was originally admitted into the facility on [DATE], and readmitted on [DATE]. Record review of Resident # 39's Hospital History and Physical,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #26 and Resident #39) of 2 residents observed for oxygen management. -The facility failed to keep the oxygen concentrator filter clean for Resident #26. --The facility failed to keep the oxygen concentrator filter clean for Resident #39. These failures could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, and decline in health. Findings included: 1. Record Review of Resident #26's admission Record dated 12/12/24, revealed resident is [AGE] year-old male with original admission date into the facility 3/18/2018 and readmitted [DATE]. Record Review of Resident #26 MDS revealed BIMS score of 10, meaning moderate cognitive impairment. MDS revealed medical diagnosis of Chronic Obstructive Pulmonary Disease (is a common long-term lung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; and failed to have an established system in place for accurate reconciliation of controlled substances for 2 of 4 medication carts that had controlled substances and safe and secure storage of medications for of 2 of 3 medication carts reviewed for medication storage. -The facility failed to ensure Licensed staff signed the Controlled Substance Medication Count Record after counting and verifying that all controlled substances in the medication cart had been accounted for with the on-coming and off-going nurses. -The facility failed to ensure liquid medication stored in medication carts on two halls (200 and 400) did not have dried drippings on the sides of the bottles. - The facility failed to ensure medication carts located in 200 Hall and 400…

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

Based on observation, and interview, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing of medications. -The facility failed to ensure opened bottles of Acidophilus Probiotic Dietary Supplement was refrigerated after opening in the 400 Hall medication cart. These failures could place residents at risk for not having their medications available or at decrease efficacy of medications by not following manufacturer's specifications, and cross contamination. The findings included: 400 Hall In an observation on 12/11/24 at 10:34 AM of Medication Aide's medication cart on the 4th floor with LVN B, revealed bottle of Acidophilus Probiotic Dietary Supplement was dated as opened on 11/03/24. LVN B confirmed the manufacturer's label on the bottle said to Refrigerate after opening. LVN B immediately removed the medication bottle from the medication cart.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage -The facility failed to store foods in the refrigerator in sealed containers. -The facility failed to keep 1 of 23 spice bottles stored on metal storage rack completely sealed. The facility failed to keep the kitchen ceiling tiles free of dried brown water stains throughout kitchen. -The facility failed to keep ceiling vents free of lint that were directly above food preparation area. - The facility failed to replace missing ceiling tiles in room between the kitchen and Dishwashing Room and in the Dry Storage Room. - The facility failed to maintain Vegetable sink in operational condition. -The facility failed to follow the Three-Compartment Sink Procedures that specified procedure to sanitize pots and pans. -The facility failed to maintain a working trash can next to the hand washing sink in the kitchen. These failures could affect…

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 observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during laundry room observation, and 1 of 1 treatment cart observed for Infection Control. -The facility failed to ensure staff performed hand hygiene when passing out food trays. -The facility failed to ensure opened packages of gauze non-sterile sponges were stored in sealed plastic bags. -The facility failed to ensure facility staff did not store personal belongings on a clean linen table shelf. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: Hand Hygiene: In an observation on 12/09/24 at 12:48 PM LVN D was observed distributing meal trays, after distributing four meal trays LVN D repositioned a resident in her wheelchair and then continued to pass out meal trays to other residents. LVN D did not perform any hand hygiene after…

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, interviews and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 3 of 3 facility floors reviewed for environment and 1 of 1 kitchen reviewed for safe operating equipment. -Resident rooms had loose closet doors in need of repair. This failure could affect residents, placing them at risk of living in an unsafe, uncomfortable environment and decreased quality of life due to poor conditions of the facility interior and exterior; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition. Findings includes: 1. Observation on 12/09/24 at 9:54 AM during initial rounds revealed: -Rooms 219, 417 and 428 did not have sliding closet doors. -rooms [ROOM NUMBERS] closet doors were off the double track and did not have the Sliding Closet Door Bottom Guide to keep the closet doors in place when opened. -room [ROOM NUMBER], 210, 214, 217, 218, 226 and 418:…

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, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 resident (Resident #41) of 22 residents reviewed for call light placement. -The facility failed to ensure that Residents #41 call lights were within their reach on 12/09/2024. This failure places the resident at risk of not being able to call for assistance when needed. Findings included: Record Review of Resident #41's admission Record dated 12/10/24, revealed [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Record review of Resident # 41's Hospital History and Physical dated 10/02/24, revealed diagnoses: Parkinson's disease with dyskinesia (Parkinson's disease is a movement disorder of the nervous system), cerebellar ataxia (Cerebellar ataxia is a condition characterized by poor muscle control that affects walking, balance, hand coordination, speech,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents had the right to be treated with respect and dignity and to be cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 (Resident #8) of 11 residents reviewed for being treated with dignity and respect. The facility failed to ensure that an unidentified nurse staff did not enter Resident #8's room at an unidentified time and date without permission after knocking, leaving him without time to put on clothing. This failure put residents at risk of embarrassment, decreased self-esteem, and loss of a sense of independence and control. Findings included: Record review of Resident #8's face sheet dated 04/03/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #8's History and Physical dated 07/29/2023 revealed he had diabetes, multiple amputations to his right foot, and was being treated for a non-healing wound. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents had the right to receive unopened mail and other letters, packages and other materials delivered to the facility for the resident for one (Resident #8) of 11 residents reviewed for receiving unopened mail and other materials delivered to the facility for the resident. The facility failed to ensure that Resident #8 received an unopened personal correspondence. This failure places residents at risk of violations of their right to privacy due to their letters and packages being opened before they are delivered to the resident. Findings included: Record review of Resident #8's face sheet dated 04/03/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #8's History and Physical dated 07/29/2023 revealed he had diabetes, multiple amputations to his right foot, and was being treated for a non-healing wound. Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from abuse when an altercation occurred on 2/26/24 between two residents (Resident #1 and Resident #2) of 11 reviewed for implementation of policies that prevent abuse. 1. The facility failed to investigate an altercation on 2/26/2024 at 9:29 AM between Resident #1 and #2. 2. The facility failed to protect Resident #1 from Resident #2 resulting in a resident-to-resident physical altercation on 02/26/2024 at 1:00 PM. This failure puts residents at risk of physical altercations that could result in injury. Findings included: Record review of the facility form 3613-A dated regarding an incident on 02/26/2024 at 1:00 PM revealed that it involved Resident #1 and Resident #2. Per the report Resident #2 made contact with Resident #1's left cheek when he became agitated that he was talking to Resident #1 and Resident #1 was ignoring him. The report stated that Resident #1 and Resident #2 were seated next to each other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement written policies that prohibit and prevent abuse, neglect, and exploitation of residents for two residents (Resident #1 and Resident #2) of 11 reviewed for implementation of policies that prevent abuse. 1. The facility failed to investigate altercation on 2/26/2024 at 9:29 AM between Resident #1 and #2. 2. The facility failed to protect Resident #1 from Resident #2 resulting in a resident-to-resident physical altercation on 02/26/2024 at 1:00 PM. This failure puts residents at risk of physical altercations that could result in injury. Findings included: Record review of the facility Abuse/Neglect revised 03/29/2018 revealed that the resident has the right to be free from abuse. Residents should not be subjected to abuse from anyone, including other residents. The facility will provide and ensure the protection of resident rights. It is each individual's responsibility to recognize and report actual or alleged abuse and situations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse are reported immediately, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for two residents (Resident #1 and Resident #2) of 11 reviewed for implementation of policies that prevent abuse. LVN C failed to report an alterction between Resident #1 and #2 that took place the morning of 02/23/2024 to the Administrator. This failure puts residents at risk of physical altercations that could result in injury. Findings included: Record review of the facility form 3613-A dated regarding an incident on 02/26/2024 at 1:00 PM revealed that it involved Resident #1 and Resident #2. Per the report Resident #2 made contact with Resident #1's left cheek when he became agitated that he was talking to Resident #1 and Resident #1 was ignoring him. The report stated…

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 observations, interview and record review the facility failed to ensure that a resident who displays or was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one resident (Resident #1) of 3 reviewed for appropriate treatment and services to attain or maintain their highest practicable well-being. 1. The facility failed to track resident's ongoing wandering behaviors which placed him at risk of not having these behaviors identified and addressed. 2. The facility failed to identify and establish a care plan to address Resident #1's wandering behavior which placed him at risk of verbal and physical abuse from other residents. This failure puts residents with dementia at increased risk of not having their dementia-related needs met. Findings included: Record review of Resident #1's Face Sheet dated 03/21/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for 4 (Resident #22, Resident #30, Resident #11 and Resident #237) of 23 residents reviewed for PASARR coordination. -The facility failed to ensure that Resident #22 ' s PASARR status was reviewed when he was given a new psychiatric diagnosis and prescribed antipsychotic medication -The facility failed to ensure that Resident #30 ' s PASARR status was reviewed when he received a new diagnosis and began receiving psychological services -The facility failed to submit a request for specialized services for Resident #11 in order for him to continue his therapy. -The facility failed to submit a request for initial specialized services for Resident #237. This failure could result in residents not receiving specialized services to address their unique needs. Findings included: Resident #22 Record review of Resident #22 ' s face sheet dated 11/16/2023 revealed he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 27 residents (Resident #13 and Resident #237) reviewed for care plans in that: - The facility failed to include Resident #13 ' s smoking on his care plan. - The facility failed to include in Resident #237 ' s comprehensive care plan that he was PASSAR positive (had mental illness diagnosis and/or intellectual/developmental disability qualifying him for specialized PASSAR Services). This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings include: Resident #13 Record review of Resident #13 ' s face sheet revealed he 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 interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #62) of 4 reviewed for medication orders. The facility failed to re-order pain medication for Resident # 62 after the blister pack had been completed. The facility failed to remove insulin from medication on the second floor for a resident that was moved to the third floor on 10/12/23. The facility failed to remove medications from medication carts when residents were discharged to the hospital. This deficient practice could result in a decline in health if medication was not ordered for residents when needed. Findings included: Resident #62 Record review of Resident #62 ' s face sheet dated 11/17/2023 revealed a [AGE] year-old male with an admission date to the facility of 12/12/2022. Record review of Resident #62 ' s undated electronic diagnosis list…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked storage area and to limit access to authorized personnel for 3 of 3 rooms reviewed for medication storage. -The facility failed to ensure all drugs and biologicals were stored in locked storage area and limited access to authorized personnel. -The facility failed to permanently attach metal box containing controlled substances to the refrigerator rack for 2 of 3 medication refrigerators. The facility's failure could place residents at risk for not receiving prescribed medications as ordered and risk for drug diversion. Findings included: Observation and interview on 11/14/23 at 10:30 AM with LVN J revealed facility did not have designated medication room on any of the floors. The nurse stated there was a room behind the nurse's station on each floor where they kept a locked cabinet to store discontinued medications, OTC (over the counter medications) floor stock, extra medication blister packets, and a locked medication refrigerator to store medications…

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, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to keep floor in the dry storage room free of black grease built up. -The facility failed to keep wall in the dry storage room free of Scraped paint. -The facility failed to keep bottles of vinegar stored on metal storage racks in the dry storage room free of white powder residual on caps. -The facility failed to keep floor in the dry storage room clean, and free of food and paper particles. -The facility failed to keep refrigerator storage racks free of rust. -The facility failed to store foods in refrigerator in sealed containers; food containers had dried food drippings around the caps and dried brown stains on side of food container. -The facility failed to keep large skillets stored on metal racks free of black burnt grease built up on the sides and bottoms of pans. The facility failed to store foods in dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection in 1 of 3 (2nd floor) dining rooms and for 2 of 27 residents (Resident #16 and Resident #57) reviewed for infection control. -The facility failed to ensure staff followed infection control practices when passing out meal trays during dining service. -The facility failed to ensure that Resident #57 ' s catheter tubing did not drag on the floor. -The facility failed to ensure LVN I washed her hands and put on gloves prior to checking for G-Tube Placement. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: Observation on 11/14/23 at 12:34 PM of the second-floor dining room revealed CNA D was observed taking a meal tray from the food cart and passed it out to a resident.…

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

Based on Observation, interviews, and record reviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment. The oven thermostats did not properly set the temperature in the four ovens. Vegetable sink has not been operable in over 3 months. These failures could place residents at risk of foodborne illnesses and injury. Findings included: An initial tour of the kitchen on 11/14/23 started at 8:14 AM, revealed oven thermostats were not working. There was a sign posted above the Vegetable sink that stated it was out of service. Observation and interview on 11/14/23 at 8:36 AM with [NAME] and Dietary Director revealed that 4 of 4 ovens were not working properly. [NAME] reported they had been having problems with oven temperatures for several months. He demonstrated to the surveyors; oven thermostats did not work. The [NAME] said, The oven will not heat up to the temperature set with the thermostat. Sometimes the oven temperatures are too cold or too hot. Maintenance staff had attempted to fix the problem.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 8 (Resident #10) residents reviewed for resident rights in that: The facility failed to respect Resident #10 ' s Next of Kin ' s decisions regarding refusing DNR and attempted to seek legal guardianship to obtain DNR consents. This failure could place residents at risk of receiving services without their or their representative ' s consent. Findings include: Record review of Resident #10 ' s face sheet dated 11/17/2023 revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and dementia (the loss of cognitive functioning — thinking, remembering, and reasoning — to such an extent that it interferes with a person's daily life and activities). Record review of Resident #10 ' 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 interview and record review, the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident ' s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident ' s concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 8 (Resident # 44) reviewed for resident rights. The facility failed to ensure an investigation was initiated promptly for Resident #44 ' s grievance of missing money and debit card. This failure could place residents at risk for grievances not being addressed or resolved promptly in turn leading to resident ' s lost properties not being replaced. Findings include: Record review of Resident #44 ' s face sheet dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 8 (Resident # 44) reviewed for misappropriation of property. The facility failed to report an allegation of misappropriation of property (money, old coin and debit card) to the State Survey Agency within 24 hours of being made by Resident #44. This failure could place residents at risk of allegations of abuse, neglect, misappropriation of property not fully investigated and emotional distress. Findings include: Record review of Resident #44 ' s face sheet dated…

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 observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident ' s status for 2 (Residents #7 and #22) of 23 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #7 ' s MDS accurately reflected her refusal of care. - The facility failed to ensure that Resident #22 ' s MDS accurately reflected use of restraints. These failures could put residents at risk of not having their need for help with removal of facial hair or the use of bedrails assessed accurately . Findings included: Resident #7 Record review of Resident #7 ' s face sheet dated 11/17/2023 revealed she was an [AGE] year-old female, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7 ' s History and Physical dated 03/31/2023 revealed she had dementia without behavioral disturbance, and fracture of the right femur (broken right thigh bone). She was alert and oriented times one (knew her…

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 observations, interviews, and record review, the facility failed to ensure that residents are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (Resident #7) of 23 residents reviewed for quality of life. The facility failed to ensure that Resident #7 did not have facial hair on her chin and upper lip. This failure put residents at risk of embarrassment and a negative self-image. Findings included: Resident #7 Record review of Resident #7's face sheet dated 11/17/2023 revealed she was an [AGE] year-old female, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7's History and Physical dated 03/31/2023 revealed she had dementia without behavioral disturbance, and fracture of the right femur (broken right thigh bone). She was alert and oriented times one (knew her name) and was confused and agitated. Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed her BIMS score was 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who are continent of bladder receives services and assistance to maintain continence for one (Residents # 19) of 23 residents reviewed for bladder incontinence. The facility failed to ensure that Resident #19 ' s oxygen tubing was long enough for her to walk to the bathroom, resulting in increased instances of urinary incontinence. This failure put residents at increased risk of urinary tract infections, urinary incontinence, embarrassment, and a negative self-image. Findings included: Resident #19 Record review of Resident #19 ' s face sheet dated 11/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #19 ' s History and Physical dated 03/31/2023 revealed she had diagnoses including congestive heart failure, acute respiratory failure with hypoxia (a condition where lungs cannot provide enough oxygen to the blood), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice for 3 (Residents #4, #19, and #22) of 9 Residents reviewed for oxygen usage. The facility failed to ensure that Residents #4, #19, and #22 ' s oxygen concentrators had clean filters. This failure could put residents at increased risk of breathing in dust and allergens and of decreased effectiveness of oxygen concentrators. Findings include: Resident #4 Record review of Resident #4 ' s face sheet dated 11/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #4 ' s History and Physical dated 03/13/2023 revealed she had diagnoses including hypoxemia (low levels of oxygen in the blood). Supplemental oxygen was to be given as needed via nasal cannula (a thin plastic tube with two prongs for insertion into the nose). Record 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 observation, interview, and record review, the facility failed to ensure that residents were free from any physical restraints that are not required to treat the resident's medical symptoms for 1 (Resident #22) of 23 residents reviewed for restraints. The facility failed to ensure Resident #22 had an evaluation, consent, and correct orders for the bed rails that were on his bed. This failure put residents at risk of unnecessary restraints on their movement. Findings included: Resident #22 Record review of Resident #22 ' s face sheet dated 11/16/2023 revealed he was [AGE] years old, was initially admitted to the facility 04/09/2018 and readmitted on [DATE]. Record review of Resident #22 ' s History and Physical dated 08/31/2023 revealed he had a history of paraplegia (paralysis of the whole body) and was bed bound. Record review of Resident #22 ' s quarterly MDS assessment dated [DATE] revealed his BIMS score was 11 (moderate cognitive impairment). He had no symptomatic behaviors. He was dependent on…

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