The Bartlett Skilled Nursing and Assisted Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 (Resident #2) of 5 residents reviewed for resident records. -The facility failed to ensure the accuracy of Resident #2's medical records. The physician said to hold Resident #2's medication Donepezil due to an interaction and this was not in the medical records. This failure could put residents at risk of improper medication administration based on inaccurate documentation. Findings included: Record review of Resident #2's admission Record dated 03/10/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #2's History and Physical (H&P) dated 10/31/2024, revealed resident diagnoses to include Lewy body dementia (a decline in thinking ability, especially in areas of attention, visual perception, and planning and organization). Plan read in part: Continue donepezil and reorient patient frequently.…

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 they followed professional standards of practice in accordance with physician orders and facility policy for care of PICC for 1 (Residents #1) of 2 residents reviewed for parenteral and intravenous care. The facility failed to change Resident #1's PICC line dressing as ordered. This failure placed the residents at risk of complications with their PICC needed for infusion therapy. Findings included: Record review of Resident #1's face sheet dated 2/3/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of repeated falls, metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and pneumonia. Record review of Resident #1's admission MDS assessment still in progress had a BIMS score of 12, indicting her cognition was moderately impaired. Record review of Resident #1's care plan dated 1/15/25…

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.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed for medication storage and security. The facility failed to ensure LVN A secured the medication cart when it was left unattended. This failure: could place residents at risk for drug diversion or accidental ingestion. Findings included: In an observation on 2/3/25 at 1:34 pm, the medication cart on the 400 hall was left unattended and unlocked. 2 staff were noted in the hallway. In an observation on 2/3/25 at 1:35 pm, CNA B walked over to the medication cart and locked it. In an interview on 2/3/25 at 1:36 pm, CNA B stated that she was aware the medication cart needed to be closed and noticed that it was left unlocked while she saw the State Surveyor standing nearby. CNA B stated she then proceeded to lock the cart. CNA B stated the risk was a patient potentially accessing the medications and stated that it was the nurses' responsibility to ensure the cart remained secured. In an interview on 2/3/25 at 1:39 pm, LVN A…

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

Based on interviews and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 16 ( the Administrator, the DON, the Infection Disease Preventionist, the Social Worker, the Activity Director, the Housekeeping Supervisor, the Maintenance Supervisor, the Director of Food Services, RN H, LVN I, LVN J, LVN K, CNA L, CNA M, CNA N, and CNA O) of 16 employees reviewed for training regarding QAPI. The facility failed to include training regarding the facility's QAPI program in its training for employees. This failure put residents at risk of receiving poor-quality services as a result of staff being unaware of quality control concerns the facility was working to address. Findings included: In interview and record review on 07/11/2024 at 10:40 AM the HR Manager provided a list of employees with the following dates of hire and verbally confirmed the hire dates of these employees: Administrator- 9/17/2002, Director of Nurses-11/30/2020, Infection Control…

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 dialysis services were provided consistently with professional standards of practice for 2 (Resident #7 and Resident #40) of 2 residents reviewed for dialysis services. The facility failed to ensure post-dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) assessments were documented in Resident #7 and Resident #40's charts. These failures could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Resident #7 Review of Resident #7's admission Record, dated 7/10/24, revealed she was a [AGE] year-old female originally admitted to the facility 5/20/19 with a most recent admission date of 12/8/23. She had diagnoses which included dementia with behavior disturbances, end stage renal disease (condition in which the kidneys permanently stop working and can no longer perform their essential functions)…

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 that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 (Residents #3 and #7) of 8 residents reviewed for unnecessary medications, and failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #98) of 8 residents reviewed for unnecessary medications. The facility failed to ensure that Resident #7 and Resident #3 had appropriate diagnoses for Risperidone (an antipsychotic used to treat schizophrenia and bipolar disorder). The facility failed to ensure that Resident #98 had a 14-day limit on her order for PRN Lorazepam. These failures put residents at increased risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status from receiving unnecessary antipsychotic medications. The findings…

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, record review, and interviews, 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 food procurement. 1. The facility failed to ensure foods were properly labeled (contents of containers, opened date, date prepared), covered, and sealed. 2. The facility failed to ensure meat was thawed properly on a tray in the refrigerator. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation and interview on 7/9/24 at 8:18 am with [NAME] C, revealed an unsealed plastic bag labeled cilantro found in the refrigerator labeled Produce. [NAME] C stated the risk of having the bag open and not inside a sealed bag was that there was no way to know when it had been opened. [NAME] C stated that cilantro was perishable and if it was used to cook, there was a potential to make the residents sick. A clear plastic container with no lid and no label containing red fruit was found inside the same…

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 establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three residents (Resident #252, Resident #31, Resident #20) of eight residents observed for infection control in that: 1. Resident #252's catheter drainage collection bag was left on the floor. 2. CNA D and CNA E did not change their gloves after they became contaminated during incontinent care while assisting Resident #20 and did not practice adequate hand hygiene after. 3. CNA F did not change their gloves after they became contaminated during incontinent care while assisting Resident #31 This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder,…

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 develop a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical needs that wase identified in the comprehensive assessment for 1 (Resident #40) of 20 residents reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan that addressed Resident #40's diagnosis of diabetes. This failure could put residents at increased risk of not having their care needs met. Findings included: Record review of Resident #40's face sheet dated 07/10/2024 revealed he was [AGE] years old, initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #40's History and Physical dated 06/25/2024 revealed he had a diagnosis of kidney injury, and it was determined he would require dialysis. He had a diagnosis of diabetes mellitus and was taking medications for management of his diabetes. Record review of Resident #40'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 interviews and record review, the facility failed to ensure drug regimen irregularities reported by the Pharmacist Consultant were acted upon by the physician for 1 (Resident #3) of 6 residents reviewed for physician response to medication regimen review. The facility failed to ensure that the physician responded to Pharmacist Consultant recommendations that an appropriate diagnosis or gradual dose reduction be applied to Risperidone [Risperdal] (an antipsychotic medication) prescribed for Resident #3. This failure could place residents at risk of adverse side effects and decreased quality of life as a result of receiving unnecessary antipsychotic medications. Findings included: Record review of Resident #3's face sheet revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's history and physical dated 11/19/2023 revealed she had diagnoses including dementia. She was sent to a geriatric behavioral unit for being…

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 maintain clinical records that were complete and accurate for 1 of 4 (Resident #7) residents reviewed for clinical records. The facility failed to place resident identifying information on 5 of 17 Hemodialysis Communication forms located in the 100/200 Hall Dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) Communication Binder. The facility failed to ensure that Resident #7's Hemodialysis Communication forms were scanned into her electronic chart as part of her permanent record and post-dialysis monitoring. This failure could place residents at risk for inadequate monitoring and inaccurate records. The findings were: Review of Resident #7's admission Record, dated 7/10/24, revealed she was a [AGE] year-old female originally admitted to the facility 5/20/19 with a most recent admission date of 12/8/23. She had diagnoses which included dementia with behavior disturbances, end…

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 4 (Resident #4, Resident #11, Resident #23, & Resident #205) of 10 residents observed for oxygen management. 1. Residents #4, #11, #23, & #205 were not having there oxygen tubing dated. 2. Residents #4, #11, #23, & #205 did not have oxygen signs posted outside their bedrooms. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: Resident #4 Record review of Resident #4's face sheet dated 06/15/23 revealed admission on [DATE], readmission on [DATE], and readmission on [DATE] to the facility. Record review of Resident #4's history and physical dated 05/22/2023 revealed a [AGE] year-old male diagnosed with chronic respiratory failure. Record review of Resident #4's admission MDS dated [DATE] revealed diagnosis 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 provide pharmaceutical services that assured the accurate system is in place for acquiring, dispensing and storage of medications for pharmaceutical services; failed to have an established system in place for accurate reconciliation for 3 (Hall 100, Hall 300 and Hall 500) of 5 halls that had residents with orders for controlled substances and monitoring of over-the-counter medication in one medication storage room. The facility failed to ensure Licensed Staff were signing Controlled Drugs Count Record when Controlled Drugs were reconciled at change of shift according to facility policy. The facility failed to monitor expiration dates on the over-the-counter medication in the medication storage room leaving expired medication on the shelves. This deficient practice could affect residents by placing them at risk of drug diversion and receiving medication that will not provide the same result. Findings included: Record review and interview 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 that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #30) of 6 resident ' s reviewed for psychotropic medication, . The facility failed to ensure that Resident #30 did not receive antipsychotics (quetiapine fumarate and aripiprazole) that were not necessary to treat a specific condition These failures could put residents at risk of side effects from unnecessary psychotropic medications. Findings included: Record review of Resident #30 ' s face sheet dated 06/15/2023 documented he was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #30 ' s facility History and Physical dated 12/28/2022 documented he had diagnoses of vascular dementia with behavioral disturbance, and poor mental status. Record review of Resident #30 ' 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 the observations, interviews, and record review 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 sanitization: residents . 1. Foods in dry store, walk in, and freezer not dated or labeled properly. 2. Food containers and food bags not properly sealed in the kitchen and walk-in. 3. Stove food catchers/food traps not being cleaned regularly. 4. Staff not wearing hair nets when entering the kitchen. 5. Food Temperature Logs were not filled out correctly for May 2023 and June 2023. 6. Clean Documentation Form not filled for the week of June 07, 2023, to June 14, 2023. 7. Low Temperature dish machine log not being filled out to ensure the water temperature was hot enough to kill bacteria and the water was sanitizing according to the Parts per million to kill bacteria. 8. Daily Scheduled logs not being followed to ensure sanitation of kitchen equipment and labeling/ rotation of foods. 9…

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 the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 3 (Dumpsters #1, #2, & #3) of 3 dumpsters containers and 1 (utility tilted trash cart) of 1 utility tiled trash cart reviewed for food safety requirements. 1. Three dumpsters (#1, #2, & #3) had their dumpster lids open. 2. One utility tiled trash cart did not have a lid. 3. Three dumpsters in the back of the facility had trash on the floor outside and around the dumpsters. 4. One utility tiled trash cart in the back of the kitchen had cigarette buds on the floor outside near grease. This failure could affect residents by placing them at risk of food borne illness, illnesses, or be provided an unsafe, unsanitary and uncomfortable environment. Findings include: Observation on 06/13/23 at 8:11 AM with [NAME] J, immediately outside of the back kitchen door was a utility tilted trash cart that had no lid. The trash container had a brown bag, mini plastic cups containers, and various other pieces of trash. Near the cart was a pile of cigarette buds on ground next 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 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 diseases and infections for 1 (Resident #44) of 11 residents and treatment cart reviewed for infection prevention and control. 1.The facility failed to ensure that Resident #44 ' s nebulizer treatment mask was covered when not in use. 2.The facility failed to ensure supplies in the treatment cart were sealed properly. These failures could increase residents ' risk of respiratory infections. Findings included: 1.Record review of Resident #44 ' s face sheet documented he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #44 ' s History and Physical dated 04/21/2023 documented he had diagnoses including tongue cancer and dysphagia (problems swallowing) related to tongue cancer, Parkinson ' s disease (progressive…

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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Residents #50, #204) of 14 residents observed for call light placement. The facility failed to ensure Residents #50 and #204 ' s call lights were within their reach. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Resident #50 Record review of Resident #50 ' s face sheet dated 06/14/2023 documented he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #50 ' s History and Physical dated 05/23/2023 documented he had diagnoses including a stroke, and left hemiplegia (paralysis of the left side of the body). It was documented on the History and Physical that the resident was able to move his right arm and leg when asked to do so. Record review of Resident #50 ' s admission MDS dated [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.

Based on interview and record review the facility failed to ensure that staff may attend resident group meetings only at the respective group's invitation for one of one resident group reviewed for staff attendance at group meetings by invitation. The facility failed to inform the resident council that they could hold council meetings without staff members present. This failure could put residents at risk of reduced opportunities to express their concerns. Findings included: In a confidential group interview on 06/14/2023 at 10:30 AM, three residents who attended resident council meetings regularly stated that they were unaware they could hold meetings without facility staff members present. Residents attending the confidential group interview said they had not raised any concerns about the facility during Resident Council meetings. In an interview on 06/15/23 at 01:34 PM the Activity Director said the facility did not offer Resident Council the option to meet without staff members present. The Activities Director stated she did not know it was the Resident Council ' s right to meet…

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 1 of 6 (Resident #259) residents reviewed for telephone use. The facility failed to provide a place for Resident #259 could make telephone calls without being overhead. This failure could place residents at risk of conversations being overheard and privacy rights not being respected. The findings included: Record review of Resident # 259's face sheet dated 6/14/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident # 259's local hospital history and physical dated 5/22/23 revealed diagnoses of major depressive disorder. Record review of Resident # 259's MDS admission assessment dated [DATE] not yet completed revealed a BIMS score of 15, he was cognitively intact. Observation and interview on 6/14/23 at 2:32 PM Resident #259 was in wheelchair at nurse'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 interviews and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 6 (Resident #259 and Resident #34) residents reviewed for abuse. The facility failed to report alleged verbal abuse for Resident #259 to State Agency. The facility failed to report alleged financial exploitation for Resident #34 to State Agency. These failures could affect residents by placing them at risk of abuse if the reportable allegations are not reported in time after they are alleged. Resident #259 Record review of Resident # 259's face sheet dated 6/14/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident # 259's local hospital history and physical dated 5/22/23 revealed diagnoses of major depressive disorder. Record review of Resident # 259's MDS admission…

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

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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission for 1 of 6 residents (Resident #11) reviewed for baseline care plan. Resident #11 did not have a baseline care plan that addressed her oxygen use. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings included: Record review of Resident #11's face sheet dated 06/15/23 revealed admission on [DATE] and readmission on [DATE], and readmission on [DATE] to the facility. Record review of Resident #11's history and physical dated 05/09/23 revealed an [AGE] year-old female diagnosed with Peripheral arterial disease (happens when there is a narrowing of the blood vessels outside…

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 12 residents (Resident #10 & Resident #11) reviewed for comprehensive care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #10s urinary foley catheter and Resident #11s oxygen use. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Resident #10 Record review of Resident #10's face sheet dated 6/15/23 revealed a [AGE] year-old female admitted on [DATE]. Record review of Resident #10's history and physical dated 5/3/23 revealed a diagnosis of dementia 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 ensure that residents received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 (Resident #206) of 6 residents reviewed for indwelling catheters 1. Resident #206's indwelling catheter tubing was cloudy with solid particles in the tubing and full of urine. 2. Resident #206's catheter tubing was not anchored on resident's leg correctly. This failure place residents at risk of dislodgement of foley and of the collection tube becoming full and allowing urine to flow back into the bladder that could result in a urinary tract infection. Findings include: Record review of Resident #206's face sheet dated 06/14/23 revealed admission on [DATE] to the facility. Record review of Resident #206's history and physical dated 05/27/23 revealed a [AGE] year-old male diagnosed with strokes, paraparesis (partial paralysis of the lower limbs), diabetic (poor control),…

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 medical records on each resident were complete and accurately documented for 1 of 6 (Resident #259) residents reviewed for accuracy of clinical records. The facility failed to accurately document Resident #10 had over the counter medication in his possession via electronic and/or paper charting. This failure could have placed residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings include: Record review of Resident # 259 ' s face sheet dated 6/14/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident # 259 ' s local hospital history and physical dated 5/22/23 revealed diagnoses of major depressive disorder. Record review of Resident # 259 ' s MDS admission assessment dated [DATE] was not yet completed, but revealed a BIMS score of 15, he was cognitive aware. Record review of Resident # 259 ' s complaint/ grievance report dated 6/9/23 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.