Lily Springs Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide reasonable accommodations to meet the needs and preferences for 1 of 6 residents reviewed for accommodations. The facility failed to ensure that Resident #47 had the call light device in reach while lying in bed. The facility failed to accommodate Resident #47 with a call light device that would meet their individual needs. This deficient practice could affect and diminish the resident's quality of life by potentially placing the resident at risk of injury, not receive timely care or receive nursing interventions to meet the resident's needs. Findings include: Record review of Resident #47's Face Sheet dated 04/16/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Sepsis (condition that occurs when the body's response to an infection causes injury to its own tissues and organs), Kidney Failure (condition where the kidney reaches advanced state of loss of function. This causes…

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 and implement abuse reporting policies for one (Resident #51) of five residents reviewed for abuse and neglect. The facility failed to implement policies that required reporting of major injury after an incident on 01/17/25 where Resident #51 fell out of the shower chair while transporting back to his room from the shower and sustained a fracture to the right femur. This deficient practice could place residents at risk of continued abuse and neglect if abuse policy is not properly implemented. Findings included: Record review of Resident #51's face sheet dated 04/16/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right femur, chronic obstructive pulmonary disease(a disease that makes it hard to breath and causes lung deterioration, morbid obesity, fall from non-moving wheelchair, and osteoarthritis (arthritis of the bones which causes widespread generalized pain.)…

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 allegations involving abuse, neglect, or serious bodily injuries were reported immediately but not later than 24 hours after the allegation was made for one (Resident #51) of five residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident on 01/17/25 where Resident #51 fell out of the shower chair while transporting back to his room and sustained a fracture to the right femur. This deficient practice could place residents at risk of abuse and neglect. Findings included: Review of Resident #51's face sheet dated 04/16/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right femur fall from non-moving wheelchair, and osteoarthritis (arthritis of the bones which causes widespread generalized pain.) Review of Resident #51's MDS updated March 2, 2025 indicated he needed extensive assistance for bed mobility, transfers,…

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 immediately notify the resident's RP when there was a need to alter treatment significantly for 1 of 5 (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified when his medication Ativan (anxiety) was discontinued by the Doctor on 02/24/2025. This failure could place residents at risk of their responsible party not being involved in the communication of medication no longer being taken by the resident. Findings included: A record review of Resident #1's face sheet dated 04/11/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses were anxiety disorder (feelings of worry and fear), major depressive disorder (sadness), and primary hypertension (abnormal high blood pressure). A record review of Resident #1's Quarterly MDS assessment, dated 03/11/2025, reflected the resident had a BIMS score of 7, which indicated severe cognitive impairment. A record review…

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 professional staff were licensed, certified, or registered in accordance with applicable state laws for 4 of 7 residents (Residents #1, #2, #3, and #4) reviewed for medication administration. The facility failed to ensure Med Tech M had a current and active license. Med Tech M provided medications to Residents #1, #2, #3, and #4 while her Med Tech license was expired from [DATE] through [DATE]. This failure could place residents at risk for inadequate care and/or services. Findings include : 1. Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included heart failure (heart does not pump as well as it should), diabetes (body have trouble controlling blood sugar energy) and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognition.…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the state Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for one of seven residents (Resident #1) reviewed for abuse and neglect . The facility failed to report to the State Survey Agency an incident when Resident #1's Advanced Directive was not followed, and CPR was not administered to Resident # 1. Resident #1 expired on [DATE] at the facility. This failure could place residents at risk of abuse or and neglect. Findings include:…

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 each resident for 1 of 7 residents (Residents #2) reviewed for medications and pharmacy services The facility failed to ensure Resident #2 received his hospital ordered medications when it was not documented whether Levofloxacin (a medication used for treating infections) and Metronidazole (a medication to treat various infections) were ordered when Resident # 2 discharged from the hospital to the facility on [DATE]. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #2's face sheet, printed on 02/28/2025, reflected a [AGE] year-old male who 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 develop policies and procedures to ensure each resident was offered an influenza immunization October 1 through March 31 annually, unless the immunization was medically contraindicated or the resident had already been immunized during this time period and before offering the pneumococcal immunization, each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated or the resident had already been immunized for 2 of 7 residents (Resident #3 Resident #4) reviewed for immunizations . The facility failed to document the flu vaccine for Resident #3 and Resident #4 which resulted in double flu vaccinations. This failure could place residents at risk of not receiving necessary medical care and hospitalization. Findings include: 1. Record review of Resident #3's face sheet, dated 03/01/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included…

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 an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for inventory of personal property. The facility to have a completed inventory of personal property lists for Residents #1, #2, and #3. This failure could place residents at risk of not having personal property replaced in the event of damage or loss. Findings included: Review of the facility's undated admission packet reflected the following: 21. PERSONAL BELONGINGS. Resident/Resident Representative shall complete and sign Facility's written inventory form listing Resident's personal belongings at the time of admission. An original inventory shall be retained by Resident/Resident Representative as a receipt and a copy will be kept with the Resident's records . Review of Resident #1's undated face sheet reflected a [AGE] year-old male…

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 all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one of one medication room reviewed for pharmacy services. The facility failed to ensure the medication room was kept locked or under direct supervision of authorized staff on 10/08/24. This failure could place residents at risk of having unauthorized staff having access to their medications, and accessing and ingesting medications that could cause clinically significant adverse consequences necessitating hospitalization to stabilize residents,. Findings included: An observation of the medication room on 10/08/24 at 11:10 a.m. revealed the medication room door was unlocked. There was no staff directly supervising the unlocked medication room. Residents were rolling their wheelchairs passed the unlocked medication room. During an interview on 10/08/24 at 11:12 a.m., when asked why the medication room was unlocked, the ADON stated there was a nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop the comprehensive person-centered care plan for one resident (Resident #1) out of five residents reviewed for the development of the comprehensive care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan. This deficient practice places the resident at risk for not receiving the necessary and appropriate care. Findings included: A record review on 08/21/2024 of Resident #1's face sheet dated 06/12/2024 reflected admission to the facility on [DATE]. She is a [AGE] year-old male. The residents' diagnoses included: Alzheimer's disease (an irreversible brain disease that destroys memory, thinking and the ability to carry out daily activities), polyarthritis (refers to a joint disease that involves at least 5 joints, inflammation, pain, movement restriction, warmth, swelling and redness can occur) and dementia (a group of conditions characterized by impairment of at least two brain functions such as memory…

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 ensure all drugs and biological's were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for one (Med Cart #1) of six medication carts reviewed for medication storage in that: The MA failed to lock and secure Med Cart #1. This failure could allow residents, visitors and unauthorized staff access to prescription and over-the-counter medications. Findings Included: Observation on 08/21/2024 at 9:04 am revealed, Med Cart #1, sitting in the hallway near nurses' station, was unsupervised and unlocked. Review of the cart's contents revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. The MA assigned to the cart was not within eyesight. Another staff member shouted the MA's name down the hall and quickly locked the cart. There were numerous staff and residents in the hallway around the nurse's station. In an interview on 8/21/2024 at 4:00 PM with the MA, she stated she had worked at the facility for ten years and the most…

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 reviews, the facility failed to develop the comprehensive person-centered care plan for one resident (Resident #1) out of five residents reviewed for the development of the comprehensive care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan. This deficient practice places the resident at risk for not receiving the necessary and appropriate care. Findings included: A record review on 08/21/2024 of Resident #1's face sheet dated 06/12/2024 reflected admission to the facility on [DATE]. She is a [AGE] year-old male. The residents' diagnoses included: Alzheimer's disease (an irreversible brain disease that destroys memory, thinking and the ability to carry out daily activities), polyarthritis (refers to a joint disease that involves at least 5 joints, inflammation, pain, movement restriction, warmth, swelling and redness can occur) and dementia (a group of conditions characterized by impairment of at least two brain functions such as memory…

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 reviews the facility failed to implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs for one resident (Resident #1) of three (3) residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was completed upon admission and revised or updated to reflect changes in Resident #1's care needs for falls, medications (antibiotics, anti-hypertensive, anti-depressant), Cognition. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical and psychosocial well-being. Findings included: Review of Resident #1's face sheet date 07/19/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Recurrent Major Depressive Disorder (mental health disorder having episodes of psychological depression,…

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 a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for of five residents three (Resident #2, Resident #3 and Resident #4) of five residents reviewed for ADLs. The facility failed to provide showers to Residents #2, #3 and #4 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings include: 1. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included unspecified intellectual disabilities, muscle weakness, lack of coordination, and difficulty in walking. Record review of Resident #2's quarterly MDS assessment, dated 05/20/24, reflected a BIMS of 14, which…

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 a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of three residents (Resident #1) reviewed for mobility . The facility failed to apply a hand contracture cushion to Resident #1's contracted hand. This failure could place residents at risk for not receiving the appropriate care and services to maintain their highest practicable well-being. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified dementia , generalized muscle weakness, and osteoarthritis (a type of generative joint disease). Record review of Resident #1's quarterly MDS Assessment, dated 03/19/24, reflected a BIMS could not be conducted due to her rarely/never being understood. Record review of Resident #1'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 observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 (500 hall cart and 100 hall cart) of 4 medication carts, 1 (500 hall linen cart) of 3 linen carts, and 2 (Resident #5 and Resident #6) of 5 residents reviewed for medication storage. 1) The facility failed to ensure a medication cup, with 3 types of unidentified cream, was not left unattended on a linen cart . 2) The facility failed to ensure a bottle of medicated shampoo and two tubes of a wound care cream were stored in a secure place. 3) The facility failed to ensure a medication cup, with 3 types of unidentified cream, was not left unattended at Resident #5's bedside. 4) The facility failed to ensure eyedrops were not left at Resident # 6's bedside. These failures could place residents at risk for misappropriation of medications, misuse of medications, and potential side…

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 all residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal and oral hygiene for 1 of 5 (Resident #1) residents reviewed for ADL's. The facility failed to ensure Resident #1 received regular showers. These failures placed resident at risk of poor personal hygiene. Findings included: Record review of the face sheet for Resident #1 dated 4/4/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of Legal Blindness, as defined by USA, Essential (Primary) Hypertension, Unspecified Systolic (Congestive) Heart Failure, Pain in Unspecified Joint, Morbid (Severe) Obesity, Unspecified Osteoarthritis, Unspecified, Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease, Mixed Hyperlipidemia, Gastro-Esophageal Reflux Disease, Cardiomyopathy, Unspecified, Paroxysmal Atrial Fibrillation, Weakness, Muscle Weakness Generalized, Unspecified lack…

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 that the residents' environment remained as free of accident hazards as was possible in 2 of 6 resident hallways (Hall 1 and secured hall 6). The facility failed to keep the linen carts free of items that could be dangerous to residents. This failure could result in residents experiencing accidents, injuries, loss of dignity , and diminished quality of life. Findings included: On 4/3/2024 at 10:40am during walk through observation of secured Hall 6, the linen cart contained a non-aerosol MedLine odor eliminator spray, a tube of MedLine Remedy Antifungal Ointment, a tube of Coloplast Hydrophilic Wound Dressing, a bottle of MedLine Remedy Cleansing Foam, a tube of MedLine Soothe and Cool Barrier ointment, and an opened package of disposable razors. On 04/03/2024 at 10:55am, during interview with CNA, she stated the cart should only be stocked with linens and briefs. She said wipes, creams and razors should not be on the linen cart and it is the CNA's responsibility to check the cart when they start their…

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; it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 3 of 19 residents reviewed for Resident rights (Resident #167, Resident #10, and Resident #19). Facility failed to provide dignity and respect for Resident #19 by providing privacy while transporting resident down the hall. Facility failed to provide dignity and respect for Resident #10 by providing privacy while incontinent care. Facility failed to respect Resident #167's rights;resident did not receive a bath before leaving facility to attend dialysis. The facility's failure could place residents at risk of not being treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents. Findings include: Resident #19 Record review of Resident #19's clinical record revealed that Resident #19 was a [AGE] year-old man who was admitted to the facility on [DATE], with diagnoses to include memory…

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, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and clean bed and bath linens that are in good condition for 10 of 23 (Resident #3, Resident #20, Resident #22, Resident #25, Resident #26, Resident #30, Resident #50, Resident #62, Resident #116 and Resident #167) residents reviewed for a safe, clean, comfortable, and homelike environment. The facility failed to regularly change the sheets of Residents #20, #22, #30, 50, #116 and #167. The facility failed to put a bottom sheet on Resident #25's bed. The facility failed to keep the floors of the facility clean. The facility failed to keep Resident #62's urinals clean and empty. The facility failed to keep the bathrooms of Residents #3 and #22 clean. The facility failed to provide Resident #26 with unstained towels for his shower. These failures could place…

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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal and oral hygiene for 4 (Resident #20, Resident #167, Resident #35, and Resident #116) of 19 residents reviewed for ADLs. 1. The facility failed to ensure Resident #20 received a shower regularly or changed her sheets. 2. The facility failed to ensure Resident #167 received a shower regularly. 3. The facility failed to ensure Resident #34 received a shower regularly. 4. The facility failed to ensure Resident #116 received a shower regularly. These failures could place residents at risk of poor hygiene and grooming and thereby decrease their quality of life. Findings Included: 1. Record review of Resident #20's face sheet, dated 01/30/2024, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart disease, localized edema, muscle weakness,…

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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one of one facility reviewed for sufficient staff. The facility failed to have sufficient staff available to provide resident care. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: Resident #16 Record review of Resident #16's admission record dated 01/31/24 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included,…

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 to help prevent the development and transmission of communication diseases and infections for 4 (Resident #10, Resident #5, Resident #1, and Resident #35) of 19 Residents in that: 1. CNA M did not perform hand hygiene before, after, or during incontinent care of Resident #10. 2. CNA N did not perform hand hygiene before, during, or after incontinent care of Resident # 5. 3. MA Q did not perform hand hygiene before or after administering ear drops to Resident #1. 4. MDS LVN did not perform hand hygiene before or after administering insulin injection to Resident #35. 5. Medication room did not have paper towels available to perform hand hygiene. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #55) of 19 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #55 was admitted to hospice. This failure could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition. Finding include: Record review of Resident #55's face sheet dated 01/30/2024 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include: Chronic embolism and thrombosis of unspecified axillary vein, muscle weakness, anxiety disorder due to known physiological condition, malignant neoplasm of sigmoid colon, major depressive disorder, recurrent, unspecified. 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 observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #49 and Resident #59) of 28 residents reviewed for accuracy of assessments. 1. Resident #49's MDS indicated she was rarely/never understood and able to answer a question about pain despite not being an active participant in the MDS process. 2. Resident #59 was discharged from the facility on 09/29/23 but did not have a discharge MDS in her EHR. This failure could place residents at risk of being inaccurately assessed and therefore not receiving necessary care. Findings Included: 1. Record review of Resident #49's admission record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), muscle weakness, senile degeneration of brain (a state of mental, emotional, and social deterioration…

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, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #49 and Resident #55) of 19 residents reviewed for care plans. 1. Resident #49's care plan did not address pain or the pain medications she was prescribed. 2. Resident #55's care plan listed him as full code when he was DNR. These failures could place residents at risk of not receiving desired and necessary care and treatment. Findings Included: 1. Record review of Resident #49's admission record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for one (Resident #22) of 19 residents reviewed for PRN orders for psychotropic drugs. Resident #22 had two active PRN orders for the same anti-anxiety medication (Lorazapam) with order start dates of 12/12/23. Neither order had an end date. Resident #22 did not have a diagnosis of anxiety in her clinical record. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication…

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

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles 1. 20 loose pills were found in the Hall 100 medication cart. 2. 1 loose pill was found in the Hall 400 medication cart. These failures could result in residents not receiving doses of medication as well as not being maintained at their best therapeutic level. Findings include: Observation on 01/30/24 at 10:04 AM revealed Hall 100 medication cart had 20 lose pills in the bottom of medication cart drawer. LVN O could not identify pills. LVN O discarded medication into a Drug disposal solution and did not mention who to notify when medications are found lose. Interview on 01/30/24 at 10:16 AM revealed LVN O stated that a negative outcome of having lose pills in the bottom of the medication cart drawers would be that If we don't know who the pills belong to an inaccurate count of medication will be in the system. Then we might not be able to get a medication if we need it, because the pharmacy will…

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 Resident #116 FTag Initiation Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area, for 2 (Resident #116 and Resident #41) of 19 residents reviewed for call system functioning. 1.The facility failed to ensure Resident #116's call light button was functioning and within reach. 2.The facility failed to ensure Resident #41's call light was within reach. This failure could place residents at risk of being unable to call for assistance from staff. The findings included: Record review of Resident #116's clinical record revealed Resident #116 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease, state 5, aftercare following joint replacement surgery, chronic…

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 provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 1 meal . The facility failed to ensure the resident trays were not served cold. This failure placed residents at risk for of decreased food intake, hunger, and unwanted weight loss. Findings include: An interview was conducted on 11/28/2022 at 10:20 AM with Resident #49. She had a complaint that the food was always served cold, and the eggs are rubbery when they get to her. An observation conducted on 11/28/2022 at 11:51 AM of the kitchen serving lunch trays. The regular lunch tray included a piece of fried chicken, okra, roasted potatoes, cornbread and a coffee cake and drinks included coffee, tea, or water. The [NAME] started to plate trays for residents who eat in their bedrooms. Serving container was not a heated container where the trays were being placed. Completed with trays at 12:10 PM and placed in dining room. They were left in the dining room area until 12:15 PM then the tray cart was taken out into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodates resident preferences for 2 of 2 (Resident #49 and #36) reviewed for food preferences. The facility failed to ensure Resident #49's likes and dislikes were honored when serving her lunch tray on 11/28/22. This failure could place residents at risk of not having their choices and food preferences accommodated, possible weight loss, and a diminished quality of life. Findings include: Review of Resident #49's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of wedge compression fracture, chronic obstructive pulmonary disease, and protein-calorie malnutrition. Her last weight was 92.6 pounds taken on 11/09/2022. An observation and interview conducted at 11/28/2022 at 3:18 PM, Resident #49 was sitting in bedroom and requested to talk with surveyor about lunch tray. Resident #49 informed surveyor with her lunch tray ticket which provided her meal…

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 store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure: - Raw chicken was not left out in kitchen. - Items not dated when opened. - Dented cans of food in regular pantry area. These failures could place residents at risk of food-borne illness and food that is contaminated or expired. Findings include: An observation conducted on 11/28/2022 at 09:35 AM, of the kitchen revealed, Raw chicken in a container open to air in the middle of the kitchen not covered. Hand wash station with cold water only and no paper towels. Dirty dishes laying on counter with cooling food and personal food items. Dented cans noted in the pantry area. Eggs wrapped with foil with no date on item. An observation conducted on 11/28/2022 at 11:35 AM, revealed a Milk container open with no open date on container. Personal drinking items located on puree counter area. An interview conducted on 11/28/2022 at 09:40 AM, the…

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

Based on observation and interview the facility failed to dispose of garbage properly for 2 of 2 (Dumpster #1 and #2) garbage dumpsters reviewed. The facility failed to ensure: Side door of Dumpster #1 was not left opened. 3 garbage bags were left on the floor next to the dumpster. These failures could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. Findings included: Observation on 11/28/22 at 4:18 PM, Dumpster #1's side door was left opened. 1 black garbage bag was left on the floor in the middle of both dumpsters and 2 white garbage bags were left on the floor on right side of Dumpster #2. During an interview on 11/30/2022 at 10:21 AM, the Dietary Manager said the process for trash disposal is the staff are aware the trash was to go inside the trash bin located outside. The DM said dietary was not the only department that throws out trash. She said that she would remind the dietary staff to throw trash inside the bin located outside. Interview on 11/30/22 at 04:25 PM, the DON stated nurses sometimes do throw…

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 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 11 of 11 employees reviewed for infection control. A. The facility failed to ensure wash hands and dispose of dirty gloves while handling food. B. The facility could not provide flu consents for employees: CNA B, CNA C, LVN D,LVN E, CNA F, LVN G, CNA H, RN I, Med Aide J, Med Aide K, and Social worker. These failures could have placed residents at risk for food borne illness and influenza. Findings include: During an observation on 11/28/2022 at 11:38 AM, cook and dietary aide in kitchen area preparing for lunch services. [NAME] preparing and cooking raw chicken, no gloves worn while handing chicken. [NAME] washed hands after placing chicken in frying pot. Went to handle the items for the pureed tray. Placed items in the puree machine, food handled with no gloves. At 11:54 AM, the cook with gloves…

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 Include dementia management training for 6 of 7 nursing staff reviewed for dementia training. A. The facility could not provide dementia training for 6 of 7 nursing staff. This failure could have placed residents with dementia diagnosis at risk of not receiving proper dementia care. Findings included: Review of DON's Dementia training revealed completion date 11/30/22 and date of hire was 10/17/22. Review of CNA B Dementia training revealed completion date 11/30/22 and date of hire was 12/08/2020. Review of CNA C Dementia training revealed completion date 11/30/22 and date of hire was 9/2/22. Review of LVN D Dementia training revealed completion date 11/30/22 and date of hire was 11/16/22. Review of LVN E Dementia training revealed completion date 11/30/22 and date of hire was 8/5/22. Review of CNA F Dementia training revealed completion date 11/30/22 and date of hire was 11/25/22. Interview and record review on 11/30/22 at 3:00 PM, HR stated the facility was in the process of switching all files to electronic files. HR…

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 refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #47) of 2 residents reviewed for PASSAR in that: -Resident #47 was diagnosed with Schizophrenia after PASSAR Level I was completed and was not further evaluated for Level II. This failure could cause a decline in mental health by not receiving available services for residents not evaluated accurately. Findings included: Review of Resident #47's face sheet showed a [AGE] year-old female that was admitted to the facility on [DATE]. She had diagnoses of bipolar disorder (extreme mood swings) and depression. It also showed she was diagnosed with schizoaffective disorder on 02/18/22. Review of History and Physical dated 02/09/22 confirmed Resident #47's diagnoses of depression and bipolar disorder. Review of Psychiatric note dated 11/11/22…

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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions and expiration date when applicable for 1 of 3 (500 hall) medication carts reviewed for expired medications in that: The facility failed to ensure the 500 hall medication cart did not contain expired medications, Centrum Adult Vitamin bottle had no open date and an expiration date of 2/22. This deficient practice could place residents at risk of decline in health if medication was to be administered to them. Findings included: Observations of the 500 hall medication cart on 11/29/22 at 10:35 AM, with RN A, revealed a bottle of Centrum Adult Vitamins opened with an expiration date of 2/22. In an interview on 11/29/22 at 10:42 AM, RN A said we are all mindful of our own medication carts and supplies. The staff checks their own cart. She said the medication should not have been in the cart because it was expired and did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #2) of 6 residents reviewed for physician's orders. A. Resident #2 had active physicians' orders for full code and do not resuscitate. This failure could place residents at risk for delayed treatment due to inaccurate documents that could result in harm or actual death. Findings included: Review of Resident #2's face sheet dated 11/30/22 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Review of Resident #2's history and physical dated 10/12/22 revealed a diagnosis of benign brain tumor status post-surgical removal. Review of Resident #2's out of hospital do not resuscitate order dated 1/24/17 revealed Resident #2 and physician both signed on 1/24/17. Review of Resident #2's nursing facility to hospital transfer form dated 5/25/22 revealed code status- do not resuscitate. Review of Resident #2's care plan summary 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.