Mullican Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 4 residents (Resident #4 and Resident #3) reviewed for hospice services.1.The facility failed to maintain Resident #4's hospice binder containing information related to hospice services provided for the resident such as an updated care plan or the last IDG also known as Interdisciplinary Group meetings (a regular, collaborative team review of a patient's care meetings).2. The facility failed to obtain Resident #3's most up to date hospice medication list.These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation,…

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 2 of 4 residents (Resident #20 and Resident#11) reviewed for infection control.1.The facility failed to ensure CNA B wore PPE which consisted of gown and gloves while in Resident #20's room on 07/21/26 who was on contact isolation for ESBL also known as extended-spectrum beta-lactamase, (infections are primarily transmitted through direct or indirect contact with the bacteria) and the facility failed to provide containers for the disposal of linen and trash.2. The facility failed to ensure LVN A wore PPE (gown) while performing wound care for Resident #11.These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included:1.Record review of Resident #20's face sheet,…

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 notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 4 residents (Resident #1) reviewed for discharge. 1.The facility failed to notify the resident representative, (Office of the State Long-Term Care Ombudsman,) of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. 2.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #1. 3.The facility failed to notify Resident #1's responsible party of his discharge prior to him being discharged from the facility. These failures could place residents at risk of not receiving an advocate who could inform them of their options, rights,…

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, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to dispose of expired food items. 2) The facility failed to label and date all food items in the refrigerator and freezer. 3) The facilty failed to main safe holding temps on the steam table. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Record Review of in-services on labeling and dating was last completed by staff on 5/27/25. During observation in the kitchen refrigerator 1 of 2 on 5/27/25 at 9:25 a.m., the following was observed with the Dietary Manager: -2 quarts of BBQ Beef had an expiration date of 5/22/25. (Expired) -1/2 quart of container of Jelly had a preparation date of 5/19/25 and no expiration date. -2 quarts of ketchup in a container had a preparation date of 5/17/23 and no expiration date. -1 quart of diced tomatoes was not labeled, had no…

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 3 meals (lunch) reviewed for palatability and temperature. 1. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 5/28/25 (lunch) meal. 2. The facility failed to follow puree recipe for lunch meal served on 5/28/25. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: 1. Record Review of the facility week 1 menu dated on 5/28/25, indicated the lunch meal (A) items included Chicken Parmesan, Bowtie Pasta, Italian Blend vegetables, garlic bread, margarine, chocolate turtle poke cake, and iced tea. During an interview on 5/27/25 at 10:10 a.m., Resident #6 stated most of the times she liked the food. Resident #6 stated the hamburger meat made her stomach upset so she was always asking for alternative meal like a peanut butter and jelly sandwich. During an interview on 05/27/25 at 11:26 AM,…

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 each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community, in that: The facility failed to serve meals, at the specific times posted, in the main dining room. This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth. Findings included: Record Review of in-services on time management was last completed by staff on 4/29/25. Record review of the facility's posted meal service reflected breakfast mealtime was 7:00 AM; lunch mealtime was 12:00 PM; and dinner mealtime was 5:00 PM. During an interview in the dining room on 5/28/25 at 9:00 a.m., Resident #38 stated that the breakfast and lunch meal was always served late. During observations on 05/28/25 at 12:42 PM, in the facility's main room, lunch meal service had not begun, and the residents had not begun to eat lunch. During an interview on 5/29/25 at 8:15 a.m., the Dietary manager stated he had been employed…

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 prompt efforts were made to resolve grievances for 1 of 16 residents (Resident #17) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #17 was appropriately apprised of progress toward a resolution when Resident #17 reported to the Administrator that she was missing her $250 from her room on 1/31/25. This failure could place residents at risk for a decreased quality of life, and grievances not being addressed or resolved promptly. Findings included: Record review of Resident #17's face sheet dated 05/29/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses of high blood pressure, chronic obstructive pulmonary disease (a disease in which the pulmonary system has limited airflow), anxiety, and congestive heart failure. Record review of Resident #17's quarterly MDS dated [DATE] indicated she made herself understood and was able to understand others. The MDS also…

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 coordinate assessments with the PASRR program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 residents (Resident #34) reviewed for PASRR. The facility failed to coordinate quarterly PASRR IDT meetings to discuss specialized services with the PASRR Coordinator for Resident #34. This failure could place residents with positive PASRR status at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #34's face sheet dated 05/29/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior) and major depressive disorder,…

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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #39) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #39's foley catheter was secured on 05/27/2025. This failure could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: Record review of a face sheet dated 05/28/2025 indicated Resident #39 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the prostate (prostate cancer) and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate which results in difficulty urinating). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #39 understood others and was understood. The MDS assessment indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 6 residents (Resident #28) reviewed for pharmacy services. The facility failed to ensure RN A accurately reconciled Resident #28's narcotic medication log when she disposed Resident #28's clonazepam (controlled medication used for anxiety) tablet on 05/27/25. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Record review of Resident #28's face sheet dated 05/28/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included anxiety and gastrostomy status (surgical opening into the stomach for nutritional support…

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 laboratory services were obtained to meet the needs of 1 of 16 residents reviewed for laboratory services (Residents #4). The facility failed to obtain Resident #4's Keppra level (level obtained to ensure medication is in therapeutic range) as ordered. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs. Findings included: Record review of Resident #4's face sheet dated 05/28/25 indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included dementia (memory loss) and epilepsy (seizures). Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated she was usually understood and usually understood others. The MDS assessment indicated she had a BIMs score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #4 had a seizure…

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 communicable diseases and infections for 1 of 3 residents (Resident #11) reviewed for infection control. The facility failed to ensure LVN C and CNA D followed enhanced barrier precautions while providing wound care to Resident #11 on 05/28/2025. This failure could place residents at risk for cross contamination and the spread of infection due to lack of implementation of orders. Findings included: Record review of a face sheet dated 05/28/2025 indicated Resident #11 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities severe enough to interfere with daily life) and peripheral vascular disease (narrowed blood vessels reduce blood flow 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 ensure assessments accurately reflected the resident status for 3 of 12 residents (Resident # 17, Resident #4, Resident 11) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 17's, Resident #4's, and Resident #11's, restraints were accurately coded. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1.Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #17's quarterly MDS assessment, dated 02/05/24, indicated Resident…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 5 halls (C hall) reviewed for physical environment. The facility failed to ensure the flooring on the C hall was free from trip hazards. This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment. The findings were: During an Observation on 04/09/24 at 3:05 PM the flooring on the C hall was raised and split across the hallway. During an Observation and interview on 04/10/24 at 05:07 PM The ADON was shown the place on the floor that was raised, and she said she did not realize it had gotten worse. The ADON said she was not responsible for the floor but said she would notify the correct person to ensure it was addressed. She said the failure placed a risk for residents falling. During an observation and interview on 04/10/24 at 05:35 PM The DON She said she could see potential for someone to fall. The DON said she was not aware 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 interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II for 1 of 3 residents (Resident #17) whose records were reviewed for mental disorders. The facility failed to refer Resident #17 for a PASARR evaluation based on mental disorder diagnoses of Psychosis. This deficient practice could affect residents with mental illness and contribute to a delay in services needed. The findings included: Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #17's quarterly MDS assessment, dated 02/05/24,…

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 and implement a comprehensive person-centered care plan for each resident, 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 for 1 of 14 residents (Residents #2) reviewed for care plans. 1.The facility failed to include Resident #2's diagnosis and interventions for post-traumatic stress disorder (PTSD) in the care plan. This failure could have placed residents at risk for not having their needs met. The findings included: A record review of Resident #2's face sheet dated 04/10/24 indicated she was a [AGE] year-old female who originally admitted to the facility on [DATE] and last admission date of 03/27/24 with diagnosis PTSD (anxiety and flashbacks triggered by a traumatic event). A record review of Resident #2's significant change MDS assessment dated [DATE] indicated Resident #2 was rarely/never understood 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 review and revise the person-centered care plan to reflect the current condition for 3 of 3 (Resident #17, Resident #15, and Resident #25) residents reviewed for care plan revisions. 1.The facility failed to revise Resident #17's care plan to include he removed his Foley catheter leg strap (a device used to reduce the risk of tension or pulling on the catheter, which could cause some very unpleasant trauma within the bladder or urethra) as ordered at times. 2. The facility failed to revise Resident #15 care plan to remove her wander guard. 3. The facility failed to revise Resident #25 care plan to remove he was a smoker. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1.Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses…

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 requiring respiratory care were provided such care, consistent with professional standards of practice for 2 of 12 residents (Resident #8 and #31) reviewed for respiratory care. 1. The facility failed to ensure Resident #8 had oxygen orders. 2. The facility failed to ensure Resident #31 oxygen concentrator filters were cleaned. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of Resident #8's face sheet, dated 04/10/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (no airflow for breathing), high blood pressure, Dementia (impaired ability to remember, think, or make a decision) and Depression (feeling of sadness). Record review of Resident #8's quarterly MDS…

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 maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 (Resident #17) of 4 residents whose records were reviewed for accuracy and completeness. The facility failed to maintain accurate documenation in the MAR for April 2024 for Resident #17. This deficient practice could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings included: Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness). Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 of 3 residents (Resident #26) reviewed for infection control practices. CNA D failed to wash or sanitize hands when changing gloves between dirty and clean while providing peri care for Resident #26. This failure could place residents and staff at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #26's face sheet dated 04/10/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnoses diabetes mellitus type 2, epilepsy, high blood pressure, urine retention, and mood disorder. Record review of Resident #26's annual MDS dated [DATE] indicated he had a BIMS score of 11 which meant he had moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit abuse and neglect for 1 of 15 residents reviewed for abuse. (Residents #1) The facility failed to report\per policy to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place residents at risk of unreported abuse, neglect, and exploitation. Findings included: Record review of facility's Policy for Abuse and Neglect with a revised date of 03/29/2018 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart e. Reporting Any person having reasonable cause to believe, and elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to 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 interview 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, if the events that cause the allegation involve abuse or 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 1 of 15 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place the residents at risk for abuse. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 3 residents (Residents #1) reviewed for transfer and discharge. The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type…

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 establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of 3 residents reviewed for transfer/discharge. 1. The facility failed to admit Resident #1 back to facility after he was sent to the psychiatric hospital on [DATE]. 2.The facility failed to give Resident #1 a 30-day discharge notice. This failure could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive…

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.