Ashland Nursing And Rehabilitation

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in resident rights for one of ten employee records reviewed, CNA (certified nursing assistant) #3.The findings include:On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #3. The review of the employee training records revealed that CAN #3 did not have the required training in resident rights. On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that the CNA #3 did not have the required training in resident rights.A request for the policy for the required training elements was requested but not provided prior to exit.The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m.No further information was provided prior to exit.

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in QAPI (quality assurance performance improvement) for one of ten employee records reviewed, CNA (certified nursing assistant) #3.On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #3. The review of the employee training records revealed that CNA #3 did not have the required training in QAPI. On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that the CNA #3 did not have the required training in QAPI.A request for the policy for the required training elements was requested but not provided prior to exit.The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m.No further information was provided prior to exit.

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in Behavioral Health for four of ten employee records reviewed, CNA (certified nursing assistant) #2, CNA #3, other staff member (OSM) #2, dietary, and OSM #3, housekeeping.The findings include:On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #3. The review of the employee training records revealed CNA #2, CNA #3, OSM #2 and OSM #3 no documented education regarding behavioral health.On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that CNA #2, CNA #3, OSM #2 and OSM #3 did not have the required training in behavioral health.A request for the policy for the required training elements was requested but not provided prior to exit.The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m.No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to facilitate resident council meetings for three of nine months, potentially affecting all residents, and failed to resolve grievances identified in the resident council meetings for two months reviewed.1. The facility staff failed to facilitate resident council meetings from 5/1/2025 through the present potentially affecting all residents in the facility. A review of the facility resident council meeting minutes from 10/1/2024 to the present failed to evidence any meeting minutes after 4/17/2025. On 8/20/2025 at 2:00 p.m., an interview was conducted with Resident #18 (R18) who stated that there were no activities in the building from February through June. R18 stated that he called resident council meetings himself when there was no activities director and he had independently met with some other residents and former administrative staff to discuss the need for an activities director and person to file grievances through. R18 stated…

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

Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure the activities program was directed by a qualified professional between 1/29/2025 and 6/27/2025 potentially affecting all residents in the facility.The findings include:The facility staff failed to ensure a director of activities was in place between 1/29/2025 and 6/27/2025.On 8/19/2025 at 2:09 p.m., an interview was conducted with Resident #17 (R17) who stated that they could remember a time this year when there were no activities. R17 stated that he liked to go to various activities, but there were none being done that he knew of. He stated he thought there should have been someone to do them for him and other residents. R17 was assessed as being cognitively intact for making daily decisions on the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/26/2025.On 8/20/2025 at 2:00 p.m., an interview was conducted with Resident #18 (R18) who stated that there were no activities in the building from…

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 staff interview and facility document review, it was determined that the facility staff failed to review and revise the facility assessment after a change of ownership effective 6/1/2025.The findings include:Review of the provided facility assessment documented a date of 7/18/2024. The facility assessment documented the former executive director and director of clinical services at the facility. It further documented information under the staff training/education and competencies that reflected the previous owner.On 8/20/2025 at 5:08 p.m., an interview was conducted with ASM (administrative staff member) #1, the executive director, who stated that the facility assessment provided was from 2024 prior to the change of ownership. He stated that they had planned to update the assessment in a QAPI (Quality Assurance Performance Improvement) meeting that they had scheduled for 8/20/2025. ASM #1 stated that the change of ownership sale was completed effective 6/1/2025 when the former owner ceased to exist and the new owner took over. He stated that they had to renew all 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.

Based on staff interview and facility document review, the facility staff failed to provide evidence of updated contracts with outside providers for three of three contracts reviewed, potentially affecting all residents.The findings include:The facility staff failed to provide updated contracts for mobile imaging services, mobile imaging equipment, and an agreement for contract dialysis services.On 8/20/25 at 5:13 p.m., copies of current facility contracts were requested as part of the extended survey process. ASM (administrative staff member) #1, the executive director, stated he may not be able to provide the survey team with contracts that meet the regulation. He stated that due to the facility sale in June of 2024, the former company ceased to exist, and a new company took over as owner. He added: We had to go back in and negotiate contracts with all of our venders.On 8/21/25 at 8:36 a.m., ASM #1 provided a book of contracts for outside service providers to the facility. A review of three of these contracts revealed there was no contractual agreement between the providers of…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure attendance of the infection preventionist at one of five QAPI (quality assurance performance improvement) meetings reviewed, Q4 (quarter four) 2024 potentially affecting all residents in the facility.The findings include:Review of the provided facility QAPI meeting sign-in attendance sheets failed to evidence the infection preventionist present at the Q4 2024 meeting.On 8/21/2025 at 9:28 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of clinical services, who stated that the infection preventionist had resigned in November of 2024 and the assistant director of nursing was covering the role at the time of the QAPI meeting and was not present at the meeting. On 8/21/2025 at 10:01 a.m., an interview was conducted with ASM #1, the executive director who stated that QAPI meetings were held quarterly at a minimum and attended by the interdisciplinary team which included the administrator, director of nursing, medical director,…

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 staff interview and facility document review, the facility staff failed to implement a complete infection control program for two of two months reviewed, November and December 2024. The findings include:For November and December 2024, the facility staff failed to provide evidence of a surveillance system to identify possible communicable diseases before they can spread to other persons in the facility.On 8/18/25 at 4:30 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of clinical services, were asked to provide evidence of the facility's infection surveillance system for November and December 2024.On 8/19/25 at 1:18 p.m., ASM #2 stated the infection surveillance logs for November and December 2024 could not be located. She stated she and the current infection preventionist had only been working at the facility since January 2025. She stated she had searched for the logs and could not find them.On 8/19/25 at 3:56 p.m., LPN (licensed practical nurse) #1, the infection preventionist, was interviewed. She stated she had started work…

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 staff interview, facility document review, and clinical record review, the facility staff failed to protect residents from abuse for four of 27 residents in the survey sample, Residents #20, #21, #22, and #23. The findings include:1. For Resident #20 (R20), the facility staff failed to protect the resident from physical abuse from Resident #25 (R25). On 1/24/25, R25 hit R20 in the face. A review of R20's clinical record revealed a nurse's note dated 1/24/25 that documented, At about 345pm staff member observed another resident on top of resident in bed (number) hitting him in the face. Writer assessed resident small skin tear noted to resident's nose. Facial swelling and bruising noted to left side of resident's face. Vitals checked, 128/77 (blood pressure), 97.9 (temperature), 72 (pulse), 18 (respirations). NP (Nurse Practitioner) called and made aware of incident. Xray order given. (Name of power of attorney) called and made aware of incident. No concerns voiced. She stated she would be in tomorrow to see resident. An initial facility synopsis submitted to the SA (State…

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 staff interview, facility document review and clinical record review, the facility staff failed to implement their policies for the investigation of an allegation of abuse for two of 27 residents in the survey sample, Residents #7 and #2. The findings include: 1a. For Resident #7 (R7), the facility staff failed to implement their policies and procedures for the investigation of abuse. The facility synopsis of event dated 12/20/24 and reported on 12/20/24, documented in part, “The Interim DON (director of nursing) was notified that the Nurse witnessed (R7) hit (R27). She was not able to get to them in time. The residents were separated. Skin assessments were done. No injuries. MD (medical doctor) and RP (responsible party) updated. (R7) will be placed on Q (every) 15 safety checks.” The final report from the facility dated 12/27/24, documented in part, “This letter is to serve as our final report for an FRI (facility reported incident) submitted to your office on 12/20/24. On that date, staff witnessed…

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 staff interview, facility document review and clinical record review, the facility staff failed to thoroughly investigate an allegation of abuse for two of 27 residents in the survey sample, Residents #7 and #2. The findings include: 1. For Resident #7 (R7), the facility staff failed to evidence a thorough investigation for an allegation of abuse. The facility synopsis of event dated 12/20/24 and reported on 12/20/24, documented in part, “The Interim DON (director of nursing) was notified that the Nurse witnessed (R7) hit (R27). She was not able to get to them in time. The residents were separated. Skin assessments were done. No injuries. MD (medical doctor) and RP (responsible party) updated. (R7) will be placed on Q (every) 15 safety checks.” The final report from the facility dated 12/27/24, documented in part, “This letter is to serve as our final report for an FRI (facility reported incident) submitted to your office on 12/20/24. On that date, staff witnessed (R7) strike (R27). (R27) was assessed…

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, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for six of 27 residents in the survey sample, Resident #6, #13, #8, #10, #25, and #1.The findings include:1. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to provide toileting assistance on multiple dates in August 2023, September 2023 and October 2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/4/23, the resident was assessed as being severely impaired for making daily decisions. The resident was assessed as requiring supervision of one person for toileting and personal hygiene and being occasionally incontinent of urine and always continent of bowel. Review of the ADL documentation for R6 dated 8/1-8/31/2023 failed to evidence toileting assistance provided on day shift on 8/1/23, 8/2/23, 8/7/23, 8/10/23,…

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, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for four of 27 residents in the survey sample, Residents #14, #8, #20 and #25.The findings include:1. For Resident #14 (R14), the facility staff failed to revise the comprehensive care plan to reflect A) the resident no longer using a wanderguard device and B) no longer on every 15-minute checks. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/26/25, the resident was assessed as being severely impaired for making daily decisions. The assessment documented no wandering behaviors or wander/elopement alarm devices in use. On 8/18/2025 at 11:37 a.m., an observation was made of R14 who was observed in the hallway without shoes or socks on. No wanderguard device was visible at that time. Additional observation of R14 on 8/18/2025 at 1:14 p.m. and 8/19/2025 at 8:44 a.m. revealed no wanderguard observed. The comprehensive care plan for R14…

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, staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for four of 27 residents in the survey sample, Resident #8, Resident #14, Resident #6, and Resident #1. The findings include: 1. For Resident #8 (R8), the facility staff failed evidence that showers were provided. The June 2025 ADL records documented the resident received two showers, 6/17/25 and 6/25/25. He received four partial baths on 6/7/25, 6/8/25, 6/10/25 and 6/13/25. Of the 78 opportunities for documenting baths, showers or any bathing activity, there were only 13 documented, the rest were all blank. The July 2025 ADL records documented that the resident received no showers. He received seven partial baths, 7/1/25, 7/2/25, 7/5/25, 7/6/25, 7/7/25, 7/20/25 and 7/29/25 and two bed baths 7/3/25 and 7/9/25. Of the 93 opportunities for documenting baths, showers or any bathing activity, there were only 16 documented, the rest were all blank. The August 2025 ADL records documented the resident did not receive any…

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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide activities for five of 27 residents in the survey sample, Residents #17, #13, #14, #2, and #8.The findings include:1. For Resident #17 (R17), the facility staff failed to provide activities according to the resident’s preferences from February through June 2025. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/26/25, R17 was coded as having no cognitive impairment. R17 was coded as prioritizing the following activities as “very important:” listening to music, keeping up with the news, doing things with groups of people, doing his favorite activities, and going outside to get fresh air when the weather is good. On 8/20/25 at 9:01 a.m., ASM (administrative staff member) #1, the executive director, stated the facility did not have evidence of activities for R17 or other residents between February and June 2025. He stated that the current activities director had started working at the facility…

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 staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision for one of 27 residents in the survey sample, Resident #25. The findings include:For Resident #25 (R25), the facility staff failed to provide adequate and consistent monitoring, resulting in multiple incidents of the resident hitting and inappropriately touching other residents. A review of R25's clinical record revealed a nurse's note dated 1/24/25 that documented, At about 345pm staff member observed resident on top of another resident (in bed number) hitting him in the face. Cna (Certified nursing assistant) that observed incident immediately separated residents. Writer assessed resident. No new skin concerns noted. When asked why were you hitting him, he stated, he was in my room. NP (Nurse Practitioner) called and made aware. Sister called and made aware of incident.An initial facility synopsis submitted to the SA (State Agency) on 1/24/25 documented, Facility staff responded to resident to resident incident on locked dementia unit. (R20) had…

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 staff interview, it was determined that the facility staff failed to provide sufficient staff in one of one facility kitchens. The findings include:On 08/18/2025 at approximately 3:50 p.m., an observation of the last food cart for the resident's lunch revealed it arrived on Unit One at 3:50 p.m. Further observations revealed the last lunch tray was served to a resident on Unit one at 4:10 p.m. On 08/19/2025 at approximately 11:15 a.m. an interview was conducted with OSM (other staff member) #7 and OSM #6, account manager for dietary. OSM #6 stated the first breakfast food carts are sent to the floor between 7:35 a.m. and 7:40 a.m., the first lunch food carts are sent to the floor at 11:45 a.m., and the first dinner food carts are sent to the floor at 4:30 p.m. When informed of the observation of the resident's first lunch cart arriving on Unit Three at 2:00 p.m. and the last lunch cart arriving on Unit One at 3:50 p.m. she stated that it was not acceptable for the residents and the residents should not have to wait for the meals. When asked to describe 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 staff interview, it was determined that the facility staff failed to serve palatable food on one of three facility units, Unit One. The findings include:On 08/18/2025 at approximately 3:50 p.m., a test tray consisting of chicken stir-fry, chopped spinach, enhanced potatoes was placed on a food cart in the facility's kitchen, sent to Unit One of the facility. The cart was followed by the surveyor, OSM (other staff member) #7, district manager for dietary. At approximately 4:10 p.m., the last lunch tray was served to a resident on Unit One and OSM # 7 was asked to remove cover from the test plate then proceeded to take the temperatures of the food. Two surveyors observed OSM #7 obtaining the food temperatures of the test tray. The chopped spinach was 118 degrees F (Fahrenheit), the stir-fry was 111 degrees F, and the potatoes were 115 degrees F. The test tray was sampled by two surveyors, OSM #7 for appropriate holding temperatures and palatable taste. When asked to describe the taste of the food OSM #7 stated the food was lukewarm. After tasting all the food…

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 staff interview, it was determined that the facility staff failed to serve lunch in a timely manner on one of three facility units, Unit One. The findings include:On 08/18/2025 at approximately 3:50 p.m., an observation of the last food cart for the resident's lunch revealed it arrived on Unit One at 3:50 p.m. Further observations revealed the last lunch tray was served to a resident on Unit one at 4:10 p.m. On 08/19/2025 at approximately 11:15 a.m. an interview was conducted with OSM (other staff member) #7 and OSM #6, account manager for dietary. OSM #6 stated the first breakfast food carts are sent to the floor between 7:35 a.m. and 7:40 a.m., the first lunch food carts are sent to the floor at 11:45 a.m., and the first dinner food carts are sent to the floor at 4:30 p.m. When informed of the observation of the resident's first lunch cart arriving on Unit Three at 2:00 p.m. and the last lunch cart arriving on Unit One at 3:50 p.m. she stated that it was not acceptable for the residents and the residents should not have to wait for the meals. When asked 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.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to invite residents and/or residents' representatives to attend and participate in care plan meetings for two of 27 residents in the survey sample, Residents #16, and #8. The findings include:1. For Resident #16 (R16), the facility staff failed to invite the resident and the resident's representative to attend and participate in care plan meetings in 2025. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/20/25, R16 scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R16's clinical record for 2025 failed to reveal the resident and/or the resident's representative were invited to participate in the resident's care plan meetings. On 8/19/25 at 12:10 p.m., an interview was conducted with R16 and the resident's representative. During the interview, R16's representative stated R16 or the representative…

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, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to promote dignity for one of 27 residents in the survey sample, Resident #14, and on one of three nursing units, the [NAME] unit.The findings include:1. For Resident #14 (R14), the facility staff failed to promote dignity by maintaining trimmed facial hair on a female resident. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/26/2025, the resident was assessed as being severely impaired for making daily decisions. Rejection of care was documented occurring 1 to 3 days during the assessment period but not daily. R14 was assessed as requiring substantial to maximal assistance with personal hygiene. On 8/18/2025 at 11:37 a.m., an observation was made of R14 in the hallway of the memory care unit that they resided on. R14 was observed walking in the hallway outside of their room engaging in pleasant conversation…

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 staff interview, facility document review, and clinical record review, the facility staff failed to notify a resident's responsible party of a change in condition for one of 27 residents in the survey sample, Resident #12The findings include:For Resident #12 (R12), the facility staff failed to notify the resident's responsible party when the resident presented with behaviors and was transferred to the hospital on 4/24/24. A review of R12's clinical record revealed a nurse's note dated 4/24/24 that documented, Pt (Patient) transferred out to ER for further eval (evaluation) related to med refusal, aggressive behaviors, combativeness with staff during ADL (activities of daily living) care, impulsiveness and inappropriate responses to eval questions. Pt eval by psych MD (Medical Doctor) and nurse advised to send to ER for psychosis. Further review of R12's clinical record failed to reveal R12's responsible party was notified regarding the resident's behaviors and hospital transfer. On 8/20/25 at 11:20 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN…

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, resident interview and staff interview, it was determined that facility staff failed to maintain a clean, homelike environment for one of 13 current residents in the survey sample, Residents #2 (R2) and one of three units ([NAME] Unit). The findings include:1. For R2, facility staff failed to maintain the room in a clean and sanitary manner. R2 was admitted to the facility with diagnosis that included but were not limited to a stroke. On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/05/2025, R2 was coded as having both short- and long-term memory difficulties and was coded as being severely impaired of cognition for making daily decisions. On 08/18/2025 at approximately 12:45 p.m., an observation of R2 room was conducted. Observation of the floor next to left side of R2’s bed revealed two packages of unopened ketchup, two packages of unopened sugar, two packages of two packages of unopened salt and pepper, several…

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 staff interview, facility document review and clinical record review, the facility staff failed to report an allegation of abuse in a timely manner for one of 27 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7) the facility staff failed to report an allegation to the state agency in a timely manner. The incident occurred on 12/27/25 and was not reported to the state agency until 12/30/25. The facility synopsis of event dated, 12/30/24 with the incident dated 12/27/24, documented in part, The Interim DON was notified that the nurse witnessed (R7) hit (R26) in the face. She was not able to get to them in time. The residents were separated. Skin assessments were done. Note discoloration to the side of (R26)'s face. MD and RP updated. (R7) will be placed on Q 15 (minute) safety checks. The final report to the state agency documented in part, On 12/30/24 the Interim DON was notified that the Nurse witnessed (R7) hit (R26) in the face. She was not able to get to them in time. The residents were separated. Skin assessments were done. Note…

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 staff interview, facility document review, and clinical record review, the facility staff failed to provide a written notice of transfer, and a written notice of the bed hold policy to the resident and/or resident representative upon hospital transfer for two of 27 residents in the survey sample, Residents #12, and #8. The findings include:1. For Resident #12, the facility staff failed to provide a written notice of transfer, and a written notice of the bed hold policy when the resident transferred to the hospital on 4/24/24. A nurse's noted dated 4/24/24 documented, Pt (Patient) transferred out to ER for further eval (evaluation) related to med refusal, aggressive behaviors, combativeness with staff during ADL (activities of daily living) care, impulsiveness and inappropriate responses to eval questions. Pt eval by psych MD (Medical Doctor) and nurse advised to send to ER for psychosis. Further review of R12's clinical record failed to reveal evidence that the resident and/or responsible party were provided with a written notice of transfer and a written notice of the bed…

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, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide foot care for one of 27 residents in the survey sample, Resident #14.The findings include:For Resident #14 (R14), the facility staff failed to provide foot care to maintain trimmed toenails.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/26/2025, the resident was assessed as being severely impaired for making daily decisions. Rejection of care was documented occurring 1 to 3 days during the assessment period but not daily. R14 was assessed as requiring substantial to maximal assistance with personal hygiene and bathing. R14 was not documented as being diabetic.On 8/18/2025 at 11:37 a.m., an observation was made of R14 in the hallway of the memory care unit that they resided on. R14 was observed walking in the hallway outside of their room in bare feet. R14's feet were observed with long untrimmed toenails that were uneven and approximately 1/8 inch from the nailbed. 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 staff interview, facility document review, and clinical record review, the facility staff failed to provide sufficient nursing staff for one of 27 residents in the survey sample, Resident #25. The findings include:For Resident #25 (R25), the facility staff failed to provide sufficient nursing staff to ensure adequate monitoring, resulting in multiple incidents of the resident hitting and inappropriately touching other residents. A review of R25's clinical record revealed a nurse's note dated 1/24/25 that documented, At about 345pm staff member observed resident on top of another resident (in bed number) hitting him in the face. Cna (Certified nursing assistant) that observed incident immediately separated residents. Writer assessed resident. No new skin concerns noted. When asked why were you hitting him, he stated, he was in my room. NP (Nurse Practitioner) called and made aware. Sister called and made aware of incident.An initial facility synopsis submitted to the SA (State Agency) on 1/24/25 documented, Facility staff responded to resident to resident incident on locked…

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 staff interview and facility document review, the facility staff failed to complete an annual performance evaluation for one of five CNA (certified nursing assistant) records reviewed, CNA #5.The findings include:For CNA #5, the facility staff failed to provide evidence of the required annual performance evaluation in the past 12 months.On 8/20/25 at 5:13 p.m., CNA #5's most recent performance evaluation was requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff performance evaluations from this point forward. She stated she could not speak to why the evaluation had not been done in a timely manner in the past,…

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 staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 27 residents in the survey sample, Resident #20. The findings include:For Resident #20 (R20), the facility staff failed to assess the resident's psychosocial status and implement psychosocial interventions to address physical abuse on 1/24/25. A review of R20's clinical record revealed a nurse's note dated 1/24/25 that documented, At about 345pm staff member observed another resident on top of resident in bed (number) hitting him in the face. Writer assessed resident small skin tear noted to resident's nose. Facial swelling and bruising noted to left side of resident's face. Vitals checked, 128/77 (blood pressure), 97.9 (temperature), 72 (pulse), 18 (respirations). NP (Nurse Practitioner) called and made aware of incident. Xray order given. (Name of power of attorney) called and made aware of incident. No concerns voiced. She stated she would be in tomorrow to see resident. Further review of R20's clinical record failed 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.

Based on staff interview and clinical record review it was determined that the facility staff failed to maintain a completed and accurate clinical record for two of 27 residents in the survey sample, Resident #2 (R2) and R23. The findings include:1. For R2, the facility staff failed to accurately document when showers were provided. R2 was admitted to the facility with diagnosis that included but were not limited to a stroke. On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/05/2025, R2 was coded as having both short- and long-term memory difficulties and was coded as being severely impaired of cognition for making daily decisions. The facility’s resident shower schedule dated 01/03/2025 documented in R2’s room number for showers on every Monday and Thursday evening. The facility’s shower sheets dated 07/07/2025 through 08/18/2025 documented R2 received showers every Monday and Thursday. The facility’s ADL (activities of daily living) tracking sheets dated 07/07/2025 through 08/18/2025 failed to document 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.

Based on staff interview, facility documentation, and clinical record review, it was determined the facility staff failed to evidence communication between the hospice company and the facility for one of 27 residents in the survey sample, Resident #19 (R19). The findings include: For Resident #19, the facility staff failed to evidence communication between the hospice company and the facility. The physician order dated, 6/12/25, documented, Resident admitted to (Name of Hospice).A request was made for communication between the facility and the hospice company. On 8/20/25 at 1:27 p.m. ASM (administrative staff member) #2, the director of clinical services, presented information related to hospice communication. The documents had been faxed to the facility on 8/20/25. The documents contained notes from visits from the hospice company on 6/12/25, 6/13/25, 6/27/25 and 7/1/25. When asked the process for having the information from the hospice company available to the staff caring for the residents, ASM #2 stated, when the facility receives information, it is given to the medical records…

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 staff interview and facility document review, the facility staff failed to provide communications training for one of ten staff records reviewed, CNA (certified nursing assistant) #5.The findings include:For CNA #5, the facility staff failed to provide required communications training.On 8/20/25 at 5:13 p.m., CNA #5's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these. She stated she will be keeping up with the required training content…

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.

For RN #2 and OSM #15, the facility staff failed to provide required resident rights training.On 8/20/25 at 5:13 p.m., RN #2's and OSM #15's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these. She stated she will be keeping up with the required training content and tracking the training for each staff member. She explained that staff training is one way to meet residents' needs. She added that managers are responsible for making sure staff are…

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 staff interview and facility document review, the facility staff failed to provide training in prevention of resident abuse, neglect, and exploitation for one of ten staff records reviewed, RN (registered nurse) #2.The findings include:For RN #2, the facility staff failed to provide required training in the prevention or resident abuse, neglect, and exploitation.On 8/20/25 at 5:13 p.m., RN #2's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of…

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

Based on staff interview and facility document review, the facility staff failed to provide QAPI (quality assurance and performance improvement) training for two of ten staff records reviewed, RN (registered nurse) #2 and OSM (other staff member) #15, a member of the dietary staff.The findings include:For RN #2 and OSM #15, the facility staff failed to provide required QAPI training.On 8/20/25 at 5:13 p.m., RN #2's and OSM #15's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future,…

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 staff interview and facility document review, the facility staff failed to provide infection control training for one of ten staff records reviewed, RN (registered nurse) #2.The findings include:For RN #2, the facility staff failed to provide required infection control training.On 8/20/25 at 5:13 p.m., RN #2's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these. She stated she will be keeping up with the required training content and…

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

Based on staff interview and facility document review, the facility staff failed to provide compliance and ethics training for one of ten staff records reviewed, RN (registered nurse) #2. The findings include:For RN #2, the facility staff failed to provide required compliance and ethics training.On 8/20/25 at 5:13 p.m., RN #2's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these. She stated she will be keeping up with the required training content…

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.

For CNA #5 and CNA #8, the facility staff failed to provide at least 12 hours of education annually for the past 12 months.On 8/20/25 at 5:13 p.m., CNA #5's and CNA #8's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training from this point forward. She stated she could not speak to why the required hours were not done in the past, but in the future, she will be taking care of these. On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.No additional information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to provide behavioral health training for two of ten staff records reviewed, RN (registered nurse) #2 and OSM (other staff member) #15, a member of the dietary staff. The findings include:For RN #2 and OSM #15, the facility staff failed to provide required behavioral health training.On 8/20/25 at 5:13 p.m., RN #2's and OSM #15's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking…

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 staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to promote the highest level of well-being for one of 49 residents in the survey sample, Resident #102. The findings include: For Resident #102 (R102), the facility staff failed to administer the physician prescribed medication levothyroxine (1) on multiple dates from January 2024 through February 2024. A review of R102's clinical record revealed a physician's order dated 11/28/23 for levothyroxine sodium 150 mcg (micrograms) once a day for thyroid cancer. A review of R102's January and Febraury 2024 MARs (medication administration records) revealed the same physician's order for levothyroxine and revealed the code, 7=Sleeping on 1/31/24, 2/1/24, 2/6/24, 2/7/24, 2/8/24, 2/12/24, 2/13/24, 2/14/24, and 2/15/24. On 4/10/24 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the code 7=Sleeping on the MAR means the medication was not administered because the resident was sleeping. LPN #1 stated that if a…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for an indwelling catheter for one of 49 residents in the survey sample, Resident #102. The findings include: For Resident #102 (R102), the facility staff failed to provide physician ordered catheter care on multiple dates December 2023 through February 2024. A review of R102's clinical record revealed a physician's order dated 11/30/23 for catheter care every shift. R102's comprehensive care plan dated 12/8/23 documented, (R102) has Indwelling Suprapubic Catheter (1): dx (diagnosis) obstructive uropathy. Cath care as ordered and prn (as needed). A review of R102's TARs (treatment administration records) for December 2023 through February 2024 failed to reveal evidence that catheter care was provided on 12/2/23 day shift, 12/14/23 evening shift, 12/15/23 day shift, 12/21/23 evening shift, 12/23/23 day shift, 1/2/24 night shift, 1/17/24 evening shift, 1/22/24 evening shift, 1/24/24 evening shift, 1/26/24 evening shift, 1/26/24 night shift, 1/29/24…

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.

Based on observation, staff interview, and facility document review, the facility staff failed to store and prepare food in a sanitary manner in one of one kitchen. The findings include: 1. The facility staff failed to store a bulk container of thickener in a sanitary manner. On 4/9/24 at 10:45 a.m., an observation of the kitchen was conducted. A Styrofoam cup was stored in a bulk container of thickener. On 4/10/24 at 2:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated a Styrofoam cup should not be stored in the bulk container of thickener for infection control reasons. OSM #1 stated the dietary staff probably used the cup to retrieve thickener from the container and didn't remove the cup when they were done. OSM #1 stated the staff should use a scoop to retrieve thickener then wash, sanitize and hang the scoop in the designated area. On 4/10/24 at 4:13 p.m., ASM (administrative staff member) #1 (the interim executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the care plans for one of 49 residents in the survey sample, Resident #128. The findings include: For Resident #128 (R128), the facility staff failed to review and revise the comprehensive care plan for care of a urostomy. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 1/27/2024, the resident scored 15 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented R128 being dependent on staff for toileting and having an ostomy. The comprehensive care plan for R128 documented in part, [Name of R128] has a urostomy related to factors that include other artificial openings of urinary tract status. Date Initiated: 08/02/2023. Revision on: 08/02/2023. Under Interventions it documented two interventions including Observe/Document prn (as needed) for s/sx (signs/symptoms)…

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

Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for one of 49 residents, Resident #112. The findings include: For Resident #112 (R112), the facility staff failed to evidence monitoring of the oxygen rate for continuous oxygen. R112 was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia (1) and venous thrombosis and embolism (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/15/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section O documented R112 receiving oxygen at the facility. On 4/9/2024 at 4:18 p.m., an observation was made of R112 in their room. R112 was observed in bed wearing an oxygen cannula. The oxygen was observed…

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, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to assess a resident for the use of bed rails prior to installation for one of 49 residents, Resident #112. The findings include: For Resident #112 (R112), the facility staff failed to evidence a completed bed rail assessment prior to installation and use. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/15/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 4/9/2024 at 4:18 p.m., an observation was made of R112 in their room. R112 was observed in bed with bilateral bed rails in place. At that time an interview was conducted with R112 who stated that they used the rails for positioning and liked having them in place. Additional observations were made of R112 on 4/10/2024 at 8:24 a.m. and 1:45 p.m. in bed with bilateral bed rails in place. 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 staff interview and facility document review, the facility staff failed to complete an annual performance review for two of five CNA (certified nursing assistant) record reviews. The findings include: For CNA #2 and CNA #3, the facility staff failed to complete an annual performance review. CNA #2 was hired on 1/5/89 and CNA #3 was hired on 6/30/2009. The facility staff could not provide an annual performance review for the CNAs. On 4/11/2024 at 11:55 a.m., an interview was conducted with ASM (administrative staff member) #1, the interim executive director. ASM #1 stated that they did not have an annual performance review to provide for CNA #2 or CNA #3. She stated that they were currently recruiting for a staff development/educator at the facility and currently the human resource manager was being trained to handle a spreadsheet to track the annual performance reviews and anniversary dates. She stated that the plan was for human resources to track the due dates for the annual performance reviews and for the executive director to oversee the tracking. She stated 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.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain physician ordered laboratory tests for one of 49 residents in the survey sample, Resident #102. The findings include: For Resident #102 (R102), the facility staff failed to obtain a urinalysis (1), ordered by the nurse practitioner on 12/26/23, and failed to obtain a BNP (brain natriuretic peptide) (2), ordered by the nurse practitioner on 2/1/24. A review of R102's clinical record revealed a physician's order dated 12/26/23 for a urinalysis due to urinary discomfort, and a physician's order dated 2/1/24 for a BNP due to a cough. Further review of R102's clinical record failed to reveal the labs were obtained. On 4/10/24 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the facility just switched to a new lab company because they were having issues with the former lab company. LPN #1 stated the nurses used to enter orders for labs into the former company's website, but the former company's employees were not coming 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.

Based on staff interview and facility document review, the facility staff failed to ensure the activities program was directed by a qualified professional potentially affecting all residents in the facility. The findings include: The facility staff failed to ensure OSM (other staff member) #15, the director of activities, was qualified upon hire. A review of OSM #15's employee record revealed OSM #15 was hired as the director of activities on 10/12/23. On 2/6/24 at 3:00 p.m., an interview was conducted with OSM #15. OSM #15 stated she was previously employed as a CNA (certified nursing assistant) and supply/transportation coordinator, but on 10/12/23, she became the director of activities. OSM #15 stated she recently completed an activity management certification class from 1/15/24 through 1/19/24 and was not certified prior to then. On 2/7/24 at 4:49 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were made aware of the above concern. On 2/8/24 at approximately 8:30 a.m., ASM #1 presented OSM #15's certificate that documented…

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 4. For Resident #48 (R48), the facility staff failed serve a meal using the facility's standard everyday place settings. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/14/2023, R48 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R48 was cognitively intact for making daily decisions. On 02/04/24 at approximately 5:14 p.m., an interview was conducted with R48 regarding the facility's meals. R48 stated he did not get breakfast until after 9:00 a.m. this morning, and it was served on Styrofoam. R48 further stated it was not dignified. On 02/05/24 at approximately 3:13 p.m., an interview was conducted with OSM (other staff member) #1, dining services manager, regarding the use of Styrofoam place settings for breakfast on 02/04/2024. OSM #1 stated Styrofoam place setting are only used when a resident is sick or if there is an outbreak in the facility. When asked if and why Styrofoam place settings were used during breakfast…

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 staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician about a change in condition for four of 68 sampled residents, Resident #32, #46, #114 and #22. The findings include: 1. For Resident #32 (R32), the facility staff failed to notify the physician that the resident did not receive medications on 10/8/24. A review of R32's provider's orders from October 2023 revealed the following: 8/9/2023 Carvedilol Oral Tablet (1) 12.5 MG (milligram) (Carvedilol) Give 1 tablet by mouth ever 12 hours for HTN (hypertension). A review of R32's October 2023 MAR (medication administration record), revealed that they did not receive Carvedilol as ordered on 10/8/24. A review of R32's progress notes for October 2023 failed to reveal any evidence that staff notified a provider (either a nurse practitioner or physician) that the resident did not receive their medication on 10/8/24. On 2/7/24 at 11:40 p.m., LPN (licensed practical nurse) #8 was interviewed. She stated that medications should be given on time as ordered. She stated…

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

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to investigate an allegation of abuse and report the finding to the State Agency for two of 68 residents in the survey sample, Resident #115 and Resident #93. The findings include:The facility submitted a synopsis of an event on 7/28/23 to the required state agency involving Residents #115 and #93. After the initial submission of the event, the facility failed to investigate the event. Resident #115 was coded on the quarterly MDS (Minimum Data Set) dated 7/5/23 which was the MDS conducted closest to the time of the event (7/28/23) as being cognitively impaired in ability to make daily life decisions, scoring a 7 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #93 was coed on the quarterly MDS (Minimum Data Set) dated 7/31/23 which was the MDS conducted closest to the time of the event (7/28/23) as being cognitively intact in ability to make daily life decisions, scoring a 13 out of a possible 15 on the BIMS…

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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that all required documentation was provided for hospital transfers for three out of 68 residents in the survey sample; Residents #21, #61, and #160. The findings include: 1. For Resident #21, the facility staff failed to evidence what, if any, documents were provided to the receiving facility upon a hospital transfer on 10/12/23; and that the comprehensive care plan goals were provided to the receiving facility upon a hospital transfer on 11/1/23. 10/12/23: A physician's progress note dated 10/12/23 documented, Resident is being assessed for change in condition per staff. The resident is currently sitting in the wheelchair. She is alert but nonverbal she is staring to the left side she is not following any commands at this time looks like she may be having a stroke Plan: Stroke send to ED (emergency department) for evaluation now. Further review of the clinical 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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that a written bed hold notice was provided to the resident representative upon hospital transfers for three out of 68 residents in the survey sample; Residents #21, #61, and #160. The findings include: 1. For Resident #21, the facility staff failed to evidence that a written bed hold notice was provided to the resident representative upon a hospital transfer on 10/12/23 and 11/1/23. 10/12/23: A physician's progress note dated 10/12/23 documented, Resident is being assessed for change in condition per staff. The resident is currently sitting in the wheelchair. She is alert but nonverbal she is staring to the left side she is not following any commands at this time looks like she may be having a stroke Plan: Stroke send to ED (emergency department) for evaluation now. Further review of the clinical record failed to reveal any evidence of a written bed hold notice being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide services for a baseline care plan for four of 68 residents in the survey sample, Residents #312, #160, #165, and #362. The findings include: 1. For Resident #312 (R312), the facility staff failed to develop a baseline care plan to address the resident's pressure injuries. R312 was admitted to the facility on [DATE]. A nurse's note dated 1/26/24 documented R312 presented with an unstageable pressure injury (1) on the right lateral lower leg and a stage three pressure injury (1) on the left buttock. R312's baseline care plan initiated on 1/31/24 failed to document any information regarding pressure injuries. On 2/7/24 at 2:10 p.m., an interview was conducted with LPN (licensed practical nurse) #12 (A minimum data set nurse). LPN #12 stated the baseline care plan should be opened by the admission nurse and the baseline care plan should contain the resident's initial disease processes and things staff…

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, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for 20 of 68 residents in the survey sample, Residents #75, #111, #62, #148, #141, #145, #78, #21, #54, #6, #41, #42, #45, #55, #119, #47, #10, #3, #73 and #46. The findings include: 1. a. For Resident #75, the facility staff failed to implement the comprehensive care plan for a wander guard. Resident #75 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, bipolar, and neurocognitive disorder with Lewy Bodies. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/6/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded 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 staff interview, resident interview, clinical record review, and facility document review, it was determined the facility staff failed to review/revise the care plan for eight of 68 residents in the survey sample, Residents #111, #129, #41, #25, #21, #54, #72 and #162. The findings include: 1. The facility failed to revise the comprehensive care plan to include a resident-to-resident altercation for Resident #111. A review of a facility synopsis of events with incident date of 1/13/24 revealed, (Resident #111) slapped (Resident #129) on the left side of her face due to Resident #129 trying to open the back door. Residents separated. Resident to Resident incident substantiated. The final report dated 1/19/24 included, This letter serves as the final 5-day final internal investigation for the facility reported incident related to Resident #111 and Resident #129. Actions taken skin and pain assessments conducted on both residents. Psychosocial review with both residents conducted by the director of social…

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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of quality for five of 68 residents in the survey sample, Residents #46, #114, #148, #362, #3, and #54. The findings include: 1. For Resident #46 (R46), the facility staff failed to administer medications as ordered by the physician on 10/23/23. A review of R46's provider's orders revealed the following: 8/24/2023 Ferrous Sulfate (1) Oral Tablet 325 (65 Fe) MG (milligrams) (Ferrous Sulfate) Give 1 tablet by mouth two times a day for anemia. 8/18/2023 Gabapentin (2) Oral Capsule (Gabapentin) Give 300 mg by mouth every 8 hours for pain mgt (management). 8/18/2023 Hydralazine HCL (3) Oral Tablet 50 MG (Hydralazine HCL) Give 1 tablet by mouth every 8 hours for htn (hypertension). 8/23/2023 Saline Nasal Spray (4) Solution 0.65% (Saline) 2 spray in both nostrils every 8 hours for nasal dryness. A review of R46's October 2023 MAR (medication administration…

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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for six of 68 residents in the survey sample, Residents #119, #39, #148, #75, #145, and #165. The findings include: 1. For Resident #119 (R119), the facility staff failed to provide incontinence care during the entire day shift on 2/4/24. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/27/23, R119 was coded as being cognitively intact for making daily decisions, and as being always incontinent of bowel and bladder. On 2/4/24 at 2:35 p.m., an interview was conducted with R119 who stated the facility staff does not take care of the patients. He stated: There is not enough staff, people go 16 or 17 hours without being changed. He stated he had not had his incontinence brief changed since 10:30 p.m. the night before (2/3/24). R119 agreed to allow the surveyor to observe…

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, staff interview, facility document review, and clinical record review, the facility staff failed to provide activities to meet residents' interests and needs for five of 68 residents in the survey sample, Residents #63, #93, #141, #145, and #167. The findings include: 1. For Resident #63 (R63), the facility staff failed to provide the resident's preferred activities. R63's comprehensive care plan dated 8/5/21 documented, (R63) is alert and verbal with confusion but is able to voice her wants and needs. She enjoys going outside for walks, snacks, listening to country music and being around other people at times. She also enjoys keeping to herself at times. She will be reminded and encouraged to engage with 1-3 OOR (out of room) activities of choice per week. Section F of R63's annual minimum data set assessment with an assessment reference date of 10/23/23 documented it was very important for the resident to listen to music and participate in religious services. On 2/4/24 at 2:50 p.m.,…

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, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and services for pressure injuries for five of 68 residents in the survey sample, Residents #41, #54, #312, #145, and #47. The findings include: 1. For Resident #41 (R41), the facility staff failed to provide pressure injury (1) treatment as ordered on 1/3/2024, 1/14/2024, 1/18/2024, 1/20/2024, 1/25/2024, 1/31/2024 and 2/2/2024, failed to set up an evaluation for the outpatient wound clinic as requested by the resident and in-house wound physician, and failed to evidence pressure injury assessments completed between 10/27/23-11/22/23, 11/22/23-12/20/23, 1/2/24-1/15/24 and 1/22/24-2/6/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/21/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that the resident was moderately impaired for making daily decisions. The assessment documented R41…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #54, the facility staff failed to investigate falls to evaluate root causes and prevention for falls on 11/16/23 and 12/13/23. A review of the clinical record revealed a nurse's note dated 11/16/23 that documented, Resident had a fall today on 11/16/23. Resident was walking to his walker that was place beside his bed and fell without hitting his head. Resident fell on the floor matt that is placed on the floor. Resident has no injuries or bruising from the fall. Resident's vital signs are within normal limits, blood pressure a little high after the fall. Will continue to monitor residents' status post fall. Interventions that were put into place was to place the resident's walker closer to the bedside so that the resident has less increase of a fall happening. Further review revealed a nurse's note dated 12/13/23 that documented, Resident was walking in the hall without his walker writer asked him why he was walking without it he told writer to mind her business then he started taking things from…

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.

4. For Resident #6, the facility staff failed to administer oxygen per the physician's order. On 2/4/24 at 2:53 PM, Resident #6 was observed in bed with the oxygen concentrator rate set at 3 liters per minute. When asked if he knew what his rate should be, he stated two to three liters. On 2/6/24 at 11:47 AM, Resident #6 was observed in bed with the oxygen concentrator rate at 3.5 liters per minute. Resident #6 stated that the staff changed it last night. A review of the clinical record revealed a physician's order dated 11/1/23 for Oxygen therapy 2LPM (liters per minute) via NC (nasal cannula) continuously every shift for COPD (chronic obstructive pulmonary disease). There were no orders to change the rate on or about 2/5/24, as the resident had indicated. On 2/7/24 at 1:08 PM an interview was conducted with LPN #7 (licensed practical nurse). She stated that Resident #6's oxygen rate was supposed to be two liters per minute. She stated that sometimes the resident will remove his oxygen or turn it off or unplug it but that she was not aware of him ever adjusting the rate himself.…

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 resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 68 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications of Oxycodone-Acetaminophen 5-325mg (milligrams) and Oxycodone-Acetaminophen 5mg. R3 was admitted with diagnoses that included, but not limited to, chronic pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/07/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R3 was cognitively intact for making daily decisions. Section J Pain Management coded R3 as having occasional pain at a pain level of seven out of ten, with ten being the worse pain. The physician order for R3 documented in part, Oxycodone-Acetaminophen Oral Tablet 5-325 MG. Give 1 (one)…

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.

2. For Resident #119 (R119), the facility staff failed to provide sufficient nursing staffing to meet the resident's incontinence needs. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/27/23, R119 was coded as being cognitively intact for making daily decisions, and as being always incontinent of bowel and bladder. On 2/4/24 at 2:35 p.m., R119 was interviewed and stated the facility staff does not take care of the patients. He stated: There is not enough staff, people go 16 or 17 hours without being changed. He stated he had not had his incontinence brief changed since 10:30 p.m. the night before (2/3/24). R119 agreed to allow the surveyor to observe his brief change. CNA (certified nursing assistant) #14 stated she was assigned to R119 during that day shift. She stated: It is a little hectic when I am the only aide for 22 residents. No. I have not changed [R119] all day. I am still making my rounds. At 3:00 p.m., CNA #14 assisted R119 to position himself on the bed for incontinence care. CNA #14 removed the incontinence…

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 staff interview, facility document review, and clinical record review, the facility staff failed to determine competencies for nurses for one of 68 residents in the survey sample, Resident #164. The findings include: For Resident #164 (R164), who received TPN (total parental nutrition) (1), the facility staff failed to determine that nurses were competent to administer it. A review of R164's clinical record revealed he was no longer a current facility resident. While R164 was a resident at the facility, he had physician's orders for, and received, TPN. A review of R164's MARs (medication administration records) from May, June, July, and August of 2023 revealed that both RNs (registered nurses) and LPNs (licensed practical nurses) administered TPN to R164. On 2/6/24 at 2:26 p.m., ASM (administrative staff member) #2, the director of nursing, and ASM #3, the regional director of clinical services, were requested to provide evidence that nurses were evaluated for competencies to administer TPN. On 2/7/24 at 11:35 a.m., ASM #3 stated: We don't have the competencies. On 2/7/24…

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.

Based on staff interview, and facility document review, the facility staff failed to meet the RN (registered nurse) requirements for two of 30 days of RN coverage review. The findings include: The facility staff failed to ensure the Director of Nursing did not serve as a charge nurse on 1/20/24 and 1/21/24. A review of the facility nursing staff schedules revealed the facility census was 158 on 1/20/24 and 157 on 1/21/24. Further review of the facility nursing staff schedules revealed the Director of Nursing served as the RN charge nurse, working the day shift on Saturday 1/20/24 and Sunday 1/21/24. On 2/8/24 at 12:10 p.m., an interview was conducted with ASM (administrative staff member) #2, the Director of Nursing. ASM #2 stated the facility does not have enough staff so sometimes he works on the floor as a charge nurse on the weekends or evenings. ASM #2 stated that he does this in addition to working his full-time role as the Director of Nursing. On 2/8/24 at 2:45 p.m., ASM #1, the executive director, and ASM #2 were made aware of the above concern. The facility policy titled,…

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 staff interview and facility document review, the facility staff failed to complete an annual performance review for five of five CNA (certified nursing assistant) record reviews. The findings include: For CNA #11, CNA #12, CNA #13, CNA #14, and CNA #15, the facility staff failed to complete an annual performance review. CNA #11 was hired on 3/11/76; CNA #12 was hired on 1/5/89; CNA #13 was hired on 3/22/22; CNA #14 was hired on 5/31/22; and CNA #15 was hired on 8/16/22. The facility staff could not provide an annual performance review for all five CNAs. On 2/7/24 at 9:04 a.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated she was only employed at the facility since 1/15/24 but it is her responsibility to keep up with performance reviews and make sure they are done. OSM #17 stated at the beginning of each month, she prints out performance reviews that are due and passes them out to supervisors who need to complete them, then follows up throughout the month. OSM #17 stated she was going to conduct an audit 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 staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent administration of unnecessary psychotropic medications for two of 68 residents in the survey sample, Resident #78 and #63. The findings include: 1. For Resident #78 (R78), the facility staff failed to monitor for behaviors and side effects while on the antipsychotic medication, Quetiapine Fumarate (1). R78 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of R78's clinical record revealed the following order dated 2/2/24: Quetiapine Fumarate Oral Tablet 50 MG (milligram) (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for mood disorder related to neurocognitive disorder with Lewy bodies (G31.83); unspecified dementia; unspecified severity, without behavioral disturbance, psychotic disturbance, mood…

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, staff interview and facility document review, it was determined that the facility staff failed to serve food at an appetizing temperature and form from one of one facility kitchens. The findings include: On 2/4/24 starting at 4:31 PM, the tray line services was observed. The temperature of food items were as follows: Chicken breast was 190 degrees (an alternative item), burger patties were 175 degrees (an alternative item), grilled cheese sandwiches were 165 degrees, tomato soup was 203 degrees, french fries were 192 degrees, chopped chicken was 195 degrees, puree chicken was 180 degrees, puree soup was 169 degrees, mashed potatoes was 160 degrees, cucumber salad was 39 degrees. At 6:02 PM the last cart was being prepared. At that time a test tray was requested to go on the cart as the last tray prepared. At 6:29 PM, the last cart was sent out but not all trays were on it. Several resident trays were placed on an open push cart rather than an enclosed dietary cart. This cart left the kitchen at 6:33 PM. At that time, OSM #1 carried the test tray in her hand 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.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to provide meals at the scheduled time from one of one facility kitchens. The findings include: A review of the facility dining schedule revealed the following: Breakfast is served between 7:30 AM and 8:30 AM. Lunch is served between 11:30 AM and 12:30 PM. Dinner is served between 4:30 PM and 5:30 PM. On 2/4/24 starting at 4:31 PM, the tray line services was observed. At 6:02 PM the last cart was being prepared. At 6:29 PM, the last cart was sent out but not all trays were on it. Several resident trays were placed on an open push cart rather than an enclosed dietary cart. The open cart left the kitchen at 6:33 PM. On 2/05/24 at 3:17 PM, an interview was conducted with OSM #1 and OSM #16, the District Manager of dietary services. OSM #16 stated that they will in-service staff to make sure tray line is done properly. OSM #1 stated that they don't understand the importance of having the tray line done in a certain time frame. The facility policy, Frequency of Meals…

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, staff interview, and facility document review, it was determined that the facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens and for three of 68 residents in the survey sample, Residents #46, #163 and #22. The findings include: 1. On 2/4/24 at 2:16 PM, an observation was made of the facility kitchen. The following were identified: in the walk-in freezer was a box of frozen green beans which had been opened, with the bag also open and the green beans exposed to the environment. In the walk-in refrigerator were loaves of prepackaged bread on which was water that had dripped from the condensation from a pipe above the bread. In the dishroom area there was a thick layer of white/yellowish substance spilled and dried all over floor by the paper products that were stored on shelves in the dishroom. Next to the substance was an open hole in dishroom floor approximately 10 inches by 10 inches filled with white unidentified liquid. Note: On follow up at 4:00 PM, OSM #1 (Other Staff Member) the Dietary Manager,…

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 staff interview, and facility document review, the facility staff failed to maintain a written transfer agreement with a hospital potentially affecting all residents in the facility. The findings include: The facility staff failed to provide a written transfer agreement with one or more hospitals. On 2/9/24 at 11:51 a.m., an interview was conducted with ASM (administrative staff member) #1, the executive director. ASM #1 stated he was not able to produce a hospital transfer agreement. ASM #1 was made aware this was a concern and stated he will make sure it is corrected. The facility policy titled, Contract Management documented, All contracts entered into by Facilities should be routed through the contract management software to ensure they receive appropriate approval prior to execution and are properly stored.

Based on staff interview, and facility document review, the facility staff failed to maintain an effective training program for six of ten employee record reviews and failed to develop and implement a training program based on the facility assessment. The findings include: The facility staff failed to ensure training for multiple training topics, including communication, resident rights, abuse/neglect/exploitation, QAPI, compliance/ethics, and behavioral health, was completed by all required staff. Refer to F941, F952, F943, F944, F946, F947, and F949 for specific staff and topics that were not in compliance. A review of the facility assessment was conducted during the survey. On 2/9/24 at 10:48 a.m., ASM (administrative staff member) #1, the administrator stated he did not have evidence of a training program based on the facility assessment. The facility policy titled, In-Service Training- General documented, Employees will be provided training on required topics on an annual basis. Additional training may be provided based on the center Facility Assessment, areas of deficiency…

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 staff interview and facility document review, the facility staff failed to ensure required dementia management and abuse training was completed for four of five CNA (certified nursing assistant) reviews. The findings include: For CNA #12, CNA #13, CNA #14, and CNA #15, the facility staff failed to ensure the CNAs completed dementia management training. For CNA #12 and CNA #13, the facility staff failed to ensure the CNAs completed abuse training. A review of employee records revealed CNA #12 was hired on 1/5/89, CNA #13 was hired on 3/22/22, CNA #14 was hired on 5/31/22, and CNA #15 was hired on 8/16/22. The facility staff failed to provide evidence that CNA #12, CNA #13, CNA #14, and CNA #15 had completed dementia management training, and failed to provide evidence that CNA #12 and CNA #13 had completed abuse training. On 2/9/24 at 12:28 p.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated training for dementia management and abuse is in the facility online training system for staff to complete. OSM #17 stated…

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

Based on staff interview, and facility document review, the facility staff failed to ensure CNAs (certified nursing assistants) completed required annual in-service training for four of five CNA reviews. The findings include: For CNA #12, CNA #13, CNA #14, and CNA #15, the facility staff failed to ensure the CNAs completed annual abuse prevention and dementia management training. A review of employee records revealed CNA #12 was hired on 1/5/89, CNA #13 was hired on 3/22/22, CNA #14 was hired on 5/31/22, and CNA #15 was hired on 8/16/22. The facility staff failed to provide evidence that CNA #12, CNA #13, CNA #14, and CNA #15 had completed annual abuse prevention and dementia training. On 2/9/24 at 12:28 p.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated training for abuse and dementia management is in the facility online training system for staff to complete. OSM #17 stated the facility does not currently have a staff development coordinator, so she is going to monitor to make sure staff completes all required…

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 staff interview, facility document review, and clinical record review, the facility staff failed to inform a resident/resident representative of the risks and benefits of medication treatment in a timely manner for one of 68 residents in the survey sample, Resident #63. The findings include: For Resident #63 (R63), the facility staff failed to inform the resident/resident representative of the risks and benefits for the use of the anti-psychotic medication Seroquel (1), when the medication was ordered on 9/22/23. R63 was admitted to the facility on [DATE] with a diagnosis of schizophrenia. A review of R63's clinical record revealed a physician's order dated 9/22/23 for Seroquel 25 milligrams every 12 hours. Further review of R63's clinical record failed to reveal the facility staff informed the resident or the resident's representative of the risks and benefits for the use of Seroquel until 12/20/23. An informed consent for use of psychotropic medication form signed by R63's representative on 12/20/23…

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, resident/staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate needs for one of 68 residents, Resident #62. The findings include: For Resident #62, the facility staff failed to maintain the call light in a position where they could access it. A review of the comprehensive care plan dated 11/26/19 revealed, FOCUS: Resident has had an actual fall. INTERVENTIONS: Educate resident to use call bell for assistance when getting out of bed. On 2/4/24 at 2:50 PM, Resident #62 was observed sitting on the side of her bed with the call bell under the bed near the headboard, with the cord caught under the bedside cabinet. On 2/5/24 at 7:30 AM, the call bell was under the bed near the headboard with the cord caught under the bedside cabinet. On 2/5/24 at 8:00 AM, an interview was conducted with Resident #62. When asked where her call bell was, Resident #62 stated she did not know where it was. On 2/5/24 at 8:05 AM, an interview was conducted with CNA (certified nursing assistant) #1. When asked 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.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide required notification of a room change for one of 68 residents in the survey sample, Resident #22. The findings include: For Resident #22 (R22), the facility staff failed to notify the resident and/or responsible party (RP) of a room change. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/6/23, R22 was coded as being severely cognitively intact for making daily decisions. A review of R22's clinical record revealed the following nurse's note dated 1/25/24: Resident adjusting well to room change, no problems or complaints voiced. The nurse who wrote this note was not available for interview during the survey. Further review of the clinical record revealed no evidence that the resident or RP received written notice of the reasons for the room change, and that the room change was happening. On 2/6/24 at 3:25 p.m., OSM (other staff member) #10, the director of social services was interviewed. When asked who…

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, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide personal privacy for one of 68 residents in the survey sample, Resident #45. The findings include: For Resident #45 (R45), the facility failed to accommodate personal privacy in their room from wandering residents. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/14/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. On 2/4/2024 at 3:14 p.m., an interview was conducted with R45 in their room. R45 stated that they got along well with their roommate but had concerns with a female resident who wandered around the hallways. She stated that the resident was in the room next door and they shared a bathroom. Observation of R45's room revealed a shared bathroom separating two semi-private rooms. Observation of the bathroom revealed two doors, one…

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, resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to provide a clean, comfortable, homelike environment for two of 68 residents (Residents #21 and #119) in the survey sample; and for one of three facility shower rooms (Unit 1). The findings include: 1. For Resident #21, the facility staff failed to maintain a clean and comfortable homelike environment. There were seven tiles missing from the bathroom wall. On 2/04/24 at 3:45 PM, an observation was made of Resident #21's room. The bathroom was noted to have seven tiles missing on the lower wall, near the floor, between the sink and toilet. On 2/7/24 at 12:53, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that Resident #21 was her resident but that she does not always go into the bathrooms. She stated that if she noticed something she would report it to maintenance. She stated that housekeeping should also be noticing things when they are in the rooms. She stated she was not aware if anyone else knew about the missing…

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 staff interview, resident interview, facility document review, and clinical record review, it was determined the facility staff failed to protect three of 68 residents from abuse and/or neglect, Residents #129, #148 and #119. The findings include: 1. The facility failed to protect Resident #129 from physical abuse from another resident, Resident #111. A review of a facility synopsis of event with incident date of 1/13/24 revealed, (Resident #111) slapped (Resident #129) on the left side of her face due to (Resident #129) trying to open the back door. Residents separated. Resident to Resident incident substantiated. Resident #129 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecific dementia, cognitive communication deficit and anxiety disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/30/23, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental…

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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement policies and procedures for the investigation and reporting of abuse for two of 68 residents in the survey sample; Residents #115 and #93. The findings include: The facility submitted a synopsis of an event on 7/28/23 to the required state agency. After the initial submission of the event, the facility failed to follow policy to investigate the event and submit a five-day follow up report of the event to the required state agency. The facility policy, Abuse, Neglect, Exploitation & Misappropriation was reviewed. This policy documented, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary…

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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to report findings regarding an allegation of abuse for two of 68 residents in the survey sample; Residents #115 and #93. The findings include: The facility submitted a synopsis of an event on 7/28/23 to the required state agency involving Residents #115 and #93. After the initial submission of the event, the facility failed to report a five-day follow up report of the event to the required state agency. Resident #115 was coded on the quarterly MDS (Minimum Data Set) dated 7/5/23 which was the MDS conducted closest to the time of the event (7/28/23) as being cognitively impaired in ability to make daily life decisions, scoring a 7 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #93 was coed on the quarterly MDS (Minimum Data Set) dated 7/31/23 which was the MDS conducted closest to the time of the event (7/28/23) as being cognitively intact in ability to make daily life decisions, scoring a 13 out of a possible 15 on 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 staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence written notification of transfer provided to the resident and/or responsible party at the time of transfer and/or ombudsman notification of transfer for three of 68 residents in the survey sample, Residents #25, #45 and #42. The findings include: 1. For Resident #25 (R25), the facility staff failed to evidence that written notification of transfer was provided to the resident and/or responsible party and the long-term care ombudsman for a facility-initiated transfer on 1/4/2024. The progress notes for R25 documented in part, 1/04/2024 10:26 Resident was sent out to [Name of hospital] via EMT's (emergency medical technicians) @ 10am to r/o (rule out) internal bleeding from unwitness [sic] fall, per NP (nurse practitioner) [Name of NP], request CT (computerized tomography) scan, nurse sent all paperwork and bed hold with EMT's, report given to EMT's and ER (emergency room) nurse. RP (responsible party) brother notified, unit manager and DON (director…

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 clinical record review and staff interview it was determined that the facility staff failed to evidence completion of a Level 1 PASRR (preadmission screening and resident review) for one of 68 residents, Resident #55. The findings include: For Resident #55 (R55), the facility staff failed to complete a Level 1 PASRR, who was admitted to the facility on [DATE]. R55 was admitted to the facility with diagnoses that included but were not limited to post traumatic stress disorder, unspecified dementia, depression and anxiety. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/27/2023, the resident scored four out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Review of R55's clinical record failed to evidence a Level 1 PASRR. On 2/5/2024 at approximately 8:30 a.m., a request was made to ASM (administrative staff member) #1, the executive director, for the Level 1…

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, staff interview, and clinical record review, the facility staff failed to implement communication techniques to maintain a resident's highest level of quality of life for one of 68 residents in the survey sample, Resident #145. The findings include: For Resident #145 (R145), the facility staff failed to utilize the resident's communication board to promote the most effective communication and highest quality of life. R145 was admitted to the facility on [DATE] with a diagnosis of [NAME] de [NAME] syndrome (1). Review of R145's clinical record revealed a psychosocial evaluation dated 12/4/23 that documented, Community Life Considerations: 4. Adaptations to communication needed to participate in activities? PICTURE BOARDS WILL BE HELPFUL. R145's comprehensive care plan dated 12/4/23 failed to document information regarding communication. A speech therapy evaluation dated for the certification period of 1/1/24 through 1/30/24 documented, Pt (Patient) is nonverbal at baseline and with hx…

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, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide assistance to maintain ADL (activities of daily living) abilities for two of 68 residents in the survey sample, Residents #45 and #55. The findings include: 1. For Resident #45 (R45), the facility staff failed to provide assistance with toileting/incontinence care as needed during the night shift on 1/2/24, 1/4/24, 1/6/24-1/9/24, 1/11/24-1/16/24, and 1/18/24-1/31/24, 2/1/24 and 2/1/24-2/5/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/14/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that the resident was cognitively intact for making daily decisions. The assessment documented R45 requiring supervision with toileting and toilet transfers. Section H documented R45 being frequently incontinent of bowel and bladder. On 2/4/2024 at 3:14 p.m., an interview was conducted with R45. R45…

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, staff interview, facility document review, and clinical record review, the facility staff failed to provide care to promote the highest level of well-being for two of 68 residents in the survey sample, Residents #22 and #312. The findings include: 1. For Resident #22 (R22), the facility staff failed to position a resident's fractured arm to promote comfort and safety. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/6/23, R22 was coded as being severely cognitively impaired for making daily decisions. On the following dates and times, R22 was observed in her room, with her right harm hanging by her side. There was no sling or other positioning device visible on the resident's right arm at any of these observations: 2/4/24 at 2:33 p.m. and 5:23 p.m.; 2/5/23 at 8:53 a.m. A review of R22's clinical record revealed the following nurses' notes: 12/14/23 at 9:29 p.m. Resident return (sic) from ortho (orthopedic) app (appointment at 6:15 p.m .'Resident has comminuted displaced periprosthetic fracture 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 observations, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide foot care for two of 68 residents in the sample Resident #166 and Resident #47. The findings include: 1. For Resident #166, the facility failed to provide and/or arrange timely foot care. Resident #166 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Alzheimer's disease, dementia, and diabetes mellitus (DM). A review of the progress note dated 3/15/23 at 6:10 PM revealed, Family would like resident to have toenails clipped. A review of the progress note dated 3/29/23 at 3:25 PM, revealed Daughter spoke with writer this afternoon. She requested her mom's toenails be clipped and her heels cleaned. This writer reported request to nurse. A review of the progress note dated 4/11/23 at 12:53 PM, revealed, Daughter requested her mom's toenails be clipped and her heels smoothed down. This writer had her…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent a decrease in ROM (range of motion) for a resident's contractures for one of 68 residents in the survey sample, Resident #47. The findings include: For Resident #47 (R47), the facility staff failed to assess and implement interventions to prevent a decrease in ROM for the resident's bilateral leg contractures. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/10/23, R47 was coded as being severely cognitively impaired for making daily decisions. She was coded as being completely dependent on staff for moving in the bed, and as being impaired on both sides for lower extremity range of motion. On the following dates and times, R47 was observed lying on her side in bed, with both legs severely contracted at the knees: 2/4/24 at 2:36 p.m. and 5:55 p.m.; 2/5/24 at 8:41 a.m., 11:58 a.m., and 1:18 p.m. There were no positioning pillows visible at any of these observations. A…

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

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to promote continence and/or provide indwelling catheter care for three of 68 residents in the survey sample, Residents #39, #93, and #61. The findings include: 1. For Resident #39 (R39), the facility staff failed to offer the resident the opportunity to transfer to the toilet for urination, to help her to become more continent of urine. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/12/24, R39 was coded as being cognitively intact for making daily decisions. She was coded as being always incontinent of urine. On the preceding MDS, an admission assessment with an ARD of 10/12/23, R39 was also coded as being incontinent of urine. On both assessments, she was coded as being completely dependent on staff for transferring from surface to surface, and as not having attempted to move from the bed to the toilet. A review of the clinical record, including all ADL (activities of…

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

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for one of one residents receiving dialysis care, Resident #119. The findings include: For Resident #119 (R119), the facility staff failed to assess the resident's dialysis access site for bruit and thrill (1). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/27/23, R119 was coded as being cognitively intact for making daily decisions. He was coded as receiving dialysis services. A review of R119's clinical record revealed the following order dated 8/21/23: [Name of dialysis center] Dialysis, transport at 10:00 a.m., chair time at 11:00 a.m., return pick up at 3:00 p.m. MWF (Monday, Wednesday, Friday). The review failed to reveal additional orders for or evidence of assessments of the resident's dialysis access site. A review of R119's care plan dated 1/23/23 and updated 6/19/23 revealed, in part: [R119] needs dialysis. The interventions did not include assessing 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 68 residents in the sample Resident #111. The findings include: The facility failed to evidence provision of trauma informed care for Resident #111. Resident #111 was admitted to the facility on [DATE] with diagnosis that included but were not limited to vascular dementia, PTSD (post-traumatic stress disorder), DM (diabetes mellitus) and COPD (chronic obstructive pulmonary disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/26/23, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being independent for mobility/transfers and eating. Section P:…

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, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence bed rail requirements were completed prior to use for two of 68 residents in the survey sample, Residents #41 and #54. The findings include: 1. For Resident #41 (R41), the facility staff failed to obtain consent for the use of bed rails, and failed to assess the resident for bed rail use or evaluate for alternatives prior to use. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 12/21/2023, the resident scored 11 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented R41 having impairment to both upper extremities and requiring substantial/maximal assistance with bed mobility. On 2/4/2024 at 4:47 p.m., an observation was made of R41 in their room. R41 was…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure required physician visits for two of 68 residents in the survey sample, Residents #14, and #124. The findings include: 1. For Resident #14 (R14), the facility staff failed to ensure the resident was seen by the physician after 6/8/23. A review of R14's clinical record revealed the resident was seen by the physician on 6/8/23. Further review of R14's clinical record revealed the resident was seen by a nurse practitioner on 6/30/23, 7/27/23, 8/22/23, 8/30/23, 9/21/23, 9/22/23, 9/26/23, and 12/21/23. R14 was not seen by the physician since 6/8/23. On 2/9/24 at 9:20 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated the facility staff follows the facility policies in regard to physician visits. On 2/9/24 at 12:39 p.m., ASM #1, the executive director, and ASM #2 were made aware of the above concern. The facility policy titled, Medical Care/Standards of Practice documented, Physician visits are required…

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, staff interview, facility document review, and clinical record review, the facility staff failed to provide mental and behavioral health services for two of 68 residents in the survey sample, Residents #63 and #95. The findings include: 1. For Resident #63 (R63), the facility staff failed to obtain a psychiatry follow up appointment. R63 was admitted to the facility on [DATE] with diagnoses of schizophrenia, major depressive disorder, and anxiety disorder. R63's comprehensive care plan dated 4/12/21 documented, (R63) has behaviors of trying to bribe people to leave the facility with her, pretending that she is using the bathroom, but will try to avoid staff using the other room, talking in her sleep, biting, kicking and punching staff, and trying to elope the facility. Refuses medication and Showers and refuses meals and Fluid. A review of R63's clinical record revealed the resident was last seen by psychiatry on 3/31/22. The note documented, Patient seen today to evaluate for inadequate…

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, staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for three of 68 residents in the survey sample, Residents #63, #95, and #111. The findings include: 1. For Resident #63 (R63), the facility staff failed to provide medically related social services regarding the resident's psychiatric needs. R63 was admitted to the facility on [DATE] with diagnoses of schizophrenia, major depressive disorder, and anxiety disorder. R63's comprehensive care plan dated 4/12/21 documented, (R63) has behaviors of trying to bribe people to leave the facility with her, pretending that she is using the bathroom, but will try to avoid staff using the other room, talking in her sleep, biting, kicking and punching staff, and trying to elope the facility. Refuses medication and Showers and refuses meals and Fluid. A review of R63's clinical record revealed the resident was last seen by psychiatry on 3/31/22. The note documented,…

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 staff interview, facility document review, and clinical record review, the facility staff failed to prevent significant medication errors for one of 68 sampled residents, Resident #32. The findings include: For Resident #32 (R32), the facility staff failed to administer Carvedilol (1) as ordered. A review of R32's physician orders revealed the following order dated October 31, 2023: Carvedilol Oral Tablet 12.5 Mg [milligrams] (Carvedilol) Give 1 tablet by mouth every 12 hours for HTN (hypertension). A review of R32's January and February 2024 MARs (medication administration records) revealed that he did not receive his Carvedilol on October 8, 2023 (due at 9:00 p.m.). On 2/7/24 at 11:40 p.m., LPN (licensed practical nurse) #8 was interviewed. She stated that medications should be given on time as ordered. She stated that it is important because they could really need that medication at a certain time or before or after a meal. If the medication is not given, the doctor and family should be notified and it should be documented on a nurses note in the clinical record. On…

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

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to obtain timely radiology services for one of 68 residents in the survey sample, Resident #42. The findings include: For Resident #42 (R42), the facility staff failed to obtain an ordered x-ray in a timely manner. R42 had an order for an x-ray to the right hip for severe pain on 12/13/2023 which was not completed until 12/15/2023. The progress notes for R42 documented in part, - 12/13/2023 11:15 (11:15 a.m.) Resident unable to sit on side of bed this morning to eat breakfast, which is abnormal for resident as she eats every meal. Assessment completed- resident c/o (complains of) severe Right hip pain, prn (as needed) tylenol given with semi effective results. NP (nurse practitioner) notified- new order for x-ray to Right hip and one time dose of ibuprofen- again, semi-helpful. X-ray called in at this time. [Claim #]. RP (responsible party) aware. - 12/13/2023 Nurse Practitioner Progress note .The resident's been assessed today status post a fall with…

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, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide dental services for one of 68 residents in the survey sample, Resident #41. The findings include: For Resident #41 (R41), the facility staff failed to obtain dental services as requested by the resident for mouth pain. R41 was admitted to the facility on [DATE] with a readmission on [DATE] with the primary payer being Medicaid. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 12/21/2023, the resident scored 11 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. On 2/4/2024 at 4:47 p.m., an interview was conducted with R41 who stated they had several teeth that hurt them off and on and had requested to see a dentist for at least three months but had not heard anything about an…

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, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to follow the posted menu for two of 68 residents in the survey sample, Residents #48, and #362. The findings include: 1. For Resident #48 (R48), the facility staff failed to provide a complete meal. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/14/2023, R48 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the R48 was cognitively intact for making daily decisions. The facility's meal ticket for R48 documented, Sunday Dinner. 2/4/2024. Grilled two cheese sandwich, 1/2 (half) cup French fries, 1/2 cup cucumber and onion salad, 6 (six) oz (ounce) of tomato soup, 1 (one) PKT (packet) saltine crackers, 1/2 cup chilled pears, 1 cup iced tea, 4 (four) oz juice of choice, 4 (four) oz juice of choice. (Name of R48). On 02/04/24 at approximately 5:14 p.m., an observation of R48's evening meal revealed that the meal tray did not contain tomato…

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, staff interview, facility document review, and clinical record review, the facility staff failed to serve food in the form ordered by the physician for one of 68 residents in the survey sample, Resident #47. The findings include: For Resident #46 (R47), the facility failed to serve pureed eggs at breakfast on 2/5/24. On 2/5/24 at 8:41 a.m., CNA (certified nursing assistant) #9 stood next to the resident's bed and was feeding the resident breakfast. The resident's plate contained pureed bread and scrambled eggs that were a regular consistency. The resident did not cough or sputter at any time she was eating the scrambled eggs. A review of R47's physician's orders revealed the following order, in effect on 2/5/24: Regular diet, dysphagia puree texture. On 2/6/24 at 11:47 a.m., OSM (other staff member) #18, the speech pathologist, was interviewed. When asked if a resident who has orders for pureed food should receive regular consistency scrambled eggs, she stated: No. If a resident has an order for pureed food, they should have a pureed scrambled egg on the plate.…

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, staff interview, and clinical record review, the facility staff failed to provide an assistive device for a meal for one of 68 residents in the survey sample, Resident #145. The findings include: For Resident #145 (R145), the facility staff failed to provide an adaptive cup during lunch on 2/5/24. A review of R145's clinical record revealed a physician's order dated 1/31/24 that documented, Regular diet Regular texture, Regular/Thin Liquids consistency, drinks via PROVALE cup or feeder-controlled volume 10cc (cubic centimeters). On 2/5/24 at 9:27 a.m., R145 was observed lying in bed. A Styrofoam cup that contained ice water was observed on the nightstand beside the bed. An adaptive cup with a handle and a controlled volume lid was empty and on the nightstand. On 2/5/24 at 12:25 p.m., a CNA (certified nursing assistant) was observed feeding R145 and giving the resident spoonfuls of tea, instead of using the adaptive cup. On 2/6/24 at 2:11 p.m., an interview was conducted with CNA #21. CNA…

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 staff interview, facility document review, and clinical record review, the facility staff failed to provide a complete pneumonia immunization program for two of five residents reviewed for immunizations, Residents #46 and #61. The findings include: 1. For Resident #46 (R46), who was admitted on [DATE], the facility staff failed to screen, educate, or offer to administer the pneumonia immunization. A review of R46's clinical record failed to reveal evidence that the resident was assessed for or offered the pneumonia vaccine. On 2/8/24 at 11:50 a.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. He stated that pneumonia vaccinations should be given during admission and the resident should be educated on the risks and benefits of the vaccine. On 2/8/24 at 4:16 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #5, the vice president of risk management, were informed…

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 staff interview, clinical record review, and facility document review, the facility staff failed to provide a complete COVID-19 immunization program for one of five residents reviewed for immunizations, Resident #61. The findings include: For Resident #61 (R61), who was admitted on [DATE], the facility staff failed to provide evidence of education to the resident of the risks and benefits of the COVID-19 vaccine and failed to offer or administer the vaccine to the resident. A review of R61's clinical record revealed no evidence of the resident being educated about or offered the COVID-19 vaccine. On 2/8/24 at 11:50 a.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. He stated that COVID-19 vaccines should be given during admission and the resident should be educated on the risks and benefits of vaccine. On 2/8/24 at 4:16 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #3, the regional director of clinical services…

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, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence bed inspections for one of 68 residents in the survey sample, Residents #148. The findings include: The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #148. Resident #148 was observed in bed with bilateral quarter bed rails in use on 2/04/24 at 12:00 PM, on 2/05/24 at 9:45 AM and on 2/6/24 at 11:10 AM. A review of the physician orders dated 12/15/23, revealed, One fourth top rails to bed for turning and repositioning. A review of the facility's Seven Zones of Entrapment Worksheet revealed no bed inspections for the bed in the last twelve months. An interview was conducted on 2/4/24 at 12:00 PM with Resident #148. When asked if she used the bed rails, Resident #148 stated, Yes, they help me move. I like them for safety so I do not fall out of bed. An interview was conducted on 2/5/24 at 3:45 PM with OSM (other staff member) #2, the maintenance director. When asked to 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 observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain an effective pest control program for one of three facility units, Unit 3. The findings include: On 2/06/24 at 1:45 p.m., a tour of resident rooms was conducted. Large flies were observed flying in room [ROOM NUMBER] and outside room [ROOM NUMBER]. On 2/06/24 at 1:52 p.m. an interview was conducted with Resident #8 (R8). She stated that there were and still are cockroaches, flies and spiders that she will see in her room. A review of the pest control inspection reports revealed the following: 1. 9/5/23: Ecolab large fly program serviced .Performed exterior fly treatment. Performed interior spot treatment for large flies. No cockroach activity was noted during the inspection and/or service. 2. 9/20/23: Cockroach/Rodent program- Pest Activity Found. 3. 9/29/23: Cockroach/ Rodent program. Large fly problem . Cockroach activity was noted during services .Inspected and treated selected…

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 staff interview, and facility document review, the facility staff failed to ensure effective communication training was completed for one of five direct care staff employee reviews. The findings include: For RN (registered nurse) #2, the facility staff failed to ensure effective communication training was completed. RN #2 was hired on 1/18/22. The facility staff failed to provide evidence that RN #2 had completed effective communication training. On 2/9/24 at 12:28 p.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated training for effective communication is in the facility online training system for staff to complete. OSM #17 stated the facility does not currently have a staff development coordinator, so she is going to monitor to make sure staff completes all required trainings. On 2/9/24 at 12:39 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were made aware of the above concern. The facility policy titled, In-Service Training-General documented, 1. 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 staff interview, and facility document review, the facility staff failed to ensure resident rights training was completed for one of five employee reviews. The findings include: For RN (registered nurse) #2, the facility staff failed to ensure resident rights training was completed. RN #2 was hired on 1/18/22. The facility staff failed to provide evidence that RN #2 had completed resident rights training. On 2/9/24 at 12:28 p.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated training for resident rights is in the facility online training system for staff to complete. OSM #17 stated the facility does not currently have a staff development coordinator, so she is going to monitor to make sure staff completes all required trainings. On 2/9/24 at 12:39 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were made aware of the above concern. The facility policy titled, In-Service Training-General documented, 1. The Executive Director and/or the Director of Nursing…

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

Based on staff interview, and facility document review, the facility staff failed to ensure QAPI (quality assurance and performance improvement) program training was completed for two of five employee reviews. The findings include: For RN (registered nurse) #2, and OSM (other staff member) #12, a laundry tech, the facility staff failed to ensure training regarding the facility QAPI program was completed. RN #2 was hired on 1/18/22 and OSM #12 was hired on 11/3/21. The facility staff failed to provide evidence that RN #2 or OSM #12 had completed training regarding the facility QAPI program. On 2/9/24 at 12:28 p.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated training for QAPI is in the facility online training system for staff to complete. OSM #17 stated the facility does not currently have a staff development coordinator, so she is going to monitor to make sure staff completes all required training. OSM #17 stated the laundry staff did not have access to the facility online training system but had their own training…

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 staff interview, and facility document review, the facility staff failed to ensure annual compliance and ethics training was completed for two of five employee reviews. The findings include: For RN (registered nurse) #2, and OSM (other staff member) #12, a laundry tech, the facility staff failed to ensure annual compliance and ethics training was completed. RN #2 was hired on 1/18/22 and OSM #12 was hired on 11/3/21. The facility staff failed to provide evidence that RN #2 or OSM #12 completed annual compliance and ethics training. On 2/9/24 at 12:28 p.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated training for compliance and ethics is in the facility online training system for staff to complete. OSM #17 stated the facility does not currently have a staff development coordinator, so she is going to monitor to make sure staff completes all required training. OSM #17 stated the laundry staff did not have access to the facility online training system but had their own training system. The laundry department was…

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

Based on staff interview, and facility document review, the facility staff failed to ensure behavioral health training was completed for one of five employee reviews. The findings include: For RN (registered nurse) #2, the facility staff failed to ensure behavioral health training was completed. RN #2 was hired on 1/18/22. The facility staff failed to provide evidence that RN #2 had completed behavioral health training. On 2/9/24 at 12:28 p.m., an interview was conducted with OSM (other staff member) #17, the director of human resources. OSM #17 stated training for behavioral health is in the facility online training system for staff to complete. OSM #17 stated the facility does not currently have a staff development coordinator, so she is going to monitor to make sure staff completes all required training. On 2/9/24 at 12:39 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were made aware of the above concern. The facility policy titled, In-Service Training-General documented, 1. The Executive Director and/or the Director 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 resident interview, staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a change in status for two of five residents in the survey sample, Residents #2 and #4. The findings include: 1. For Resident #2 (R2), the facility staff failed to notify the physician of a positive urinalysis reported on 11/18/23. The urinalysis was positive for a UTI (urinary tract infection) and the resident was receiving an antibiotic that the organism was resistant to. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 8/25/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R2's clinical record revealed a physician's order dated 11/13/23 for a urinalysis with culture and sensitivity for a possible UTI. R2 was transferred to the hospital on [DATE], per 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 resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of five residents in the survey sample, Resident #2, was free from unnecessary medication. The findings include: 1. For Resident #2 (R2), the facility staff failed to ensure a urinalysis reported on 11/18/23 was addressed. The urinalysis was positive for a UTI (urinary tract infection) and the resident was receiving an antibiotic that the organism was resistant to. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 8/25/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R2's clinical record revealed a physician's order dated 11/13/23 for a urinalysis with culture and sensitivity for a possible UTI. R2 was transferred to the hospital on [DATE], per the resident's request for 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.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement infection control standards of practice for one of five residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to implement infection control precautions when a urinalysis result with a reported date of 11/18/23 documented the resident was positive for ESBL (Extended spectrum beta-lactamase) E. coli (1). A review of R2's clinical record revealed a physician's order dated 11/13/23 for a urinalysis with culture and sensitivity for a possible UTI (urinary tract infection). R2 was prescribed an antibiotic for a UTI on 11/15/23. A urinalysis report with a reported date of 11/18/23 documented R2's urine was positive for ESBL E. coli. The report also documented the organism was resistant to the antibiotic that was prescribed for R2. A nurse's note dated 11/19/23 (7:17 a.m.) documented, UA (Urinalysis) reflex to culture/ urine culture results from labs was called in critical from lab. Results abnormal,…

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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide supervision for six of 17 residents in the survey sample, Resident #4, #5, #6, #7, #8, #12. The findings include: The facility staff failed to ensure a staff member supervised the residents during smoking times, and failed to ensure wander guard monitoring was performed per the plan of care. On 9/6/23 at 8:30 AM, during entrance, a list of smoking residents was requested. This list included the following Residents: Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8. 1. Resident #4 did not have interventions implemented to supervise smoking. On 9/6/23 at approximately 9:00 AM, Resident #4 was observed in the courtyard off the dining room, smoking without supervision. A smoking apron was on the resident. When asked who had provided his cigarette and lit it, Resident #4 would not answer. No burns noted on resident. Resident #4 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.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide sufficient staffing to meet resident needs for one of three resident hallways which affected 35 residents on 8/6/23. The findings include: The facility staff failed to provide sufficient staffing to meet resident needs. On 9/6/23 at approximately 8:30 AM, a request was made during the entrance conference to ASM (administrative staff member) #1, the executive director and ASM #2, the interim director of nursing to provide the as worked staffing schedules from 8/6/23-9/6/23. When asked during the entrance conference if there were any staffing waivers, ASM #2 stated, No, there are no waivers. ASM #2 stated, We did not have RN (registered nurse) coverage for a couple of days and we did not have an LPN (licensed practical nurse) on a unit for one day 8/6/23. A review of the as worked staffing sheet for 8/6/23, revealed no LPN or RN worked on Wing 3, the secured unit hallway. An interview was conducted on 9/6/23 at approximately 12:35 PM, with ASM #2, 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, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide RN (registered nurse) coverage 8 hours a day, 7 days a week, with the potential to affect all residents that require RN services. The findings include: The facility staff failed to provide RN (registered nurse) coverage 8 hours a day for 2 of 30 days. On 9/6/23 at approximately 8:30 AM the ASM (administrative staff member) #1, the executive director and ASM #2, the interim director of nursing were asked to provide the as worked staffing schedules from 8/6/23-9/6/23. When asked during the entrance conference if there were any staffing waivers, ASM #2 stated, No, there are no waivers. ASM #2 stated, we did not have RN (registered nurse) coverage for a couple of days. A review of the as worked staffing sheets evidenced no RN worked on 2 of 30 dates requested, 8/19/23 and 9/2/23. An interview was conducted on 9/6/23 at approximately 12:35 PM, with ASM #2, the interim director of nursing. When asked the standard for RN coverage, ASM #2…

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, staff interview and facility document review it was determined facility staff failed to administer medications on one of three hallways of Wing 3, which affected 35 residents. The findings include: A review of the medication error report for 8/6/23 revealed on one of three hallways, which affected thirty-five residents, no medication administration occurred on the day shift 7:00 AM-3:00 PM. A review of the medication error report of medications missed on 8/6/23, revealed three medications which met the criteria for a significant medication error: 1. Insulin Lispro Sliding scale subcutaneously before meals: Notify provider if BS (blood sugar) less than 60, 151-200: 3 units, 201-250: 6 units, 251-300: 9 units, 301-350: 12 units, 351-400: 15 units, greater than 400: 18 units and check again in one hour and notify the provider missed on Resident #15 at 11:30 AM. 2. Vancomycin 1 gram intravenously, once a day for leukocytosis missed on Resident #16 at 9:00 AM. 3. Tegretol 6.25 milliliter by mouth three times a day, missed on Resident #17 at 9:00 AM and 2:00 PM.…

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 resident interviews, responsible party interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to prepare and provide well-balanced meals that take into consideration the needs and choices of the residents, in one of one kitchen. The findings include: Residents and family members voiced complaints about the food, to include, but not limited to, the amount, taste, and temperature, however, facility staff have not resolved the concerns/complaints. On Resident #3's (R3) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 9/6/2023 at 11:30 a.m., an interview was conducted with R3. R3 stated that the food at the facility was horrible with no flavor and was often served cold when it was supposed to be hot. R3 stated that they had been served undercooked vegetables and overcooked…

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 resident interviews, responsible party interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide food that was palatable or served at an appetizing temperature. The findings include: On 9/6/2023 at 11:30 a.m., an interview was conducted with Resident #3 (R3) who was assessed as cognitively intact. R3 stated that the food at the facility was horrible with no flavor and was often served cold when it was supposed to be hot. R3 stated that they had been served undercooked vegetables and overcooked meats. R3 stated that they felt like the facility kitchen staff did not care what they gave to the residents because they thought everyone had dementia and did not know what was going on. R3 stated that they wanted to have fresh fruit and alternate food options, that they were only given sandwiches when they did not like what was served currently. R3 stated that they had talked to kitchen staff about their complaints about the food but no one had done anything to improve anything. On 9/6/2023 at…

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

Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to follow infection control practices for twelve of seventeen COVID-19 positive resident isolation rooms. The findings include: On 9/6/23 at 8:30 AM, a list of COVID-19 positive residents was requested and received. The list included room numbers with COVID positive residents on the 100, 200, and 300 hallways (rooms numbers are redacted in this report to maintain resident personal health information confidentiality). The facility staff failed to follow infection control practices for COVID-19 positive resident rooms. Twelve rooms were observed with their doors open on 9/6/23 at 9:40 AM: (three rooms on the 100 hallway, eight rooms on the 200 hallway, and one room on the 300 hallway). One room on the 100 hallway and one room on the 200 hallway did not have a contact/airborne precautions sign. On 9/7/23 at 9:30 AM, three rooms on the 100 hallway, one room on the 200 hallway, and one room on the 300 hallway were observed with doors to the COVID…

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 staff interview, facility document review and clinical record review, the facility failed to protect the resident's right to be free from physical abuse by another resident, for one of 17 residents in the survey sample, Residents #10. The findings include: The facility failed to protect Resident #10 from physical abuse by another resident, Resident #14 on 8/4/23. Resident #10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: schizophrenia, psychosis not due to a substance and colostomy. Resident #10's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/14/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident was independent for bathing, transfers, bed mobility, dressing, eating and hygiene. Resident required supervision for…

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 staff interview and facility document review, it was determined the facility staff failed to develop/implement the care plan for two of 17 residents in the survey sample, Resident #10 and Resident #12. The findings include: 1. For Resident #10, the facility staff failed to develop a comprehensive care plan for abuse for Resident #10. Resident #10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: schizophrenia, psychosis not due to a substance and colostomy. Resident #10's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/14/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident was independent for bathing, transfers, bed mobility, dressing, eating and hygiene. Resident required supervision for locomotion and walking. A 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.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to monitor weights as directed for one of 17 residents in the survey sample, Resident #13. The findings include: For Resident #13 (R13), the facility staff failed to obtain an order for, and obtain weekly weights as documented by the nurse practitioner on 5/25/2023, and the dietician on 8/18/2023. R13 was admitted to the facility with diagnoses that included but were not limited to unspecified protein-calorie malnutrition and abnormal weight loss. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/9/2023, coded the resident as scoring a 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented R13 having a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Review of the clinical record documented weight values obtained for R13 monthly on…

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

Based on observation, staff interview and facility document review, the facility staff failed to follow dietary menus for for one of five meals served during the survey dates, lunch service on 9/6/2023. The findings include: During lunch service on 9/6/2023, the facility staff failed to prepare a sufficient amount of food for service which resulted in the kitchen not being able to follow the posted menu. The scheduled lunch menu posted for residents for 9/6/23 documented: Main: - Cheese ravioli with marinara sauce - Caesar salad - Garlic bread - Oranges Alternate: - Ham sandwich On 9/6/2023 at 12:40 p.m., observation of the lunch meal pre-service line temperatures was conducted with OSM (other staff member) #2, dietary manager. The following food was prepared and available for lunch: - Cheese ravioli with marinara sauce - Caesar salad - Garlic bread - Oranges - [NAME] beans - Mashed potatoes OSM #2 stated that the alternate meal of Ham sandwiches were prepared to order at the time of request. On 9/6/2023 at 2:00 p.m., observation of the tray line preparation was conducted. Kitchen…

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 resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review food preferences/dislikes with one of 17 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to obtain the resident's food preferences and dislikes. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R3's clinical record failed to evidence a review of the resident's food preferences. On 9/6/2023 at 11:30 a.m., an interview was conducted with R3. R3 stated that the food at the facility was horrible with no flavor and was often served cold when it was supposed to be hot. R3 stated that they had been served undercooked vegetables and overcooked meats. R3 stated that they felt like the facility kitchen staff did not care what they gave…

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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to maintain a complete record for one of 17 residents, Resident #12. The findings include: For Resident #12, the facility staff to document if a wander guard was checked for placement and functionality on each shift. A review of the comprehensive care plan dated 4/23/23 which revealed, FOCUS: The resident is an elopement risk/wanderer related to resident wanders aimlessly, exit seeking to go home, tugging on unit entrance door randomly, resident exit seeking walking out of door. INTERVENTIONS: Assess for elopement risk. Check wander guard for placement/function/expiration date as ordered and as needed. Electronic monitoring device wander guard. Resident #12 was observed with the wander guard on their right ankle on 9/6/23 at 1:00 PM A review of the physician orders dated 10/20/22, revealed Wander guard check every shift for placement. A review of the Elopement Risk Evaluation dated 4/22/23, revealed, Resident is AT RISK for elopement. A review of the TARs…

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, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to maintain a clean, comfortable, homelike environment for 7 of 44 residents in the survey sample, Residents #97, #45, #52, #31, #1, #54 and #114. The findings include: 1. The facility staff failed to maintain Resident #97's (R97) bathroom in a homelike manner. Three tiles on the bathroom wall were duct taped to adjoining tiles and one tile was broken and caved into the wall. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/7/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 6/5/22 at 4:28 p.m., R97 was observed lying in bed and an interview was conducted. R97 stated to look at the wall in the bathroom and the wall had been in disrepair for a year. Observation of the wall across from the toilet in the bathroom revealed three…

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, resident interview, and staff interview, it was determined that the facility staff failed to serve food in a palatable manner from one of one kitchen. The findings include: On 06/05/2022 during individual interviews with residents, complaints were voiced about the facility's meals not being hot and not having any flavor. On 06/05/2022 at approximately 6:30 p.m. a test tray consisting of chicken tenders, french fries, chopped spinach, pureed chicken, mashed potatoes and carrots were placed on a cart in the kitchen, sent to the North-east section of unit two and placed in the food cart. The cart was followed by this and another surveyor, OSM (other staff member) #3, account manager (facility's title for dietary manager) and OSM # 4, cook. At approximately 6:54 p.m., the last dinner tray was served to a resident on the North-east section of unit two and OSM # 4 was asked to remove the test tray from the food cart. OSM #4 placed it on top of a cart then proceeded to take the temperatures of the food. OSM #4 was observed obtaining the test tray food temperatures…

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, staff interview, and facility document review it was determined the facility staff failed to prepare food in the facility's kitchen in a sanitary manner in one of one facility kitchens. The findings include: 1. The facility staff failed to wear a hair net while preparing residents dinner trays in the facility's kitchen. On 06/05/2022 at approximately 4:25 p.m., an observation of the dinner preparation was conducted in the facility's kitchen in the presence of OSM (other staff member) # 3, account manager. Observation of the tray line in the kitchen revealed OSM # 9 standing approximately half way down the tray line. The cook plated the food and place it on the tray opposite OSM # 9 and OSM # 9 placed beverages on the resident's meal trays before the plates were covered from 4:55 p.m. through 5:55 p.m. Observation of OSM # 9 revealed that they did not have their hair covered during the observation time stated above. On 06/05/2022 at approximately 6:00 p.m. an interview was conducted with OSM # 9. When asked about the use of a hair net when working in the kitchen…

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, staff interview and clinical record review, it was determined the facility staff failed to ensure a resident's call bell was within their reach while in bed for one of 44 residents in the survey sample, Resident #122 (R122). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 5/23/2022, the resident scored a seven out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. Observation was made on 6/5/2022 at 3:22 p.m. of R122 in their bed. The call bell was not within the resident's reach. A second observation was made on 6/6/2022 at 10:25 a.m. of R122 in their bed. The call bell was not within the resident's reach, it was located on a foot pedal, which had been removed from a wheelchair, sitting next to their bed. A third observation was made on 6/6/2022 at 4:48 p.m. The call bell was not within the resident's reach, it was located on a foot pedal, which had been removed from a wheelchair,…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to complete a required PASRR (Preadmission Screening and Resident Review) (1) for one of 44 residents in the survey sample, Resident #90 (R90). The facility failed to complete a Level 2 PASRR as recommended on the resident's Level 1 PASRR dated 8/14/19. The findings include: R90 was admitted to the facility with diagnoses that included bipolar disorder and depression. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/5/22, R90 was coded as being severely cognitively impaired for making daily decisions, having scored 4 out of 15 on the BIMS (brief interview for mental status). A review of R90's PASRR dated 8/14/19 (completed prior to admission to the facility) revealed, in part: 5 Recommendations (either 'a' or 'b' must be checked) .a. Refer for secondary assessment .MI (mental illness) or related condition: YES. All other questions in 5.a. and 5.b. were blank. On 6/7/22 at 9:03 a.m., OSM (other…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for one of 44 residents in the survey sample, Resident #122 (R122). The facility staff failed to implement the comprehensive care plan for having R122's call bell within their reach for the prevention intervention for falls. The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 5/23/2022, the resident scored a 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. The comprehensive care plan dated, 2/18/2022 documented in part, Focus: (R122) is at risk for falls. The Interventions documented in part, 2/18/2022 - call bell encouraged. 4/6/2022 - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation was made on 6/5/2022 at 3:22 p.m. of R122 in their bed. The call…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan after a fall, for one of 44 residents in the survey sample, Resident #122 (R122). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 5/23/2022, the resident scored a seven out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. In Section J - Health Conditions, the resident was coded as having had falls since their last admission/entry/readmission/prior assessment. R 122 was coded as having had two or more falls during the look back period. The nurse's note dated 4/2/2022 at 12:49 p.m. documented, Resident awake and alert can make needs known denied pain/discomfort when writer was giving medication to roommate resident was observed sitting in bathroom in wheelchair…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services in accordance with professional standards and the comprehensive care plan for the treatment of wounds for one of 44 residents in the survey sample, Resident #180 (R180). The findings include: The facility staff failed to administer treatments for a diabetic foot wound and a lateral ankle infectious wound. R180 was admitted to the facility with diagnoses that included but were not limited to: diabetes, history of venous thrombosis, congestive heart failure, bullous pemphigoid, atrial fibrillation, osteoarthritis, and chronic kidney disease. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/23/2021, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. In Section M - Skin…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services in accordance with professional standards and the comprehensive care plan for the treatment of pressure injuries for one of 44 residents in the survey sample, Resident #180 (R180). The findings include: The facility staff failed to administer treatments for a pressure injury on R180's left foot, big toe and treatment to the right lateral malleolus for prevention of pressure injuries. R180 was admitted to the facility with diagnoses that included but were not limited to: diabetes, history of venous thrombosis, congestive heart failure, bullous pemphigoid, atrial fibrillation, osteoarthritis, and chronic kidney disease. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/23/2021, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was…

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

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide medically related social services for one of one of 44 residents in the survey sample, Resident #90 (R90). The facility failed to complete a Level 2 PASRR (Preadmission Screening and Resident Review) (1) as recommended on the resident's Level 1 PASRR dated 8/14/19. The findings include: R90 was admitted to the facility with diagnoses that included bipolar disorder and depression. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/5/22, R90 was coded as being severely cognitively impaired for making daily decisions, having scored 4 out of 15 on the BIMS (brief interview for mental status). A review of R90's PASRR (Preadmission Screening and Resident Review) dated 8/14/19 (completed prior to admission to the facility) revealed, in part: 5 Recommendations (either 'a' or 'b' must be checked) .a. Refer for secondary assessment .MI (mental illness) or related condition: YES. All other…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure a medication error rate less than five percent for two of four residents observed during the medication administration observation. During the medication administration observation, 2 errors out of 27 opportunities occurred, resulting in a 7.41 percent medication error rate. The findings include: 1. The facility staff failed to administered the correct physician prescribed dose of 500 mg (milligrams) of an antacid medication to Resident #37 (R37). Instead, LPN (licensed practical nurse) #1 administered 750 mg of the medication on 6/6/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/31/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of R37's clinical record revealed a physician's order dated 3/11/22 for a chewable calcium carbonate antacid- 500…

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 resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to honor reasonable food preferences and choices for one of 44 residents in the survey sample, Resident #24. The findings include: On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 3/13/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was not cognitively impaired for making daily decisions. On 6/5/2022 at 5:05 p.m., an interview was conducted with Resident #24 (R24). R24 stated that they used to be able to order a salad from the kitchen for their dinner when they did not want a full meal but over the past two months the menus had changed and they did not receive salads anymore. R24 stated that it had been about 4 weeks since they had gotten a salad and the last one they received was with a meal as a side and was only lettuce with dressing on it. R24 stated that they were a diabetic and at times they…

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 resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for 1 of 44 residents in the survey sample, Resident #29 (R29). The findings include: On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 3/18/2022, the resident scored 8 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. Section O documented Resident #29 (R29) receiving dialysis while a resident. On 6/5/2022 at approximately 3:30 p.m., during entrance conference a request was made to ASM (administrative staff member) #1, the executive director, to review the dialysis contracts held by the facility. Review of the facility dialysis contracts provided by ASM #1 failed to evidence a contract between the facility and [Name of dialysis center]. On 6/6/2022 at approximately 8:45 a.m., an…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure four of sixty-three sampled residents, (Residents #62, #73, #101, and #36), were free from abuse and neglect. On 4/12/19, Resident #217 exposed his genitals to Resident #62. On 10/14/2019, Resident #10 hit Resident #73 in the stomach. On 11/27/19, Resident #101 was grabbed around the neck in the dining room by Resident #107. On 11/4/2019, when Resident #36 was found lying on the floor by staff, the staff picked the resident up and assisted her back to bed and neglected to implement the fall management protocol to assess for injury and a change in condition. The findings include: 1. Resident #62 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebral infarction (1), dehydration (extreme loss of water from the body tissues often accompanied by electrolyte imbalance) (2) polyneuropathy (abnormal condition of a large amount of peripheral…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the comprehensive plan of care for four of 63 residents in the survey sample, Residents #70, #98, #38 and #153. The facility staff failed to implement Resident #70's comprehensive care plan regarding insulin administration on multiple dates in December 2019, January 2020, and February 2020. The facility staff failed to implement Resident #98's comprehensive plan of care to complete a gradual dose reduction (GDR) for Mirtazapine in the required time frame. The facility staff failed implement the comprehensive care plan to attempt non-pharmacological interventions prior to the administration of as needed pain medications to Resident # 38 and #153. The findings include: 1. Resident #70 was admitted to the facility on [DATE]. Resident #70 was most recently readmitted on [DATE]; diagnoses include, but are not limited to history of a stroke with left side paralysis, colon…

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 staff interview, clinical record review, facility document, and in the course of complaint investigation, it was determined that the facility staff failed to provide ADL (activities of daily living) care for one of 63 residents in the survey sample, Resident #416. The facility staff failed to provide a bed bath and/or shower to Resident #416, coded as dependent on staff for bathing on multiple occasions in June, July, August and September 2019. The findings include: Resident #416 was admitted to the facility on [DATE]. Resident #416's diagnoses included but were not limited to anxiety disorder, paralysis and diabetes. Resident #416's most recent MDS (minimum data set) (prior to discharge), a quarterly assessment with an ARD (assessment reference date) of 8/1/19, coded the resident's cognition as moderately impaired. Section G coded Resident #416 as totally dependent on one staff for bathing. Review of Resident #416's ADL documentation for April 2019 through October 2019 revealed Resident #416 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide treatment and care in accordance with professional standards of practice, and the comprehensive person-centered plan of care for one of 63 residents in the survey sample, Resident #70. The facility staff failed to administer Resident #70's insulin as ordered by the physician on multiple dates in November 2019, December 2019, January 2020, and February 2020. The findings include: Resident #70 was admitted to the facility on [DATE]. Resident #70 was most recently readmitted on [DATE]; diagnoses include, but are not limited to history of a stroke with left side paralysis, colon cancer, and diabetes (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/5/19, he was coded as being moderately impaired for making daily decisions, having scored 13 out of 15 in the BIMS (breif interview for mental status). He was coded as…

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 resident interview, staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the medication regimen for three out of 63 residents in the survey sample, Residents #70, #153, and #38, was free from unnecessary medications. The facility staff administered Resident #70's insulin on multiple dates in November 2019, December 2019, January 2020, and February 2020, despite the resident's blood sugar reading being below the physician prescribed parameter for administering the medication. The facility administered as needed pain medication to Resident #153 and #38 without attempting non-pharmacological interventions. The findings include: 1. Resident #70 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including, but not limited to history of a stroke with left side paralysis, colon cancer, and diabetes (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to prevent significant medication errors for one of 63 residents in the survey sample, Resident #70. The facility staff administered insulin to Resident #70 when the resident's blood sugar level was below the physician prescribed parameter for administration of the medication. The findings include: Resident #70 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to history of a stroke with left side paralysis, colon cancer, and diabetes (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/5/19, he was coded as being moderately impaired for making daily decisions, having scored 13 out of 15 in the BIMS (breif interview for mental status). He was coded as having received insulin injections on all seven days of the look back period. A review of Resident #70'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.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The facility staff failed to maintain ovens in a sanitary manner and failed to dispose of expired food during the facility task- kitchen observation on 2/4/20 at 10:58 AM. The findings include: On 2/4/20 at 10:58 AM, an observation was conducted in the dry storage room of the main kitchen. Eleven bags of mini marshmallows with delivery date of 12/20/18 and expiration date of 4/9/19 were found. Observation of the top and bottom ovens found dried food residue on bottom of both ovens. An interview was conducted on 2/4/20 at 11:00 AM, with OSM (other staff member) #3, the kitchen manager. When shown the expiration date on the marshmallows, OSM #3 stated, I will need to check with our vendor if that is correct date. On 2/5/20 at 11:45 AM, OSM #3 stated, The marshmallows expiration date was correct. An interview was conducted on 2/4/20 at 11:20 AM with OSM #3. When shown the food residue on top oven, OSM #3 stated, We baked…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify and consult the physician when prescribed medication was not administered as ordered for one of 63 residents in the survey sample, Resident #70. The facility staff failed to notify and consult the physician, when Resident #70's prescribed insulin was not administered as ordered by the physician on multiple dates in December 2019. The findings include: Resident #70 was admitted to the facility on [DATE]. Resident #70 was most recently readmitted on [DATE]; diagnoses include, but are not limited to history of a stroke with left side paralysis, colon cancer, and diabetes (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/5/19, he was coded as being moderately impaired for making daily decisions, having scored 13 out of 15 in the BIMS (breif interview for mental status). He was coded as having received insulin (1)…

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, facility document review and staff interview, it was determined the facility staff failed to maintain a clean, comfortable, homelike environment for two of 98 resident rooms, resident rooms [ROOM NUMBERS]. The closet doors in resident 109 and 110 were observed in disrepair with edge molding coming off both closet doors; the door in 110 was observed separating coming apart from the core. The findings include: Observation was made of resident rooms [ROOM NUMBERS] on 2/4/2020 at 11:10 a.m. The closet door in room [ROOM NUMBER] had the edge molding coming off for approximately eight inches. The closet door in room [ROOM NUMBER] had missing pieces of the molding and had sharp edges where the molding was missing. The closet door also was separating. The door had a core and two glued on panels on the front and the back. The panel on the inside of the closet was coming apart from the core. This was approximately twelve inches from the bottom of the door upward and approximately inward from the edge…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence physician documentation for a facility imitated transfer to the hospital transfer for one of 63 residents in the survey, Resident #147. The attending physician failed to document the rationale and reason for Resident #147's transfer and admission to the hospital on [DATE]. The findings include: Resident #147 was admitted to the facility on [DATE]; Resident #147 was most recently readmitted on [DATE], diagnoses included, but are not limited to influenza, pneumonia, and dementia (1). On the most recent MDS (minimum data set), a significant change assessment with an assessment reference date of 1/8/2020, Resident #147 was documented as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as having received both oxygen therapy and intravenous (in the vein) medications in the last 14…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notification of a facility-initiated transfer to the ombudsman, resident or resident representative for one of 63 residents in the survey sample, Resident # 118. On 12/20/2019, the facility transferred Resident # 118 to the hospital and staff failed to evidence written notification for the transfer to the ombudsman, resident or Resident # 118's representative. The findings include: Resident # 118 was admitted to the facility with diagnoses that included but were not limited to: quadriplegia [1] and neurogenic bladder [2]. Resident # 118's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/31/19, coded Resident # 118 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition intact for making daily decisions. Resident # 118 was coded as being dependent of one staff member for activities of daily living. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for one of 63 residents in the survey sample, Resident #153. The facility staff to clarify physician orders for two as needed pain medications to determine when and which medication to administer. The findings include: Resident #153 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: multiple sclerosis [a progressive disease in which nerve fibers of the brain and spinal cord lose their myelin cover.] (1), pressure injury on the sacrum, GERD [gastroesophageal reflux disease, is backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs.] (2) and quadriplegia [Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause] (3). The most recent 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 staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision, to ensure an environment free from resident to resident inappropriate physical contact for two of 63 residents in the survey sample, Residents #73 and #19. The facility staff failed to supervise Residents #73 and #19, resulting in an incident of in appropriate physical contact on 11/5/19, when Resident #19 was found by facility staff naked from the waist down, sitting on Resident #73's face. The facility staff failed to ensure adequate supervision to prevent in appropriate resident to resident contact. On 11/21/2019, Resident # 73 was naked from the waist down, laying on Resident # 2's bed, Resident #2 was undressed in the room standing by the bed. The findings include: 1. Resident #73 was admitted to the facility on [DATE] with diagnoses including, but not limited to, history of a stroke, psychosis (1), schizophrenia (2) and dementia with behaviors (3). On the most recent…

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, staff interview, and clinical record review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 63 residents in the survey sample, Residents # 118. The findings include: Resident # 118 was admitted to the facility with diagnoses that included but were not limited to: quadriplegia [1] and neurogenic bladder [2]. Resident # 118's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/31/19, coded Resident # 118 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition intact for making daily decisions. Resident # 118 was coded as being dependent of one staff member for activities of daily living. Section H Bladder and Bowel coded Resident # 118 as having an indwelling catheter. On 02/05/2020 during an observation of Resident # 118's wound care with LPN # 2 [licensed practical nurse] and care CNA [certified nursing assistant] # 6 present from 8:48 a.m. to 9:15 a.m., it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to have a complete pain management program for two of 63 residents in the survey sample, Residents #153 and #38. The facility staff failed to assess Resident #153's pain levels prior to the administration of pain medication, document the location of the pain and failed to document the effectiveness of the medication administered. The staff failed to assess the effectiveness of pain medication administered to Resident #38 and failed to document the resident's pain levels, and the location of the pain prior to the administration of as needed pain medication. The findings include: 1. Resident #153 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: multiple sclerosis [a progressive disease in which nerve fibers of the brain and spinal cord lose their myelin cover.] (1), pressure injury on the sacrum, GERD [gastroesophageal reflux…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure a gradual dose reduction was attempted for the psychotropic medication Mirtazapine for one of 63 residents in the survey sample, Resident #98. The facility staff failed to evidence an attempted a gradual dose reduction (GDR) or documentation the GDR was contradicted for Mirtazapine prescribed and administered to Resident #98, since 11/10/18. The findings include: Resident #98 was admitted to the facility on [DATE] with diagnoses including, but not limited to diabetes, major depression, and psychosis. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 12/16/19. He was coded as having no impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having zero concerns for mood alterations in Section D. He was coded as receiving an antidepressant on all seven…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to comply with the state licensing regulations for one of 63 residents, Resident #217.The facility failed to ensure, a sexual offender, registry background check for Resident #217 was completed prior to admission per the State of Virginia licensing regulations. G. The nursing facility shall register with the Department of State Police to receive notice of the registration or reregistration of any sex offender within the same or a contiguous zip code area in which the facility is located pursuant to § 9.1-914 of the Code of Virginia. H. Prior to admission, each nursing facility shall determine if a potential resident is a registered sex offender when the potential resident is anticipated to have a length of stay: 1. Greater than three days; or 2. In fact stays longer than three days. The findings include: A Facility Reported Incident dated 4/12/19, documented in part, Incident date: 4/12/19.…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain and complete and accurate clinical record. There was no documentation in the clinical record evidencing staff found Resident #36 lying on the floor on 11/4/19. The findings include: Resident #36 was admitted to the facility on [DATE], with a recent readmission on [DATE], with diagnoses that included but were not limited to: fracture of the neck, diabetes, high blood pressure, Alzheimer's disease (1), and osteoarthritis, [Characterized by degenerative changes in the joints, pain, stiffness and swelling can develop after exercise] (2). The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 11/15/19, coed the resident as having both short and long term memory difficulties and being severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members…

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, staff interview, facility document review and in the course of complaint investigation, it was determined that the facility staff failed to maintain a fully functional resident call system for four of 98 resident rooms. The facility staff failed to ensure the call light located in the ceiling outside the room and indicating a resident had triggered the call system was functioning for resident rooms #104, #114, #127 and #132. The findings include: On 2/4/20 at 11:32 a.m., observation of all resident call light systems was conducted with CNA (certified nursing assistant) #1. The call light located in the ceiling outside of resident rooms failed to light up to indicate the call system had been activated (by touching a call light button) for resident rooms #104, #114, #127 and #132. A switch board panel was located at the nurse's station and did light up to indicate the call system had been activated by a specific room; however, the switch board panel was not visible because it was behind a chart rack. The switch board panel did not activate any sound to alert…

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.