Parham Health Care & Rehab Center

Based on observations, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an effective quality assurance program with a focus on the outcomes of care, quality of life, and to correct quality deficiencies, which resulted in multiple residents residing on three of three units being victims of abuse. The findings included:During a survey conducted with a survey completion date of 4/28/25, the facility was cited for multiple areas of deficient practice involving abuse. Seven residents were identified as having been abused by facility staff and/or other residents, failure to report allegations, investigation of allegations, and failure to investigate, prevent, and correct abuse of residents. During the April 2025 survey, the identification of deficiencies for a safe environment was identified. The facility's quality assurance program was involved in the development of a plan of correction and ongoing monitoring to ensure ongoing compliance to sustain compliance. During this survey in December 2025, the survey…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility staff failed to accommodate resident's choices and/or needs for eight of forty-three residents (R), R102, R116, R138, R139, R140, R141, R143 and R129. The findings included:1. For R102 the facility staff failed to provide the resident with his preference for a shower. R102's diagnoses included multiple sclerosis and muscle weakness. Section C (cognitive patterns) of R102's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/11/25 included a brief interview for mental status (BIMS) score of 15, indicating R102 was cognitively intact. Section GG (functional status) was coded (1) to indicate R102 was dependent on staff for personal hygiene and shower/bathe self. R102's comprehensive care plan included the focus area requires assistance with activities of daily living related to quadriplegia and multiple health issues. Interventions included extensive total assistance needed with bathing, dressing, and grooming. On 02/10/26 at 2:20 p.m., during 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, staff interview, and facility documentation review, the facility staff failed to maintain resident clinical records in a manner to ensure privacy and confidentiality of records, on two of three nursing units (Central and [NAME] wings). The findings included:The facility staff failed to maintain resident's clinical record access in a manner to safeguard and protect the content of information from authorized disclosure by allowing facility staff to use personal computers for daily tasks and access to resident clinical records on two nursing units. On 2/12/26 at 9:30 AM, observations were conducted on each of the units. Observations revealed that six of the facility nurses working on the central and west wings, were utilizing their own personal laptop computers to access resident clinical records and documents. On 2/12/26 at 9:30- 10 AM, interviews were conducted with the facility staff about the use of their personal computers. The staff reported, They don't have enough computers, there is only one on this unit and there is no charger for it. They are 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 observation, staff interview and facility documentation review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of three units and for failure to keep a homelike environment for 1 Resident (Resident # 142) in a survey sample of 43 residents. The findings included: For residents on the East Wing, the facility staff failed to provide a safe, comfortable, homelike environment. On 2/10/2026 during the initial tour on the East Unit and during subsequent rounds throughout the survey, there were several issues that were not homelike including but not limited to: ceiling tiles in several residents' rooms were observed to be stained and some were bulging, broken blinds, broken nightstand drawers, soiled towels under bins in one room and a brownish stain and gnats were observed in the water fountain near the nurses station. For the residents on East Wing, the failed to ensure the water fountain was clean. A brownish stain and gnats were observed in the water fountain near…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to conduct a thorough investigation into allegations of abuse and misappropriation involving four residents (Resident #26- R26, Resident #40- R40, Resident #48- R48, and Resident #33- R33), in a survey sample of forty-eight residents. The findings included:1. For an incident of physical assault by Resident #26 (R26) toward Resident #40 (R40), who sustained injury, the facility staff failed to conduct a thorough investigation of the incident. On 12/12/25, during a clinical record review of R26's chart, it was noted in the nursing progress notes that R26 was on one-to-one observation due to a physical assault incident toward another resident. No details of the incident were noted. On 12/12/25, the surveyor asked the facility staff to provide any documentation they had regarding an incident in October 2025, involving R26. The director of nursing (DON) provided the survey team with 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 and staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure resident care and services were provided in accordance with accepted standards of care for five of 48 residents in the survey sample, (Residents #27, # 21, 32, 12, and #24)The findings included:1. For Resident #27, the facility staff failed to transcribe a physician's order for Benadryl and failed to document assessment of his allergic reaction from the fish served to him at lunch on 12/3/25. Resident #27 was admitted to the facility on [DATE] with diagnoses to include but not limited to hypertension, anxiety, iron deficiency anemia, asthma, type 2 diabetes mellitus and post-traumatic stress disorder. Resident #27's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/14/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. On 12/9/25 at 2:55 PM, an interview 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, clinical record review, and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for fifteen occurrences affecting one resident (Resident #201- R201) in a survey sample of 14 residents.The findings included: For R201 the facility staff failed to obtain blood pressure prior to administering his blood pressure medication as ordered by the physician on 15 occasions, which put the resident at risk for hypotensive events (event where the blood pressure drops too low). R201was admitted to the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension. R201's most recent MDS (Minimum Data Set) with anARD (Assessment Reference Date) of 2/18/26 coded R201 as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible score of 15, indicating the resident has no…

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

Based on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen.The findings include:Based on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen.The findings include:The facility dietary staff failed to wear beard guards while preparing dinner, failed to take holding temperatures of food prior to serving it from the steam table, failed to use utensils to serve baked fish and rolls, and failed to handle serving utensils in a sanitary manner at the dinner observation on 12/9/25.On 12/9/25 at 4:27 p.m., the dietary staff members were observed preparing dinner in the facility kitchen. ASM (administrative staff member) #7, the dietary director, OSM (other staff member) #9, a cook, and OSM #10, a cook, worked in the food preparation area. Each of these staff members had facial hair, but none wore a beard guard. At 4:32 p.m., all food items were removed from the stove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to follow infection control standards during medication administration on one of three units (west wing), involving four residents. The findings included:On the west wing licensed practical nurse #3 (LPN #3) failed to follow infection control standards during medication administration to prevent the spread of infection. Continuous observations revealed in a 42-minute period and following administration of medications to four residents, LPN #3 failed to perform any hand hygiene and failed to perform any cleaning/disinfecting of a glucometer. On 2/12/26 at 10:40 AM, observations of medication administration were conducted with a licensed practical nurse (LPN #3). The surveyor notified the nurse that the surveyor wanted to do a narc count when she was at a stopping point. LPN #3 was observed to have long artificial nails. Resident #132 (R132) came out of his room and the nurse (LPN #3) said she wanted to give him his medication and check his blood sugar before he left the unit. The nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, staff interview, and facility document review, the facility staff failed to provide a clean environment in four of 88 resident rooms, rooms 77, 13, 11, 53, and 58.The findings include:On 12/11/25 at 3:23 p.m., the resident in room [ROOM NUMBER] (identified as Resident #5 [R5]) was interviewed in his room. R5 stated that he had requested housekeeping services in his room three times that day and the housekeepers had not shown up. Observations of R5's room revealed trash on the floor. The floor was dirty and did not appear to have been cleaned. Upon exiting the room, two nursing staff members were notified of the resident's request. On 12/12/25 at 8:52 a.m., R5 room revealed R5's room remained unkempt, and trash was on the floor. The room and floors did not appear to have been cleaned. On 12/12/25 at 10:06 a.m., ASM (administrative staff member) #9, the environmental services manager, was interviewed. He stated that each resident's room is cleaned once daily by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to ensure it was clinically appropriate for the self-administration of medications for one resident (Resident #33) in survey sample of forty-eight residents. Findings included:For Resident # 33, the facility staff failed to ensure there was a self-administration of medication assessment related to medication found at the bedside. Resident # 33 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: Cerebral Infarct due to Thrombosis of the right posterior Cerebral Artery, Hemiplegia with hemiparesis, Cognitive Communication Deficit, and Asthma. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 09/05/2025. Resident # 33's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident # 33 required assistance 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 staff interview, clinical record review, and facility document review, the facility staff failed to notify the responsible party (RP) of a change in condition for one of forty-three residents (R) 119. The findings included:The facility staff failed to notify the RP of a fall that resulted in R119 being sent to the emergency room (ER). R119's diagnoses included vascular dementia, stridor, cerebral infarction, and dysphagia. Section C (cognitive patterns) of R119's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/25 included a brief interview for mental status (BIMS) score of 2 out of a possible 15 points, indicating R119 was severely impaired in cognitive skills for daily decision making. R119's face sheet listed a family member as being the RP and emergency contact #1. R119's clinical record included a progress note documented by the nursing staff on 01/12/26 at 4:39 a.m. indicating R119 was .on the floor in his room.sustained a small bruise to his orbital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to respond to grievances for one resident (Resident #121-R121) in a survey sample of 43 residents. The findings included:On 2/10/26, a clinical record review was conducted of R121's chart. Review of the progress notes and care plan revealed no documentation regarding a request for R121's family to provide clothing. On 2/10/26 at 3 PM, an interview was conducted with R121. R121 reported he recalled getting some new clothes a few months ago but couldn't recall what he received and said his memory wasn't perfect. On 2/10/26, attempts were made to reach R121's family, designated representative, but were not successful. On 2/12/26 the facility was asked to provide any grievances they had on file regarding R121. On 2/13/26, the facility provided a grievance that was filed by R121's family member dated 9/26/25. According to the grievance form it read, RP sent clothes to facility they were left at front desk, resident never received the clothes. The summary 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, clinical record review, and facility documentation review, the facility staff failed to respect resident's right to be free from misappropriation of property for one resident (Resident #121-R121) in a survey sample of 43 residents. The findings included:For R121, the facility staff failed to protect the residents' right to be free from misappropriation of property when clothes were delivered to the facility and the resident never received the items. On 2/10/26, a clinical record review was conducted of R121's chart. Review of the progress notes and care plan revealed no documentation regarding a request for R121's family to provide clothing or that clothing was received. On 2/10/26 at 3 PM, an interview was conducted with R121. R121 reported he recalled getting some new clothes a few months ago but couldn't recall what he received, who gave them to him, and said his memory wasn't perfect. On 2/12/26 the facility was asked to provide any grievances they had on file regarding R121. On 2/13/26, the facility provided a grievance that 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 observations, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for reporting and conducting a thorough investigation for five residents (Resident #33, 48, 40, 26, and 33) in a survey sample of forty-eight residents. The findings included:1. For Resident #26 (R26) and Resident #48 (R48), the facility staff failed to implement their abuse policy regarding the timing of reporting incidents of abuse. On 12/12/25 during a clinical record review of R26's chart, it was noted that he had a physical altercation with another resident. According to a nursing note entry dated 10/25/25 at 1 AM, which read, Writer was called to the unit by the charge nurse to assess Resident [R26's name redacted] who hit another resident also threaten and accuse the charge nurse of not given him his medication and loud verbalization causing peers to be alarmed/frighten. Resident was not able to be deescalated for some time frame for 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 resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to report an allegation of misappropriation to the required agencies in a timely manner involving three residents (Resident #33- R33, Resident #26-R26, and Resident #48-R48), in a survey sample of forty-eight residents. The findings included:1. For Resident #33 (R33), who reported an allegation of misappropriation of property, the facility staff failed to report the allegation to the state survey agency and adult protective services until four days later. On 12/15/25, during a clinical record review, it was noted that R33 had reported missing money. According to a nursing note entry dated 11/20/25, it read, Writer and another nurse went to resident's room to look for his money that he claims is missing. Upon entering resident's room, several other staff members were present with resident. Permission requested and granted to look through resident's nightstand to see if by chance he misplaced it in the drawer.Continued search showed no money found. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to develop a comprehensive person-centered care plan for one (1 ) resident (Resident #27) in a survey sample of 48 residents.The findings included: For Resident #27, the facility staff failed to develop a comprehensive person-centered care plan to address his multiple food and drug allergies.Resident #27 was admitted to the facility on [DATE] with diagnoses to include but not limited to chest pain, muscle weakness, syncope and collapse, atrial septal defect, ventricular septal defect, coarctation of aorta, calculus of kidney, hypertension, anxiety, iron deficiency anemia, hydronephrosis with renal and ureteral calculous, obstruction, morbid obesity, asthma, mast cell activation, type 2 diabetes mellitus, post-traumatic stress disorder.Resident #27's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/14/25 coded the resident as having a BIMS (Brief Interview 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, facility document review, and clinical record review, the facility staff failed to review and/or revise the care plan for two (2) of 48 residents in the survey sample, Residents #32 and #7. The findings include:1. For Resident #32 (R32), the facility staff failed to review the effectiveness of care plan interventions after a resident to resident altercation on 9/25/25.A review of a facility synopsis of events dated 9/24/25 revealed, in part: [Resident #12] reported to Activities Director that [R32] punched him in the face. [R12] asked the resident to 'come on by and move' so that he could pass through. [R32] stated that he felt he was being 'offended and didn't like it and he swung on him and didn't miss.' Residents were separated upon initial report and [R32] placed on 1:1. [R12] was assessed for further injuries with 5 small abrasions noted around the left cheek bone and left orbital (sic) of the eye. Neurochecks initiated.Further review of R32's clinical record revealed the following progress note dated 9/25/25: Per nurse aide ran to nursing station to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident received ADL (activity of daily living) assistance for one (1) resident (Resident #31) in a survey sample of 48 Residents.The findings include: The facility staff failed to provide ADL (activities of daily living) for incontinence care and repositioning for Resident #31 for a period of at least 5 continuous hours on 12/11/25.Resident #31 was admitted to the facility on [DATE] with diagnoses that included but not limited to intracerebral hemorrhage, hemiplegia and hemiparesis (paralysis affecting his left side), aphasia (a language disorder that makes it difficult to communicate affecting the residents speech) chronic respiratory failure, asthma, chronic obstructive pulmonary disease, anxiety, seizures, hyperlipidemia, muscle weakness, history of transient ischemic attacks (a brief interruption of the brain's blood flow causing stroke-like symptoms), depression, 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, clinical record review, and facility documentation review, the facility staff failed to appropriately assess and monitor a resident following a fall with injury for one resident (Resident #20-R20) in a survey sample of forty-eight residents. The findings included:For Resident #20, who had a fall and sustained a hematoma to her forehead, the facility staff failed to monitor for latent injuries by conducting neurological checks (neuro checks). On 12/8/25-12/9/25, a closed record review was conducted of R20's chart. According to the nursing progress notes, on 8/3/24 R20 fell. The note read, Description of the fall/V/S/injuries if any: : Time: about 0630-0635. unwitnessed. While doing the med pass facing the wall, overheard a thud, turning this writer's head to the left and observed resident lying on the floor face down, she is alert and responsive. she suffered a bump (hematoma) on her forehead, no other What Interventions were in place at the time of the fall? : initial check to see if okay, and help onto a chair, applied a pack of ice, on-call MD 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 clinical record review the facility nursing staff failed to complete a provider ordered treatment to a pressure ulcer for one of forty-three sampled residents, Resident (R)102. The findings included: The facility nursing staff failed to complete a provider ordered treatment to R102's sacral pressure ulcer. R102's diagnoses included multiple sclerosis and quadriplegia. Section C (cognitive patterns) of R102's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/11/25 included a brief interview for mental status (BIMS) score of 15, indicating R102 was cognitively intact. Section M (skin conditions) was coded to indicate R102 was at risk for developing pressure ulcers and had one stage 3 and one stage 4 pressure ulcer at the time of the assessment. R102's comprehensive care plan included the focus area pressure ulcer (stage 3) to the sacral area. Interventions included treatments per treatment administration record (TAR). R102's clinical record included a provider order for treatment to sacral pressure ulcer to be…

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

Based on staff interviews and facility document review, it was determined that the facility staff failed to complete annual performance evaluations for two of the five C.N.A.s (certified nursing assistants) records.The findings include: For C.N.A #11, date of hire 7/22/1986, and for C.N.A #12, date of hire 11/29/22, no annual performance review has been completed.Five C.N.A records were reviewed to determine compliance with the requirement for annual performance reviews. When the facility provided the requested documents, C.N.A #11 and C.N.A #12 did not have evidence that an annual performance evaluation had been completed.On 12/16/25, an interview was conducted with the Director of Nursing and according to her she is responsible for ensuring the clinical staff performance evaluations are completed annually. When asked about C.N.A #11 and C.N.A#12, she stated: I do not have an annual performance evaluation done for them, I gave you the evaluations for the other three 3 C.N.A's you requested. She acknowledged she is aware that performance evaluations are due annually.On 12/16/25, 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 interviews, and facility document review, the facility staff failed to consistently follow menus for resident meals for one of forty-three sampled residents, Resident (R)119. The findings included:The facility staff failed to provide R119 with all the meal items listed on their tray ticket and facility menu. R119's diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction.Section C (cognitive patterns) of R119's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/25 included a brief interview for mental status (BIMS) score of 2 out of a possible 15 points, indicating R119 was severely impaired in cognitive skills for daily decision making. Section K (swallowing/nutritional status) was coded to indicate the resident was on a mechanically altered diet.R119's comprehensive care plan (CCP) included the focus area at risk for weight loss or malnutrition related to chronic disease, cognitive impairment, requiring assistance to eat and dysphagia requiring puree diet. Date initiated 12/22/25. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, clinical record review, and facility document review, the facility failed to ensure a complete and accurate medical record in accordance with accepted professional standards for 2 (two) of 48 residents in the survey sample (Resident #27, #26).Findings included: 1.For Resident #27, the facility staff failed to transcribe a physician's order for Benadryl and failed to document assessment of his allergic reaction from the fish served to him at lunch on 12/3/25. Resident #27 was admitted to the facility on [DATE] with diagnoses to include but not limited to chest pain, unspecified, muscle weakness, syncope and collapse, atrial septal defect, ventricular septal defect, coarctation of aorta, calculus of kidney, hypertension, anxiety, iron deficiency anemia, hydronephrosis with renal and ureteral calculous, obstruction, morbid obesity, asthma, mast cell activation, type 2 diabetes mellitus, post-traumatic stress disorder. Resident #27's most recent MDS (Minimum Data Set) with 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 staff interviews and facility document review, the facility staff failed to ensure the Quality Assessment and Performance Improvement Committee consisted of the minimum required members for three of five meetings (1/9/25, 7/29/25, and 11/25/25; no meeting sign-in sheet for April 2025).Findings include: On 12/16/25, the Regional Director of Clinical Services and Director of Nursing were asked to provide the facility's Quality Assessment and Performance Improvement Committee (QAPI) meeting attendance/sign-in sheets for 2025. The Director of Nursing provided copies of four QAPI meeting attendance/sign-in sheets for 2025 dated 1/9/25, 7/29/25, 9/26/25 and 11/25/25. Review of the attendance/sign-in sheets revealed that 1/9/25, 7/29/25 and 11/25/25 meeting sign-in sheets did not show evidence that the Infection Preventionist attended the meetings. No evidence of sign-in sheet for the month of April 2025.On 2/16/25 at 2:09 PM, an interview was conducted with the Director of Nursing regarding the facility's QAPI committee. When asked who attended the facility's QAPI committee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and facility documentation review, the facility staff failed to maintain an operational call bell system and in instances of repeated outages of their call system, the facility staff failed to ensure residents had a means to call for assistance from the bedside and bathroom where the call would go directly to a staff member or central location for residents, affecting multiple residents on one of three units at various times. During the survey, a resident on the central unit did not have an operational call bell and the resident had no alternate means to call for assistance. The findings included:On 12/9/25 at 2:15 PM, an interview was conducted with the Regional Director of Clinical Services (RDCS) and Director of Nursing (DON). The RDCS and DON were asked what the facility policy was on emergency responses for call bell malfunction. The response was we have hand bells that are distributed to all who can use them and more frequent rounding on those that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility staff failed to ensure the corridors had firmly secured handrails on one of three units.Findings included:On the East Wing, the hand rail in the corridor between rooms [ROOM NUMBERS] was loose and able to be lifted off the bracket.During the initial tour of the facility on 2/10/2026, the hand rail was observed to be wobbly between room [ROOM NUMBER] and room [ROOM NUMBER]. Upon closer examination on 2/11/2026, it was noted that the handrail was able to be lifted completely from the attachment to the wall at the end closest to room [ROOM NUMBER]. Residents were observed walking in the hallway. Some residents were observed to be touching the handrail.On 2/11/2026 at 12:40 p.m., an interview was conducted with the Licensed Practical Nurse # 4 who stated hand rails should not be loose. During the end of day debriefing on 2/12/2026, the facility Administrator, Director of Nursing and Regional Nurse Consultant were informed of the findings. The Regional 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 observation, staff interview, clinical record review, and facility document review, the facility staff failed to implement their policy on smoking for one of forty-three residents, Resident (R)131.The findings included:The facility staff failed to follow their smoking policy. R131 did not have a signed Patient Smoking Acknowledgement form. The surveyor observed R131 smoking on 02/12/26 at approximately 8:30 a.m. R131's diagnoses included nicotine dependence. R131's comprehensive care plan included the focus area resident prefers to smoke, nicotine dependence, cigarettes. Interventions included may smoke independently and smoking assessment as needed. Section C (cognitive patterns) of R131's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/03/26 included a brief interview for mental status (BIMS) score of 15, indicating this resident was cognitively intact. R131's clinical record included a smoking safety screen assessment with a date of 02/02/26. This document indicated R131 may smoke independently and included a check mark beside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and facility document review, the facility staff failed to provide the required Resident's Rights training for one employee in a survey sample of six employee records. The findings include: The facility staff failed to provide credible evidence of Resident's Rights training for a dietary aide, OSM#9 (Other Staff Member #9).On 12/16/25, a sample of six employees was selected for review of training requirements as part of the extended survey. The list of employees was given to the facility's Director of Nursing, and she was asked to provide evidence of the staff training to include the area of Resident's Rights.On 12/17/25, the employee records were reviewed and revealed no credible evidence to support that OSM#9 who was hired 8/26/25 had completed the required Resident's Rights training.On 12/17/25 at 2:09 PM, the Director of Nursing (DON) was interviewed on her expectations of training for staff. According to the DON, she said she focused on the clinical staff's training primarily. When asked what her expectations for new employee training was, she replied…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and facility document review, the facility staff failed to provide required abuse training for one employee in a survey sample of six employee records.The findings include: The facility staff failed to have credible evidence of abuse training for a dietary aide, OSM#9 (Other Staff Member #9).On 12/16/25, a sample of six employees was selected for review of training requirements as part of the extended survey. The list of employees was given to the facility's Director of Nursing, and she was asked to provide evidence of the staff training to include the area of abuse and neglect training.On 12/17/25, the employee records were reviewed and revealed no credible evidence to support that OSM#9 who was hired 8/26/25 had completed the required abuse and neglect training.On 12/17/25 at 2:09 PM the Director of Nursing (DON) was interviewed on her expectations of training for staff. According to the DON, she said she focused on the clinical staff's training primarily. When asked what her expectations for new employee training was, she replied they get training 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 interviews and facility document review, the facility staff failed to provide the required Quality Assurance and Performance Improvement training for one employee in a survey sample of six employee records reviewed. The findings include: The facility staff failed to have credible evidence of Quality Assurance and Performance Improvement training for a dietary aide, OSM#9.On 12/16/25, a sample of six employees was selected for review of training requirements as part of the extended survey. The list of employees was given to the facility's Director of Nursing, and she was asked to provide evidence of the staff training to include the area of Quality Assurance and Performance Improvement.On 12/17/25, the employee records were reviewed and revealed no credible evidence to support that OSM#9 who was hired 8/26/25 had completed the required Quality Assurance and Performance Improvement.On 12/17/25 at 2:09 PM the Director of Nursing (DON) was interviewed on her expectations of training for staff. According to the DON, she said she focused on the clinical staff's 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 interviews and facility document review, the facility staff failed to provide required infection control training for one employee in a survey sample of six employee records. The findings include: The facility staff failed to have credible evidence of infection control training for a dietary aide, OSM#9.On 12/16/25, a sample of six employees was selected for review of training requirements as part of the extended survey. The list of employees was given to the facility Director of Nursing, and they were asked to provide evidence of the staff training to include the area of infection control.On 12/17/25, the employee records were reviewed and revealed no credible evidence to support that OSM#9 who was hired 8/26/25 had completed the required infection control training.On 12/17/25 at 2:09 PM the Director of Nursing (DON) was interviewed on her expectations of training for staff. According to the DON, she said she focused on the clinical staff's training primarily. When asked what her expectations for new employee training was, she replied they get training on the 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 interviews and facility document review, the facility staff failed to provide the required compliance and ethics training for one employee in a survey sample of six employee records. The findings include: The facility staff failed to have credible evidence of compliance and ethics training for a dietary aide, OSM#9On 12/16/25, a sample of six employees was selected for review of training requirements as part of the extended survey. The list of employees was given to the facility Director of Nursing, and they were asked to provide evidence of the staff training to include the area of compliance and ethics.On 12/17/25, the employee records were reviewed and revealed no credible evidence to support that OSM#9 who was hired 8/26/25 had completed the required compliance and ethics training.On 12/17/25 at 2:09 PM, the Director of Nursing (DON) was interviewed on her expectations of training for staff. According to the DON, she said she focused on the clinical staff's training primarily. When asked what her expectations for new employee training was, she replied they get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff and resident interviews, the facility staff failed to ensure the residents' right to a safe, clean, comfortable, homelike environment for the entire facility and for Residents #128, #103, and #109 in a survey sample of 21 Residents.The following observations were made during the survey period: On 8/27/25 at 10:30 AM and 8/29/25 at 9:00 Am there was a strong urine odor in hallway past the lobby. On 8/27 through 8/29/25 flies were observed throughout the facility in resident rooms and in the hallways.On 8/29/25 at 9:00am observed breakfast trays being served with plastic utensils. An interview was conducted at approximately 9:10 AM with the Dietary Manager Employee #3 who stated due to callouts they opted to use plastic ware to save time on dish washing.8/27/25 through 8/29/25 observed wall mounted hand sanitizer units either missing or loose on the wall. Missing tiles in hallways or in resident rooms 12, 34; baseboard pulled away from the wall in room [ROOM NUMBER] near window and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement an safe replacement for failing closet doors and insect pest prevention and control program concerns for 1 Resident (Resident #124) in a survey sample of 28 Residents. The findings included: For Resident #124 the facility staff failed to provide safe clothing and storage closets in a Resident's room which resulted in a door falling from the closet onto a Resident while she sat in her wheelchair causing an abrasion to her face. Further the facility did not treat an infestation of cockroaches in the failing closet. Resident #124 was admitted to the facility on [DATE] from the hospital. The Resident had a diagnosis history of a stroke with left side weakness, hypertension, chronic heart disease, and was unable to stand alone. The Resident's most recent MDS (an assessment) on 8-20-25 revealed a brief interview for mental status (BIMS) score of 15 out of a possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility documentation the facility staff failed to maintain an effective pest control program for 3 out of 3 units,. 1. For the facility, on 8/27/25 at 10:30 AM and 8/29/25 at 9:00 Am there was a strong urine odor in hallway past the lobby. 2. For the facility, on 8/27 through 8/29/25 flies were observed throughout the facility in resident rooms and in the hallways. 3. For the facility, on 8/29/25 at 9:00am observed breakfast trays being served with plastic utensils. An interview was conducted at approximately 9:10 AM with the Dietary Manager Employee #3 who stated due to callouts they opted to use plastic ware to save time on dish washing. 4. For the facility, on 8/27/25 through 8/29/25 observed wall mounted hand sanitizer units either missing or loose on the wall. Missing tiles in hallways or in resident rooms 12, 34; baseboard pulled away from the wall in room [ROOM NUMBER] near window and wall appeared to have a blackish gray residue. Mattresses in room [ROOM NUMBER]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, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to a dependent Resident (Resident #123) in a survey sample of 28 Residents. The findings included: For Resident #123, the Resident, and Resident's bed, were soaked in a brown halo of partially dried old urine from 10:00 A.M. until 1:40 PM. Resident #123 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide timely medication administration to one Resident (Resident #123) in a survey sample of 28 Residents. The findings included: For Resident #123, the Resident received her medications in March, April, and May 2025 Late, and in some cases hours after they were scheduled to be given. Resident #123 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Comfortable and safe temperature on the Central Unit: a. Resident #43 complained of not being comfortable because of coldness on 4/17/25. Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. On 4/17/25 at 11:35 AM an interview was conducted with Resident #43. He was observed lying on his bed complaining of a toothache and wrapped in a robe. The only linens on the resident's bed was sheets and a light bedspread. Resident #43 stated that it's was too cold and that's why he had a robe wrapped around him. The resident further stated that he is accustomed to the cold because lived…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility's staff failed to provide meals at regular times and in accordance with resident needs, preferences and requests on three out of three units. The facility staff failed to offer and provide snacks at bedtime and failed to serve meals timely. The findings included: During the Resident council meeting conducted on 4/21/2025 at 2:00 p.m., the ten alert and oriented residents who attended complained that they did not get offered bedtime snacks and did not receive snacks on a regular basis. The attendees represented all three units. The residents stated that it was rare to receive snacks at bedtime. They all stated they would like a snack at bedtime. The residents further stated that they had witnessed the dietary staff bring snacks to the unit occasionally, and left them at the nursing station desk. Some of the residents stated they were Diabetic and did not get a snack on a regular basis. They stated the nursing staff left the snacks at the nursing desk, which allowed ambulatory residents who could get to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation, the facility staff failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public throughout the facility. The findings included: For the facility, the staff failed to maintain comfortable ambient temperatures throughout the facility. 4/17/25 9:00 a.m. Residents on 3 of 3 units complained about the temperature being cold in the facility. Residents were observed in the hallway wrapped in blankets. The overnight temperature in the area according to the national weather service was 41 degrees. The facility maintenance director escorted Surveyors E and F to each unit and the temps were as follows: Central Unit - room [ROOM NUMBER] - 65 degrees East Unit - room [ROOM NUMBER] - 65 degrees West Unit - room [ROOM NUMBER] - 68 degrees West Unit hallway - 72 degrees The maintenance director was asked what the acceptable temperatures were for the facility, and he stated the building should…

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

Based on observation, interview, and clinical record review the facility staff failed to maintain an effective pest control program for the facility. The findings included: For the facility staff failed to keep the building free from pests, namely roaches. On 4/15/25 during the initial tour of the facility the shower rooms were observed by surveyors E & F, the shower room on East Unit had a live roach crawling in the shower area. 4/15/25 - 4/16/25 observations of meals being served on styrofoam trays. The interview with the Dietary Manager revealed the dishwasher had not been working. When asked how long the dishwasher had been down, she stated that she would have to check the work orders. Review of facility documentation from the repair technician revealed the following: 3/26/25 - Customer complaint was unit not washing at all, found 214VAC on the T1,2 and 3 of 3CON, diagnosed as bad wash pump, putting in estimate for repair. 4/10/25 - When removing the bottom panel found roaches running throughout the entire unit, found roaches and roach excrement inside of the old motor, advising…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and review of facility documentation, the facility's staff failed to act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility reported in three out of three months. The findings included: An interview was conducted on 4/17/2025 at 1 p.m. with the Activities Director who stated Resident Council meetings were conducted monthly. He stated the Council president kept minutes of each meeting. The Activities Director stated he would encourage alert and oriented residents to attend the meeting with the surveyor. On 4/18/2025 at 1 p.m., an interview was conducted with the Resident Council President who stated the residents had meetings every month. She stated she wrote the minutes for the meetings. She stated that the facility did not respond to the concerns of the group. She stated they complained every month about the food, the temperature in the facility, lack of staffing and pests in the facility. She stated there was a serious problem with those issues. The Resident Council…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, and a clinical record review, the facility staff failed to notify the Physician and/or Designee of refusals of care and services for two (2) of 57 residents (Resident #43 and 116), in the survey sample. The findings included: 1. The facility staff failed to notify the Psychiatric-Mental Health Nurse Practitioner (PMHNP) that Resident #43 refused his medications most days. Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. A care plan problem dated 12/23/24 stated the resident has behaviors (refuses medications, ADL care, and weights) related 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, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure medications were administered according to professional standards for 1 of 57 residents (Resident #43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. A care plan problem dated 12/23/24 stated the resident has behaviors (refuses medications, ADL care, and weights) related to dementia, and a depressive disorder. The goal read the resident's behaviors will not cause him or other resident's distress thru the review period, 5/22/25. The interventions included administer medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review and facility documentation, the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 2 Residents (#77, & #147) in a survey sample of 57 Residents. The findings included: 1. For Resident #77 the facility staff failed to provide 2 showers per week for Resident who is unable to provide self-care. Resident # 77 was admitted to the facility on [DATE] with diagnosis that included chronic embolism and thrombosis, mood disorder, insomnia, dysphasia, muscle, wasting and atrophy, chronic obstructive, pulmonary disease, polyneuropathy, major depressive disorder, chronic kidney disease, fibromyalgia, chronic diastolic heart, failure, hypertension, chronic pain syndrome, and generalized anxiety disorder. Resident # 77's most recent MDS (Minimum Data Set) dated, 4/23/25, scored Resident #77 as having a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating mild cognitive impairment. Resident #77 was also 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.

Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to manage pain for one (1) of 57 residents (Resident 43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. The resident had a care plan problem dated 4/15/25 which stated complaints of a toothache. The goal read the residents pain will be resolve thru review period, 5/22/25. The interventions included a dental appointment and administer medications as ordered. A review of the nurse's notes revealed the resident complained of a toothache on 4/12/25 and was evaluated by a dentist of 4/14/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents received dialysis and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 Resident (#64) in a survey sample of 57 Residents. The findings included: For Resident #64 the facility failed to ensure proper transportation to the dialysis facility and failed to ensure ongoing communication and collaboration with the facility to ensure continuity of care. Resident #64 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to acute osteomyelitis of left ankle and foot cellulitis of left lower, limb, and stage renal disease, dialysis dependent, muscle weakness, hypertension, diabetes type two, arthrosclerosis of arteries in the bilateral legs, ischemic cardiomyopathy, and congestive heart failure. Resident #64 was alert, oriented and listed as his own Responsible Party, however he admitted to 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.

Based on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to ensure that a resident who exhibited behavioral health symptoms received clinically appropriate services for one (1) of 57 residents (Resident #43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. In MDS section D0150 (Mood), the resident was coded as having trouble falling or staying asleep, or sleeping too much, nearly every day, feeling down, depressed, or hopeless, nearly every day, feeling tired or having little energy, nearly every day, and experiencing trouble concentrating on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from significant medication errors for 1 Resident (#64) in a survey sample of 57 Residents. The findings included: For Resident #64 the facilty staff failed to ensure the Resident received all of his medications as ordered by the physician. Resident number 64 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to acute osteomyelitis of left ankle and foot cellulitis of left lower, limb, and stage renal disease, dialysis dependent, muscle weakness, hypertension, diabetes type two, arthrosclerosis of arteries in the bilateral legs, ischemic cardiomyopathy, and congestive heart failure. Resident #64 was alert, and oriented and listed as his own Responsible Party, however he admitted to being non compliant with the BIMS (Brief Interview of Mental Status) asessment because he felt the questions were stupid, thus, explaining the MDS scoring of 99 on his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews, the facility staff failed to safely store drugs and biological in one of three medication rooms and in the Infection Preventionist refrigerator. The findings included: On 4/23/25 at 11:34 AM an observation of the medication room on the [NAME] wing was conducted with Licensed Practical Nurse (LPN) O. An expired dose of Prevnar 20 was observed in the refrigerator for a resident who was discharged . LPN O stated it was not administered because the resident discharged prior to administration. LPN O stated it should have been removed from the refrigerator and returned to the pharmacy. On 4/25/25 at 11:30 AM an observation was conducted with the Infection Preventionist of the Infection Preventionist's medication refrigerator and testing supplies. Two expired RSV test kits had an expiration date of 12/2024 and one culture test kit had and expiration date of 10/19/2023. The above test kits were stored with other testing supplies which were still appropriate for use. It was also identified that seventeen influenza vaccines had names which had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, staff interviews, and clinical record review, the facility staff failed to ensure meals served were palatable to consume by 2 of 57 residents (Resident #55, & #41) in the survey sample. The findings included: 1. Resident #55 was originally admitted to the facility 5/25/23 and the resident was readmitted [DATE] after a hospital stay. The resident's current diagnoses included quadriplegia secondary to gunshot wound in 2017, and neuromuscular dysfunction of the bladder. The annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/24/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #55's cognitive abilities for daily decision making were intact. The resident's nutrition care plan with a revision date of 9/3/24 stated the resident often orders food from outside entities and frequently ask other residents and staff for money to make purchases. On 4/25/25 at 12:15…

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

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to maintain all mechanical and electrical equipment in safe operating condition for the facility. The findings included: The facility staff failed to ensure all kitchen equipment was in working order. On 4/15/25 at approximately 9 a.m. observations of meals being served on Styrofoam trays were made. During the inspection of the kitchen the Dietary Manager stated that the dishwasher and the oven were not working. The interview with the Dietary Manager revealed the dishwasher had not been working. When asked how long the dishwasher had been down, she stated that she would have to check the work orders, and she stated she was not sure how long the oven had been broken either. Review of facility documentation from the repair technician revealed the following: On 4/14/25 at 2:11 p.m. (after Surveyors entered on day 1 of survey) an email was sent from the maintenance director to the company responsible for repairs to both the dishwasher and oven that read: 4/14/25 at 2:11 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #41 was originally admitted to the facility [DATE]. The resident's current diagnoses included blindness, chronic back pain and migraines. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #41's cognitive abilities for daily decision making were intact. Resident #41's had a care plan problem with a revision date of [DATE] which stated he had an ADL self-care performance deficit related to blindness, and chronic health conditions. The goal stated the resident would maintain his current level of functioning through the review date, [DATE]. The interventions included requires minimal assistance with bathing/showers, and requires set up/supervision with dressing. On [DATE] at 12:21 PM Licensed Practical Nurse (LPN) O asked that the surveyor move away from grab bars along the wall leading to the service hall where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Resident (Resident # 56) in a survey sample of 57 Residents. For Resident # 56, the facility staff failed to provide a bed that was an adequate size for someone 74 inches tall. The findings included: Resident # 56 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident #…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to promote self determination through support of choice for one (1) Resident (Resident # 75) in a survey sample of 57 Residents. The findings included: For Resident # 75, the facility staff failed to provide a cup of coffee in the mornings prior to breakfast being served as per her choice. Resident # 75 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Diabetes, Seizure Disorder, Hypertension and Stroke. The most recent Minimum Data Set (MDS) assessment was an Annual assessment with an assessment reference date (ARD) of 3/19/2025. Resident # 75 was coded with a Brief Interview of Mental Status score 15 out of 15 indicating no cognitive impairment. Resident # 75 required assistance for activities of daily living. Review of the clinical record was conducted 4/16/2025-4/28/2025. On 04/24/25 at 11:06 a.m.- Resident # 75 stated she wanted coffee in the mornings but cannot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse at the hands of Residents, and staff members. The facility further failed to report the abuse to the state agency accurately and timely, failed to fully investigate the abuse, failed to protect new victims from abuse, and further failed to implement their abuse and neglect policies for multiple known Residents who were abused, (Residents #167, Male 1, Male 2, and Female 1, #77, #50, and #56) in a survey sample size of 57 residents. The findings included: 1. The facility failures described above resulted in the willful abuse of Resident #167 and 3 other Resident victims who collectively were abused by Resident #86 on 5 occasions, (one Resident twice). Resident #167 (victim 1) was admitted to the facility on [DATE]. Diagnoses included: Motor vehicle accident with traumatic brain injury, vertebral fractures, dissection if the carotid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse at the hands of Residents, and staff members. The facility further failed to report the abuse to the state agency accurately and timely, failed to fully investigate the abuse, failed to protect new victims from abuse, and further failed to implement their abuse and neglect policies for multiple known Residents who were abused. (Residents #167, Male 1, Male 2, and Female 1, and #77) in a survey sample size of 57 residents. The findings included: 1. The facility failures described above resulted in the willful abuse of Resident #167 and 3 other Resident victims who collectively were abused by Resident #86 on 5 occasions, (one Resident twice). Resident #167 (victim 1) was admitted to the facility on [DATE]. Diagnoses included: Motor vehicle accident with traumatic brain injury, vertebral fractures, dissection if the carotid artery,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review and facility documentation, the facility staff failed to implement the abuse policy and report an allegation of abuse for one (1) resident (Resident #77) in a survey sample of 57 Residents. The findings included: For Resident #77 the facility staff failed to report and investigate allegations of abuse in a timely manner. Resident # 77 was admitted to the facility on [DATE] with diagnosis that included chronic embolism and thrombosis, mood disorder, insomnia, dysphasia, muscle, wasting and atrophy, chronic obstructive, pulmonary disease, polyneuropathy, major depressive disorder, chronic kidney disease, fibromyalgia, chronic diastolic heart, failure, hypertension, chronic pain syndrome, and generalized anxiety disorder. Resident # 77's most recent MDS (Minimum Data Set) dated, 4/23/25, scored Resident #77 as having a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating mild cognitive impairment. Resident #77 was also coded as requiring extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to investigate, prevent, and correct repeated willful abuse at the hands of Resident #86. The facility further failed to report the abuse to the state agency accurately and timely, and failed to implement their abuse and neglect policies for multiple known Residents who were abused. (Residents #167, Male 1, Male 2, and Female 1) in a survey sample size of 57 residents. The findings included: The facility failures described above resulted in the willful abuse of Resident #167 and 3 other Resident victims who collectively were abused by Resident #86 on 5 occasions, (one Resident twice). Resident #167 (victim 1) was admitted to the facility on [DATE]. Diagnoses included: Motor vehicle accident with traumatic brain injury, vertebral fractures, dissection if the carotid artery, tracheostomy with status post ventilator support, seizures, atrial fibrillation, dysphagia 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 the resident record review, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 57 residents (Resident #156), in the survey sample. The findings included: Resident #156 was originally admitted to the facility 2/8/2025 and readmitted [DATE] after a right above the knee amputation (RAKA). The resident's current diagnoses included atherosclerosis, diabetes and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #156's cognitive abilities for daily decision making were intact. In MDS section GG0130. Self-Care the resident was coded as requiring supervision or touching assistance with eating, oral hygiene, rolling from left to right, sitting on side of bed to lying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for two (2) Residents (Residents #86, and #143) in a sample of 57 residents. The Findings included: 1. For Resident #86, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed correctly prior to admission. Resident #86 was admitted on [DATE] with diagnoses including: Schizophrenia, bipolar disorder, mood disorder, and anxiety disorder. Physicians orders for medications were reviewed and revealed psychotropic medications actively being administered for anxiety, ongoing behaviors to include alcoholism, agression and nightmares, and abuse to peers. The Resident's only Passar I was completed 3-25-25, one year after his admission and it was coded incorrectly. The Resident had serious mental illness, and the document refuted that. The Resident was an abuser, and his mental illness 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 clinical record review, staff interview and facility documentation review, the facility staff failed to develop and implement a comprehensive person-centered care plan consistent with resident needs for one (1) of 57 residents in the survey sample. The findings included: Resident # 56 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident # 56 required extensive assistance on staff for activities of daily living. Review of the clinical record was conducted 4/16/2025-4/28/2025.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a clinical record review and staff interviews, the facility staff failed to provide foot care for 1 of 57 residents (Resident #116), in the survey sample. The findings included: Resident #116 was admitted to the facility on [DATE] with diagnoses of but not limited to muscle weakness, major depressive disorder, left artificial hip, seizures and fibromyalgia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 03/18/25. Resident # 116's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #116 required assistance with Activities of Daily Living. On 4/16/2025 during an afternoon tour, Resident #116's was observed in bed on her back, both legs were bent laying open to either side with feet meeting in the middle bottom to bottom. Resident #116's toenails were thick, long with uneven edges. They were mostly brown in color with some yellowish areas. Resident #116 said she had seen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, and clinical record review, the facility staff failed to provide required care to prevent complications while requiring use of an indwelling catheter for two (2) of 57 residents (Resident #124, and #50), in a survey sample of 57 Residents. The findings included: 1. Resident #124 was originally admitted to the facility 3/22/25 after an acute care hospital stay. The resident's current diagnoses multiple advanced stage pressure ulcers, a-fib and obstructive uropathy. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/28/25 coded the resident as resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #124's cognitive abilities for daily decision making were severely impaired. At section H0100 A - the resident was coded for requiring use of an indwelling catheter. Physician orders dated 3/23/25 stated change the Foley anchor every week and as needed every night…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and facility documentation review, the facility staff failed to ensure adequate nutrition to prevent weight loss for one (1) Resident (#56) in a survey sample of 57 Residents. The findings included: For Resident # 56, the facility staff failed to recognize signs of weight loss, resulting in 39 lb. weight loss from 07/10/2024 - 4/03/2025. Resident # 56 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to: Septic Shock, Hypertension, Acute Metabolic Encephalopathy, Chronic Kidney Disease-Stage 3, Acute Embolism and Thrombosis of deep veins of right lower extremity, peripheral vascular disease and non-pressure chronic ulcer of right calf. The most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an assessment reference date (ARD) of 4/10/2025. Resident #56 was coded with a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairment. Resident # 56…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure the resident received the physician ordered milliliters (ml) of oxygen for one (1) of 57 residents (Resident #271), in the survey sample. The findings included: Resident #271 was originally admitted to the facility 04/17/25 after an acute care hospital stay. The resident's current diagnoses included Acute on chronic hypoxic respiratory failure status post tracheotomy, COPD advanced age, and acute on chronic diastolic heart failure. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/27/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #271's cognitive abilities for daily decision making were intact. Resident #271 was coded in Section C1., as requiring Oxygen therapy. The baseline care plan did not address the O2 concentrator. An interview was conducted with Resident #271 on 4/22/25 at 11:18 AM. Resident #271 stated she managed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and review of the clinical record, the facility staff failed to assess and attempt to use alternatives prior to the use of bedrails for one (1) of 57 residents (Resident #156), in the survey sample. The findings included: Resident #156 was originally admitted to the facility 2/8/2025 and readmitted [DATE] after a right above the knee amputation (RAKA). The resident's current diagnoses included atherosclerosis, diabetes and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #156's cognitive abilities for daily decision making were intact. In MDS section GG0130. Self-Care the resident was coded as requiring supervision or touching assistance with eating, oral hygiene, rolling from left to right, sitting on side of bed to lying flat,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide timely medication administration to one Resident (Resident #123) in a survey sample of 28 Residents. The findings included: For Resident #123, the Resident received her medications in March, April, and May 2025 Late, and in some cases hours after they were scheduled to be given. Resident #123 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews, the facility staff failed to ensure resources necessary to provide for the needs of the residents who resided at the facility were available. The findings included; On 4/24/25 at approximately 1:00 PM., a tour of the laundry room was conducted. Three industrial sized washing machines were observed. Employee U, laundry aide, said that only 2 out of the 3 washing machines were working, It's been about a year. On 4/24/25 at approximately 1:10 PM., a brief interview was conducted with the Housekeeping Director (HD)/Laundry Services Director. The HD said that he had made the administrator aware of the washing machine not working because the administrator has only been working for a few weeks. An observation of the laundry storage area (located through the HD's office) was conduted with the HD, multiple boxes were observed stacked on the floor. The HD said that they were boxes of linen. The HD was asked if he was aware that staff and residents were saying there was not enough linen on the floors, the HD said he was not informed. A document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of facility documents, the facility's staff failed to ensure the resident's mattress was compatible for the bedframe for 1 of 57 residents (Resident #119), in the survey sample. The findings included: Resident #119 was originally admitted to the facility 11/12/24 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Low Back Pain Unspecified. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/04/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #119 cognitive abilities for daily decision making were Intact. In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial to moderate assistance with rolling from left to right, sitting to lying and lying to sitting. The person-centered care plan dated 1/13/25 read that the resident the resident prefers to stay in…

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

Based on observation, interview, clinical record review and facility documentation the facility nursing staff failed to treat residents with dignity and respect for one of four residents in the survey sample and per the resident council. The findings included: On 3/12/24 at 3:45 PM an interview was conducted with Resident #2 who stated that the staff are coming into the Resident rooms without knocking, they are using ear buds and talking on the phone while providing ADL care, they are generally rude to residents. When asked if she could name anyone in particular, she stated that it in general they have a lousy attitude when working with residents. Although these behaviors were not observed during survey, the Resident Council minutes revealed the following: June 2023-Resident council minutes state poor customer service. July 2023-Aides customer service is poor. August 2023-Resident council minutes state staff playing around and too loud during bedtime hours. September 2023-Resident council meeting minutes reflect complaints of staff being on their cell phone while providing care.…

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

Based on observation, interview, clinical record review, and facility documentation review, the facility staff failed to inform the resident representative, when there was a change in condition for one resident in a survey sample of four residents. The findings included: For Resident #3, the facility staff failed to inform the resident's representative of the resident's fall from bed on 2/9/24. Resident #3 had a diagnosis of dementia. The most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/12/24 coded her BIMS (Brief Interview of Mental Status) score of 0, indicating rarely or never understood. On 2/12/24 at approximately 4PM Resident #3's daughter came to the room while the Surveyor was interviewing Resident #2 (Resident #2 is the roommate of Resident #3). When Resident #3's daughter came into the room Resident #2 greeted her and said Did they tell you that your mom fell out of the bed on Friday? Resident #3's daughter said No, no one called me, when did she fall? Resident #2 stated that it was about 2 or 3 AM. She stated she was awake the curtain was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure the residents right to a clean, comfortable, and homelike environment, for four (4) residents (Residents #4, #2,# 7, and #8) in a survey sample of eight (8) residents. The findings included: For Residents #1, #2, #7, and #8, the facility staff failed to maintain a comfortable homelike environment due to the lack of effective and efficient HVAC cooling system in the building. The following observations were made regarding Resident #1, who has Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. On 09/13/2023 at approximately 9:50 a.m., Resident #1 was in bed with his eyes closed, appeared to be asleep, dressed in a hospital gown, had a distinct odor of urine in the room, which was compounded by the warm humid air in the room. On 09/14/2023 at approximately 2:30 p.m., Resident #1 was observed in bed, awake, and alert. The resident was noted to have beads…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility staff failed to provide routine medications to one resident (Resident #6) in a survey sample of eight (8) residents. The findings included: For Resident #6, the facility staff failed to ensure the medication, Lorazepam, was available for administration as ordered by the physician. Review of the clinical record was conducted 09/12/2023 through 09/14/2023. Resident #6 was admitted to the facility in June 2022. Diagnoses included but were not limited to: anxiety disorder, schizophrenia, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the progress notes revealed the following documentation about medications being unavailable: Effective Date: 12/25/2022 11:25 Type: Orders - Administration Note Note Text : LORazepam Tablet 0.5 MG (milligrams) Give 1 tablet by mouth two times a day for anxiety may give when arrive per MD RP (medical doctor, Responsible Party) is aware. Effective Date: 12/24/2022 20:56 Type: Orders - Administration Note Note Text : LORazepam Tablet 0.5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, and clinical record review, the facility staff failed to ensure one resident (Resident # 4) of eight (8) residents in the survey sample was free of significant medication errors. For Resident # 4, the facility staff failed to ensure the medication, Medrol, was available for administration as per physician's orders. The findings included: Resident #4 was admitted to the facility in March 2023 and discharged in April 2023. Resident # 4's diagnoses included but not limited to diabetes, methicillin susceptible staphyloccoccus aureus with sepsis (MSSA), and diabetic foot ulcer. Review of the physician's orders revealed an order for the medication: Medrol Oral Tablet Therapy Pack 4 MG (milligrams) (Methylprednisolone) Give 4 mg by mouth give four times a day. The times of scheduled administration of the medication, Medrol, 4 milligrams by mouth four times a day, were documented on the medication administration record (MAR) as to be administered at 9:00 a.m., 12:00 noon., 6:00 p.m., and 9:00 p.m. Review of Resident #4's MAR revealed…

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

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for the facility in general. The findings included: For the facility, the facility staff failed to maintain a comfortable temperature throughout the entire building, failed to operate portable air conditioners safely in accordance to the manufacturer's instructions, and failed to maintain working ice machines on 2 of the 3 units. On 09/12/2023 during the initial tour of the facility, it was noted that each hall had 2 portable air conditioning units. The [NAME] unit felt much cooler than the East and Central units. Temperatures varied from 68 degrees on the [NAME] unit to 78.8 on the East and Central units. On 09/12/2023 at approximately 3:30 p.m., an interview was conducted with Employee E who stated the chiller runs the air on East and Central units; however, the [NAME] unit has its own air system. Employee E stated that the chiller has not worked properly since before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control program so the facility is free of pests. The findings included: For the facility in general, the facility staff failed to maintain an environment free of flies, gnats, fruit flies, ants, and roaches. From 09/12/2023 through 09/14/2023 flies and gnats were noted throughout the facility by Surveyors B and C in the conference room, the hallways, and residents' rooms. On 09/14/2023 at approximately 1:00 p.m., a large live cockroach was noted under a chair in the hall just outside the kitchen area. A review of the grievances revealed the following: 08/24/2023 - room [ROOM NUMBER] A - Resident states there are ants in her bed. 09/01/2023 - room [ROOM NUMBER] B - Resident requested pest control services. 09/01/2023 - room [ROOM NUMBER] - Resident requested pest control services. 09/05/2023 - room [ROOM NUMBER] B - Resident requests pest control services. 09/11/2023 - room [ROOM NUMBER] B -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, and clinical record review, the facility staff failed to review and revise the care plan for one resident (Resident #6) of eight (8) residents in the survey sample. For Resident #6, the facility staff failed to review and revise the care plan after a significant weight loss from July 2022 to October 2022. The findings included: On 09/12/2023, a review was conducted of Resident #6's clinical record. Review revealed Resident # 6 was edentulous, had difficulty swallowing, and was prescribed a mechanically altered diet. According to the Monthly Weight Report, Resident #6 had a 20.0093% decrease in weight between July 2022 and October 2022. There were no monthly weights documented in July 2022 and August 2022. The weights from June 2022 to January 2023 were: 01/06/2023 - 96.1 lbs. 01/03/2023 - 95.2 lbs. - Wheelchair 11/21/2022 - 95.2 lbs. 10/11/2022 - 100.0 lbs. 10/06/2022 - 96.7 lbs. 07/07/2022 - 118.2 lbs. 06/28/2022 -116.0 lbs. - Mechanical Lift 05/11/2022 - 117.0 lbs. 03/10/2022 - 110.8 lbs. Further review of weights taken…

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

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure care and services met professional standards of quality for 1 resident (Resident #2 ) in a survey sample of eight (8) residents. For Resident #2, the facility staff failed to follow physician's orders to weigh Resident #2 three times per week due to a diagnosis of congestive heart failure (CHF). On 09/13/2023 at approximately 12:00 p.m., an interview was conducted with Resident #2 who was asked about her diagnosis of CHF. She stated she was diagnosed when she was in her 40's and has had to watch her diet and weight frequently and watch for swelling of her legs and feet. When asked how many times per week she is supposed to be weighed she stated 3 times per week. When asked how she gets weighed, she stated, They are supposed to use the lift scale, but a lot of times they don't do it because they don't like getting the lift out and weighing me. A review of the clinical record revealed that Resident #2's weight was not documented from 05/11/2023 until 07/07/2023.…

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

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents received the necessary services to maintain good grooming, and personal hygiene for 1 resident (Resident #1) in a survey sample of eight (8) Residents. The findings included: On 09/12/2023 at approximately 2:15 p.m., an observation was made of Resident #1 in bed with eyes closed, appeared to be resting, and did not respond to the knock on door. The room smelled of urine and feces, which was compounded by the heat and humidity of the room. On 09/13/2023 at approximately 9:50 a.m., Resident #1 was in bed with his eyes closed, appeared to be asleep, and dressed in a hospital gown. As surveyor moved closer to the resident, there was a smell of body odor, and the room had a distinct odor of urine, which was compounded by the warm humid air in the room. On 09/14/2023 at approximately 2:30 p.m., Resident #1 was observed in bed, awake, and alert. The resident was noted to have beads of sweat on his forehead and was covered in a sheet and light blanket. When…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, and clinical record review, the facility staff failed to arrange transportation to medial appointments for 1 resident (Resident #5) in the survey sample of eight (8) residents. The findings included: For Resident # 5, the facility staff failed to ensure transportation was arranged for medical appointments. Resident #5 was admitted to the facility in July 2022. Resident #5's diagnoses included but were not limited to heart failure, respiratory failure with hypoxia, diabetes, hypertension, and chronic kidney disease. Review of the clinical record was conducted on 09/12/2023 and 09/13/2023. On 09/13/2023 at 9:30 a.m., an interview was conducted with Resident #5. He stated it was upsetting that transportation to appointments was always a problem. Resident #5 stated he has missed several appointments in the past and did not have transportation to return to the facility at times. Resident #5 stated he needed to keep the medical appointments when they were scheduled. The facility's sign-in/sign-out sheet 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, clinical record review, and facility documentation review, the facility staff failed to prevent a significant weight loss for one resident (Resident #6) of a survey sample of eight (8) residents. The findings included: For Resident #6, the facility staff failed to prevent a significant weight loss of 20.0093% within 90 days. In addition, the facility staff failed to recognize, evaluate, and address Resident #6's nutritional needs in a timely manner. Resident #6 was admitted to the facility in June 2022. Resident # 6's diagnoses included but were not limited to: failure to thrive, and dementia. On 09/12/2023, a review was conducted of Resident #6's clinical record. Review revealed Resident #6 was edentulous, had difficulty swallowing, and was prescribed a mechanically altered diet. According to the Monthly Weight Report, Resident #6 had a 20.0093% decrease in weight between July 2022 and October 2022. There were no monthly weights documented in July 2022 and August 2022. The weights from June 2022 to January 2023 were: 01/06/2023 - 96.1 lbs. 01/03/2023 -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to respond to Resident Council grievances. The findings included: The Resident Council President gave permission on 4-24-22 for surveyors to review the Resident Council minutes for the last 3 months prior to a meeting with the Council, planned for 4-25-22. Resident Council minutes were reviewed from January 2022 through March 2022. The minutes revealed ongoing concerns and complaints regarding: late food delivery and comes cold, quality and quantity of meals served, water and ice not being passed, call bells not answered timely, short staffing and agency staffing, and lack of care during the night shift. These concerns persisted over the course of the 3 months reviewed, and during the survey. On 4-25-22 at 11:00 A.M., a surveyor met with 5 members of the Resident Council. The Council stated that no one from administration ever comes to Council meetings, they say they are too busy, and nothing ever gets resolved. The Residents verbalized that the same issues and complaints remain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, and in the course of a complaint investigation, the facility failed to ensure that an RN (Registered Nurse) was on duty 8 hours per day 7 days per week. The facility had no RN on duty on 3-1-22, 4-21-22, and 4-24-22. The findings included: The facility staffing was reviewed for the prior 2 months before survey, as a result of multiple complaints of inadequate staffing. Review of the as worked schedule revealed that on 3-1-22, 4-21-22, and 4-24-22, no RN was scheduled to work, and none worked on at least those three occasions. On 4-24-22 at approximately 2:30 PM, an interview was conducted with the LPN in charge, who stated, no I am in charge by default I guess, we don't have an RN today. They will be here tomorrow. On 4-26-22 at 4:45 PM, an interview with the facility Administrator was conducted. She stated that staffing had been a struggle. She stated the facility had done a wage comparison last year and that staff were going to received a raise. She also stated a sign up bonus and referral bonus was added. The Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 4 Residents (Resident #10, 100, 127, and 135), in a sample of 5 Residents reviewed for immunizations. The findings included: On 4/25/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following: 1. Resident #10 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the flu or pneumonia vaccine status of Resident #85. Review of the misc. (miscellaneous) tab revealed no evidence of vaccine administration or offering of either. Review of the Medication Administration Records (MAR) revealed no evidence of the flu or pneumonia immunization being provided to Resident #85. 2. Resident #100 had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, and clinical record review, the facility staff failed to offer COVID vaccination(s) for Residents who were not vaccinated against COVID-19, for 2 Residents (Resident #127 & #100), in a sample of 5 Residents reviewed for immunizations. The findings included: 1. The facility staff failed to provide evidence that Resident #127 was offered, educated and provided/or declined COVID vaccination. On 4/25/22, a clinical record review for Resident #127 was conducted. This review revealed the following: Resident #127 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the COVID vaccine status of Resident #127. All of the progress notes for Resident #127 were reviewed, which included social work, nursing and medical providers, to include from admission through the date of review. There was no indication of Resident #127 being offered or educated on the benefit 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, facility documentation review, and clinical record review, and in the course of a complaint investigation, the facility staff failed to notify the Resident Representative of a change in condition and room changes for one Resident (Resident #305) in a survey sample of 58 Residents. The findings included: 1. For Resident #305, the facility staff failed to notify the family of two room changes and didn't notify the family of a new diagnosis of COVID-19 until two days later. On 4/24/22 and 4/25/22, a closed record review was conducted. This review revealed that on 12/8/21, Resident #305 tested positive for COVID-19. Review of the census tab of the chart revealed that Resident #305 had a room change on the same day. There was an additional room change noted on the census part of the chart that took place on 12/23/21. The nursing notes revealed an entry dated 12/8/21, that didn't mention the positive COVID test, nor the room change. An entry dated 12/10/21 at 10:59 AM, read, RP [responsible party] notified [Resident #305's name redacted] have [sic] positive 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.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Resident (Resident #133) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. For Resident #133, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #133 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, known as a demand bill. The findings included: Resident #133 was discharged from a Medicare covered Part A stay on 2/13/22, he remained in the facility. Review of the clinical record revealed the facility staff/social worker issued a NOMNC (notice of Medicare non-coverage) which noted, Resident #133's RP was notified of the notice and appeal rights on 2/11/22. The clinical record revealed no evidence of an ABN being issued. The progress notes made no reference to the NOMNC or ABN. On 04/26/22 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 observations, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise care plans for unplanned weight loss for Two Residents (Resident #105, and #110 ) in a survey sample of 58 Residents. 1. For Resident #105, the facility failed to specifically care plan Resident centered weight loss interventions. 2. For Resident #110, the facility staff failed to care plan weight loss interventions recommended by dietary, and failed to specifically care plan Resident centered weight loss interventions. Findings include: 1. Resident #105's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3-24-22, was a quarterly assessment. The document revealed the Resident had minimal cognitive impairment and further documented the Resident was on a Therapeutic Diet, and had no weight loss. The Resident was independent in eating, and required no assistance. The Resident's weight record was reviewed and revealed the following; 12-18-21 - 165.1 lbs standing 3-10-22 - 156.6 lbs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, record review, and in the course of a complaint investigation the facility staff failed to provide activities of daily living care to one resident, Resident #1400, in a sample of 17 residents. The findings included: Resident #1400 was a closed record review. On 06/08/22 at approximately 9:22 a.m., an interview was conducted with Staff L. Staff L stated that the point-of-care system (POC) was used to track whether or not residents receive a bath. On 06/08/22 at approximately 12 p.m., review of POC documentation showed that Resident #1400 did not receive a bath between the dates of 04/12/22 - to - 04/18/22. Per POC documentation the first bath Resident #1400 received was on 04/19/22. The Administrator and Regional consultants made aware on 06/08/22 at approximately 1:00 p.m. and stated that they have no other findings to submit. Complaint deficiency

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide necessary care and treatment as ordered by the physician to promote healing of a pressure wound for one Resident (Resident #28) in a sample size of 58 Residents. Specifically, the facility staff failed to: 1) Administer pressure wound treatments on 03/18/22, 03/19/22, 03/22/22, 03/24/22, 03/25/22, 03/28/22, 04/10/22, and 04/22/22 as ordered by the physician. 2) Apply an air mattress as ordered by the provider. The findings included: On 04/24/2022 at approximately 2:10 P.M., Resident #28 was observed in bed. Resident #28 was not on an air mattress. When asked about wounds and wound care, Resident #28 indicated that he had one wound on his right buttock and the dressing changes weren't being done consistently. On 04/24/2022 at approximately 2:20 P.M., this surveyor and Licensed Practical Nurse F (LPN F) entered Resident #28's room for an observation. LPN F assisted Resident #28 to reposition. The dressing on the right buttock 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 observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen therapy as ordered by the physician for 1 Resident, Resident #118, in a survey sample of 58 Residents. The findings included: For Resident #118, facility staff failed to change the oxygen tubing weekly as ordered. During initial tour on 4/24/22 at approximately 1:30 PM, Resident #118 was observed with oxygen being administered via nasal cannula at 2 liters per minute as ordered by the physician. The date on the oxygen tubing was 4/4/22. Resident #118 stated, it has been several weeks since anyone has changed my tubing. These findings were shared with the Facility Administrator and the Corporate Clinical Nurse at the End of Day Conference at approximately 5:30 PM on 4/24/22. The facility's policy for the maintenance of oxygen equipment was requested and received. Review of Resident #118's clinical record revealed a physician's order dated 1/17/2022 that read, Oxygen tubing change weekly (11-7) .every night shift every Monday. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to label and store medications in accordance with currently accepted professional standards for 2 medication carts (Cart (1,2) and Cart (2,3) out of 9 medication carts. The findings included: On 04/27/2022 at 11:30 A.M., Surveyor C reviewed the contents of Med Cart (2, 3) on the [NAME] Wing with Licensed Practical Nurse J. The following medications were opened and not dated: 1. Active liquid protein - two 32 ounce bottles 2. Robitussin - one 16 ounce bottle 3. Lidocaine viscous 2% solution 4. Miralax 8.3 Oz 5. Senna 237 milliliters 6. Megace suspension 16 fluid ounces On 04/27/2022 at approximately 12:00 P.M., Surveyor E reviewed the contents of Med Cart (2, 3) on the [NAME] Wing with LPN F. An inhalant for Resident #259 (Mometasone 50 mcg [micrograms]/act) was housed in a medication bottle labeled with Resident #258's name on it for Humalog 100 unit/10ml [milliliters]. Upon surveyor pointing out discrepancy, LPN F…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed, for 2 Residents (Resident #105, and #110) in the survey sample of 58 residents, to provide follow preferences and/or drinks for hydration. The Findings included: 1. For Resident #105, the facility staff failed follow the resident's preference for a water pitcher so that he could consume water at will. Resident #105's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3-24-22, was a quarterly assessment. The document revealed the Resident had minimal cognitive impairment and, was independent in eating, and required no assistance. On 4-24-22 at 12:20 P.M., an interview was conducted with Resident #105. His lunch tray had not been delivered, and he stated that his food was always late. He asked if the surveyor would bring him a drink of water, and stated he was thirsty. His room mate was sitting in a wheel chair between the foot of the two beds, and the two were watching television together. Both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, and facility documentation review the facility staff failed serve food in a sanitary manner for two out of six kitchen employees observed in the kitchen over the course of the survey. The findings included: On 04/24/22 at approximately 12:18 p.m. during the initial dining observation observed one out three dietary staff members - Staff O was observed eating at the steam table in the kitchen. Staff O threw food into air and caught the food with his/her mouth. As well, Staff O was not wearing a facial mask at the steam table, nor was Staff O wearing a hair net. On 4/26/22 at approximately 1:30 p.m. Staff N was noted to wear face mask incorrectly while carrying out duties in the kitchen at the steam tables. Staff N's mask was worn in such a manner that the staff member's nose was not covered by the mask. An interview with Staff L at approximately 1:35 p.m., was conducted Staff L stated the staff are to wear facial mask that cover the nose and mouth in the kitchen. As well, Staff L states staff are to wear hair nets at all times while in 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, facility documentation review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one Resident, Resident #154, in a survey sample of 58 Residents. The findings included: For Resident #154, the facility staff failed to maintain an accurate and complete clinical record, indicating the events and actions that occurred on [DATE], to include CPR (cardio pulmonary resuscitation) being performed. On [DATE] and [DATE], a closed record review was conducted of Resident #154's clinical record. This review revealed that Resident #154 had expired at the facility. The progress notes had the following entries: 1. [DATE] at 2:27 PM, Resident pronounced deceased at 1:41 [PM] via emergency personnel. [Family members of Resident #154's names redacted] both informed via phone. Awaiting family to give funeral home arrangements. UM [unit manager] and [Nurse Practitioner's name redacted] NP aware. 2. [DATE] at 5:11 PM, Resident was picked up by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, and clinical record review, the facility staff failed to conduct COVID-19 testing in accordance with the CDC recommendations for 15 facility staff and two Residents (Resident #11 and #104) in a survey sample of 58 Residents. The findings included: 1. The facility staff failed to conduct routine testing of facility staff who were not fully vaccinated for COVID-19. On [DATE], during the entrance conference, the facility staff was provided a copy of the entrance conference worksheet and asked to submit documentation related to COVID-19 testing, to include the facility's testing plan, log of the level of community transmission, and if there were any testing issues and contact with the local and state health departments with regards to testing issues. On [DATE], the facility submitted an employee vaccination matrix and employee testing records for [DATE], [DATE], and the month of [DATE]. During the survey, the employee vaccination matrix was noted to not be…

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

Based on staff interview and facility documentation review, the facility staff failed to 1) have an accurate system to track the immunization status of all facility employees, and 2) failed to ensure 100% of facility staff were vaccinated, the facility vaccination rate was 92.9%. 1. The facility failed to include all staff members on the vaccination tracking, therefore rendering it as incomplete. 2. The facility staff vaccination rate for COVID-19 was 92.9%. The findings included: 1. The facility failed to include all staff members on the vaccination tracking, therefore rendering it as incomplete. On 4/24/22, at approximately 11:30 AM, during an entrance conference held with the facility's corporate clinical nurse, the facility's staff vaccination matrix was requested. On 4/25/22 at 10:25 AM, the facility staff submitted a staff vaccination matrix. Review of this matrix revealed 181 facility staff members were listed. A review was then conducted by Surveyor F, using the as worked schedule for 4/24 and 4/25, as well as the facility submitted key personnel listing. This 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 clinical record review the facility staff failed to ensure 1 resident (Resident #260) of 57 residents in the survey sample was assessed to self administer medications. For Resident #260, a bottle of colace (for constipation) was observed on the over bed table. The findings included: Resident #260 was admitted to the facility on [DATE]. Diagnoses included constipation, chronic obstructive pulmonary disease, and dysphagia. As Resident #260 was new to the facility, a minimum data set assessment had not been completed. On 12/4/18 at 11:10 a.m., Resident #260 was interviewed in her room. She was seated in a wheel chair. The over bed table was in front of her. During the interview, a small bottle of colace was observed on the over bed table. On 12/5/18 at 8:20 a.m. Resident #260 was observed in her room eating breakfast. The bottle of colace had been removed from the over bed table. Resident #260's care plan was reviewed. It did not include any information regarding self…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility staff failed for 1 resident (Resident 358) in the survey sample of 57 residents, to provide the resident's caregiver with written discharge instructions and prescriptions for medications for continuity of care. The facility staff failed to provide Resident #358's caregiver with written discharge instructions and prescriptions for medications for continuity of care. The Findings included: Resident #358 was an [AGE] year old who was admitted to the facility on [DATE] and discharged home on 9/28/18. Resident#358's diagnosis included Cerebral infarction, Generalized Muscle Weakness, Aphasia, Dysphasia, Spinal Stenosis, Glaucoma, Heart Failure, Polyosteoarthritis, and Age-Related Physical Debility. The Minimum Data Set, which was a 30-Day Assessment with an Assessment Reference Date of 9/12/18 was reviewed. Resident #358 was coded as having a Brief Interview of Mental Status Score of 14, indicating intact cognition. In addition, she was coded as being totally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, clinical record review, and facility documentation, the facility staff failed to develop and implement comprehensive care plans for three residents (Resident #44, #23, #34) in a sample size of 57 residents. 1. For Resident #44, the facility staff failed to develop and implement care associated with contractures in bilateral hands. 2. For Resident #23, the facility staff failed to develop and implement care associated with contractures in bilateral arms and hands. 3. For Resident #34, the facility failed to develop and implement an individualized care plan that addresses contractures The findings include: 1. For Resident #44, the facility staff failed to develop and implement care associated with contractures in bilateral hands. Resident #44, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include paraplegia, idiopathic neuropathy, failure to thrive, age-related debility, and dementia. Resident #44 also had contractures both hands. Resident #44's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility staff failed for 1 resident (Resident 358) in the survey sample of 57 residents, to ensure that a written reconciliation of pre-discharge medications with the residents post discharge medications was done. For Resident #358, the facility staff failed to ensure that a written reconciliation of pre-discharge medications with the residents post discharge medications was done. The Findings included: Resident #358 was an [AGE] year old who was admitted to the facility on [DATE] and discharged home on 9/28/18. Resident #358's diagnosis included Cerebral infarction, Generalized Muscle Weakness, Aphasia, Dysphasia, Spinal Stenosis, Glaucoma, Heart Failure, Polyosteoarthritis, and Age-Related Physical Debility. The Minimum Data Set, which was a 30-Day Assessment with an Assessment Reference Date of 9/12/18 was reviewed. Resident #358 was coded as having a Brief Interview of Mental Status Score of 14, indicating intact cognition. In addition, she was coded as 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, clinical record review, and facility documentation the facility failed to act on pharmacy alerts to possible drug interactions for 1 Resident (Resident #260) in a survey sample of 10 Residents. For Resident # 260 the facility failed to act on pharmacy alerts of medications that were incompatible or known to alter the effects of Coumadin (a blood thinner). The findings include: Resident #260 is an [AGE] year old admitted to the facility on [DATE] with diagnoses of but not limited to; Pleural Effusion, Acute Respiratory Failure, (Chronic Obstructive Pulmonary Disease) COPD, Atrial Fibrillation, Coronary Artery disease, (Gastro-Esophageal Reflux Disease) GERD and diabetes. On 01/15/2019 a review of clinical records was conducted and it was found that on 01/11/2019 orders were entered into the computer for Resident #260 that include Coumadin (a blood thinner), Prilosec (a Proton Pump Inhibitor), Symbicort (an aerosol steroid based inhaler), Lexapro (an antidepressant), Bengay, Nystatin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, family interview, staff interview, clinical record review, facility documentation, and facility policy review, the facility staff failed to provide timely dental services for one resident (Resident #115) in a sample of 57 residents. The findings include: Resident #115, an [AGE] year old female, was admitted to the facility 02/06/2016. Diagnoses include Alzheimer's disease, anxiety, depression, diabetes, gastroesophageal reflux disease, dysphagia, failure to thrive, and age-related debility. Resident #115's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 10/31/2018. Resident #115's Brief Interview of Mental Status (BIMS) was coded as 6 out of possible 15 indicative of severe cognitive impairment. Functional status for eating and toileting was coded as requiring extensive assistance. Dressing and personal hygiene was coded as total dependence on staff for assistance. On 12/04/2018 at approximately 12:00 PM, the Resident was observed awake, lying in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed, for 1 resident (Resident #17) in the survey sample of 57 residents, to administer medications in a manner to prevent the spread of infection. For Resident #17, the nurse (LPN C) failed to perform proper handwashing technique prior to preparing and administering medications. The Findings included: Resident #17 was a [AGE] year old, who was admitted to the facility on [DATE]. Resident #17's diagnoses included Generalized Muscle Weakness, Unspecified Kidney Failure, Chronic Obstructive Pulmonary Disease, and Epilepsy. The Minimum Data Set which was an Annual Assessment with an Assessment Reference Date of 1/22/18 was reviewed. Resident #17 was coded with a Brief Mental Status Score of 14, indicating that she was cognitively intact. On 12/5/18 an observation was conducted of the medication administration process. Licensed Practical Nurse (LPN C) was present. At 8:25 A.M., LPN C 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.