Premier Rehab and Healthcare at Berlin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that physicians and other providers (as delegated to per regulation) review the residents' total program of care, including skin, pressure injury risk and prevention and treatment plan at each visit as required for 3 of 7 sampled residents (Resident's #1, #3, and #4). This is a repeat deficiency for this facility, with this violation cited during a previous recertification survey dated 8/19/24. Findings include: 1) Per review of Resident #1's medical record, s/he was admitted to the facility with a diagnosis of failure to thrive and a history of pelvic fracture on 1/27/25. On 1/27/25, a nursing assessment revealed a 12 on the Braden scale for predicting pressure risk, identifying Resident #1 as a high risk for pressure injury. Resident #1 had no pressure injuries at time of admission. A 3/14/25 Advanced Practice Registered Nurse (APRN) progress note dated 3/14/25 reveals that Resdeint #1 has a stage 2 pressure injury on their sacrum. Residnet…

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

Based on interview and record review, the facility failed to ensure that licensed nurses have the specific competencies necessary to care for residents' needs as identified through resident assessments and the plan of care for 4 of 5 sampled nurses. Findings include: Per review of 5 licensed nurses' employee education files, 4 Licensed Practical Nurses (LPN) did not have evidence that they had been assessed for skin or wound assessment competencies. Per facility policy titled Staff Competency Plan, last reviewed on 8/2024, reads, It is the policy of the facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job .The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process. Evaluating competency of staff is accomplished through the facility's training program. The Facility Assessment (an assessment that determines what resources are necessary to care for the residents competently during both day-to-day operations and emergencies), dated 1/31/25, section Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify the resident's power of attorney (POA) of a change in condition on 3/14/25, related to a new pressure ulcer identified on his/her sacrum for 1 resident in the sample of 7 (Resident #1). This is a repeat deficiency for this facility, with violations cited during two previous recertification surveys, dated 2/6/25 and 3/1/24. Findings include: Per review of Resident #1's medical record, s/he was admitted to the facility with a diagnosis of failure to thrive and a history of pelvic fracture on 1/27/25. A nursing assessment dated [DATE] identified Resident #1 as a high risk for pressure injury with a Braden score of 12. Per the admission assessment dated [DATE], s/he was frequently incontinent of urine and bowel, and dependent for care, including repositioning. Per Resident #1's MDS assessment dated [DATE] there was no evidence of a pressure injury upon admission. According to the medical record, Resident #1 developed a stage 2 pressure injury 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, interview, and record review, the facility failed to provide sufficient staffing to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This has the potential to impact all residents. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 08/19/24. Findings include: 1. In an interview on 2/3/25 at 11:00 AM, Resident #25 stated that when they request as needed medications or personal care, the wait time is often over one hour, or the staff member forgets to return at all. Resident #25 said this sometimes leaves me laying in bed in pain waiting for medication, or just feeling forgotten about. Resident #25 also said that the wait time and staffing issues are noticeably worse on the weekends. Per observation and interview on 2/6/25 at approximately 11:00 AM, a Unit B's medication cart computer showed 8 residents highlighted in red. The LPN working this cart explained that the red indicates that an order is due and is over…

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

Based on observation and , it was determined that the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. Findings include: Per observation of the kitchen on 02/03/25 at 10:34 AM, there were food debris on the steam table. There were cobwebs on the coffee pot and carafe storage rack. There were food debris on the stainless-steel covers located on the steam table. An area on the inside of the microwave door appeared to have been burned off. There were food debris on the inside of the microwave and food debris under the microwave on the counter. Per observation there were water marks and food debris on all the stainless-steel counters. There were food debris under the stove burners and around the grill top. Food debris were on the clean plate holding device. The floor of the kitchen had visible remnants of food under all the stainless-steel working surfaces and in front of the stove and the grill. Per observation of the kitchen's dry storage area, the following items were found to be expired: There…

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

Based on interview and record review the facility failed to conduct and document a facility wide assessment. This has the potential to impact all residents. Findings include: Per the Division of Licensing and Protection, the facility changed ownership on 12/16/2024. During the recertification entrance conference on 2/3/25 at 10:28 AM, the Director of Nursing (DON) was asked to provide a copy of their Facility Assessment. Later, when the DON provided the facility assessment, it had not been documented as reviewed by anyone. The DON explained that it has not been reviewed by the leadership team yet. In an interview on 2/6/25 at 11:00 AM with the Regional Director of Clinical Operations [RDCO], The RDCO stated that the facility assessment was still a work in progress and had not been actually implemented yet. This surveyor questioned the RDCO about a document mentioned in the draft of the facility assessment that was provided to this surveyor titled staff development and training plan and the RDCO stated that the document had not been created yet. In an interview with the Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of policies and procedures, it was determined that the facility failed to maintain facility-wide systems for the prevention, identification, and control of infection and communicable disease of residents, staff and visitors through surveillance, staff training and following established policies and procedures related to changing oxygen tubing, hand washing, cleaning and disinfection of reusable equipment, proper use and disposal of PPE (personal protective equipment), and facility cleanliness. Findings include: 1. Per observation on 2/3/25 at approximately 11:30 AM, the Unit Manager was observed in the general milieu without a mask in place. Review of facility policy and procedure titled, Transmission-Based (Isolation) Precautions, date implemented: 5/2022, date reviewed/revised: 07/2024, under subtitle, Policy Explanation and Compliance Guidelines, #11. Droplet Precautions and 12. Airborne Precaution, state,states, a. Intended to prevent transmission of pathogens…

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

Based on interview and record review, the facility failed to develop and implement comprehensive care plans for 2 of 2 sampled residents (Resident #27 and Resident #35) related to palliative care; and failed to implement care plan interventions related to supervision for 1 of 20 sampled residents (Resident #363). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 08/19/24 and 03/01/24. Findings include: 1. Per record review, a Medication Regimen Review (MRR) dated 9/16/24 for Resident #27 stated Currently receiving cyclobenzaprine [used to treat pain and stiffness due to muscle spasms] as a standing order. Long term use not recommended due to high risk of anticholinergic side effects including drowsiness, dizziness, and dry mouth. Please evaluate continued need and consider taper to PRN [as needed] for 1 week then discontinue, if appropriate. The Nurse Practitioner disagreed, writing Palliative care patient as the reason. Per record review, Resident #27's Care Plan does not include any focus or interventions…

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

Based on observation, interview, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of group, individual, and independent activities to meet the interests of and support the well-being of each resident as evidenced by a lack of engaging activities both in and out of resident rooms for 6 of 20 sampled residents (Residents #2, #19, #26, #35, #53 and # 563). Findings include: 1. Per observation, no group activities were seen during the four days this survey was conducted, 02/03/25 through 02/06/25. Residents were, however, observed sitting and moving freely in hallways and public spaces. Observations on Unit A included two residents sitting side by side (not social distancing) in the hallway for the majority of the survey. Observation on 2/3/25 of Unit B revealed many residents sitting in the general milieu in wheelchairs, on the couch and in chairs. Some were conversing, others were visiting with family members, some had food and drink and others were sitting alone, There were no activities going on at this time. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 7 residents [Resident #363, Resident #463, Resident #57, Resident #52, Resident #312, Resident #8, and Resident #64] of 14 sampled residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Findings include: 1. Per interview with the Unit Manager on 2/5/25 at 10:09 AM, Resident #363 was identified as being on fifteen-minute checks. The Unit Manager discussed that the resident has past trauma. Per record review of Resident #364's care plan states, [Resident #363] is at risks for or is experiencing adjustment issues related to: Change in customary lifestyle and routineness and/or difficulty accepting placement in center, loss of status and/or freedom associated with transition .[Resident #363] reports past…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident for 3 of 20 sampled residents (Residents #19, #46, and #463). This is a repeat deficiency for this facility, with violations cited during the previous recertification surveys dated 08/19/2024. Findings include: The Facility's Dental Services Policy revised 10/24, states It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The Dental Policy includes the following definitions: Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures.…

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

Per observation, interview, and record review, the facility failed to determine whether it is clinically appropriate for residents to self-administer medications for one sampled resident (Resident #364). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 08/19/24 and 03/01/24. Findings include: Per observation on 2/4/25 at 9:18 AM, Resident #364 was seen sitting in bed with three pills on his/her lap. S/he was asking for more water. Per interview with LPN [Licensed Practical Nurse] #1 on 2/4/25 at 9:18 AM, it was confirmed that LPN #1 left the pills at the resident's bed side. Per record review, the medications left at the bedside were Docusate 100 mg tablet [a medication used for constipation], Metformin 500 milligram tablet [a medication used for Diabetes] and Bupropion ER 150 milligram tablet [a medication used to treat depression]. Per record review, Resident #364 did not have Docusate 100 milligram tablets on his/her MAR [Medication Administration Record]. Per the facility's Medication Administration…

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

Based on interview, and record review, it was determined that the facility failed to provide resident choices specific to aspects of their life that were important to them for 1 resident in a standard survey sample of 20 residents. (Resident #563). Findings include: Per interview on 2/5/25 at approximately 12:00 PM, Resident #563 stated she/he was recently admitted to this facility. She/he stated they came in on a Friday, 1/31/25, and spent the whole weekend in bed. Resident #563 stated they did ask staff to please get them up and was told by staff that until they (the resident) is assessed by PT (physical therapy) staff are not allowed to get them out of bed. The resident stated they had to use a bedpan because staff were not allowed to help the resident to the bathroom and she/he was upset about being there for rehab but not being able to get out of bed for 2 days. Per interview on 2/5/25 at approximately 12:40 PM, Resident #563's spouse met surveyor outside resident's room to discuss her/his concerns. They stated that their spouse was admitted on Friday, 1/31/25 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a physician was notified of symptoms requiring an as needed medication whose prescription had expired for one of 20 sampled residents (Resident #25). Findings include: In an interview on [DATE] at 11:00 AM, Resident #25 stated that they had not been given an PRN [as needed] dose of anxiety medication that they had requested on [DATE] in the AM. Resident #25 stated that they were told that the prescription had expired during the week and that the prescriber had gone home for the weekend and there was nothing the nurse on duty could do to remedy this issue. Resident #25 revealed that they had requested their PRN anxiety medication several times on both [DATE] and [DATE]. Resident #25 stated they were told by the nurse on duty [DATE] and by the nurse on duty [DATE] that Resident #25 would have to wait until Monday [DATE] for the prescriber to come back in to renew the prescription. Resident #25 said this caused them to have even more anxiety,…

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

Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident #25) was provided necessary assistance to carry out activities of daily living related to grooming and personal hygiene. Findings include: Per observation on 2/3/25 at 11:00 AM, Resident #25's fingernails were approximately 1/2 inch long with a dirt like substance under each nail, except for the right pointer finger where the nail appeared to have broken off with small amounts of a red/brown blood like stain on the tip of the finger. Per interview with Resident #25 on 2/3/25 at 11:03 AM, Resident #25 stated that they are unable to cut their own fingernails and has asked the staff to help cut them. Resident #25 also stated it's very obvious that they need cutting, it was the first thing you noticed when you [surveyor] walked in here. Resident #25 revealed the last day or two they had caught their fingernail on their blanket and accidentally ripped the tip off causing a small amount of pain and bleeding. When asked if any staff provided care for this incident,…

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

Based on observation, interview, and record review, the facility failed to ensure that one of 20 sampled residents (Resident #20) received proper treatment and assistive devices to maintain hearing abilities. Findings include: In an attempted interview with Resident #20 on 2/4/25 at 10:00 AM this surveyor was unable to communicate with the resident. Resident #20 was pointing at their ears and stated they could not hear. This surveyor approached very close to the resident and spoke in a very loud clear voice and Resident #20 stated they were still unable to hear. Resident #20 then stated their hearing aids were dead. Based on record review, Resident #20's has the following physician order apply hearing aids to both ears every AM. Resident #20's care plan reads, resident is hard of hearing and resident has hearing aids to assist with hearing. Resident #20's care plan also includes interventions that cannot be performed without the ability to hear and communicate such as maintain communication that is consistent, open, and respectful and listen to resident without judgment or guilt. On…

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

Based on observation, interview, and record review the facility failed to ensure medication error rates were not 5% or greater. The total error rate for all observations was calculated at 43%. There were 30 medication administration opportunities observed resulting in 13 errors for 1 of 7 sampled residents (Resident #12) due to the late administration of 12 medications, not following administration recommendations, and not administering an as needed (PRN) medication. Findings include: Per observation on 2/6/25 at 10:18 AM, a Licensed Practical Nurse (LPN) began the process of administering medications to Resident #12. When the LPN opened the Medication Administration Record (MAR) for Resident #12 on their computer, the resident's medications were highlighted in red. Listed below are the Physician orders for the medications listed on the MAR and the time when they were observed administered. The following medications were administered to Resident #12 at 10:23 AM: Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for A-fib [Atrial fibrillation; heart rhythm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, the facility failed to ensure medications were properly stored for 1 of 7 sampled residents (Resident #364). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 08/19/24 and 03/01/24 Findings include: Per observation on 2/4/25 at 9:18 AM, Resident #364 was seen sitting in bed unsupervised with three pills on his/her lap. S/he was asking for more water. Per record review, the medications left at the bedside were Docusate 100 mg tablet [a medication used for constipation], Metformin 500 milligram tablet [a medication used for Diabetes] and Bupropion ER 150 milligram tablet [a medication used to treat depression]. Per record review, Resident #364 did not have Docusate 100 milligram tablets on his/her MAR [Medication Administration Record]. Per interview with LPN [Licensed Practical Nurse] #1 on 2/4/25 at 9:18 AM it was confirmed that the LPN left the pills at the residents' bed side. The LPN confirmed on 2/4/24 at 9:24 AM that the medications were left 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 observation, interview, and record review the facility failed to ensure safe and sanitary storage, handling, and consumption of one of 20 sampled residents (Resident #4). Findings include: In an interview on 2/3/25 at 2:38 PM Resident #4 stated that they do not eat any of the food that the facility provides. Resident #4 said The food here is garbage, it is inedible. Resident #4 explained that every 10 days they have a friend take them to the store and they purchase all their own food using personal funds. Resident #4 stated that they keep some of the food in their own room and items that require refrigeration are stored in a refrigerator on the unit in a locked room. Resident #4 said that they give food requiring refrigeration to the staff on unit and the staff puts the food in the refrigerator. Per interview on 2/4/25 1:00 PM Resident #4 stated that someone had thrown out all their food from the unit refrigerator without notifying them. Resident #4 stated that most of this food was in unopened packages and was not close to expiration date. Resident #4 was distressed 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 interviews and record review, the facility failed to appoint an administrator licensed by the state to be responsible for managing the facility. This has the potential to negatively impact all residents. Findings include: Per facility policy titled Governing Body, implemented on 5/2022, states The governing body will appoint an administrator who is: a. Licensed by the state where required b. Responsible for the management of the facility. c. Reports to and is accountable to the governing body. Per interview on 1/22/25 at approximately 11:00 AM with the Chief Nursing Officer (CNO), s/he explained that the Interim Administrator left their role on 1/5/25 and a new Administrator resumed the position on 1/6/25 through 1/9/25. S/he revealed that the facility had been operating without a licensed administrator since the Administrator resigned on 1/9/2025. S/he explained that on 1/13/25, a new Director of Nursing was hired and they were had been designated to act as the interim administrator. Per the [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to provide necessary housekeeping and maintenance services to ensure residents have a safe, clean, comfortable, and homelike environment for 2 of 2 open resident units. Findings include: 1. Per observation on 8/6/24 from approximately 11:00 AM to 2:00 PM, both nursing units (Units A and B) needed multiple functional and cosmetic repairs, and both unit's floors were generally messy in several resident rooms and common areas. a. Baseboard radiators were damaged in rooms A4, A7, A9, A17, A19, A22, B4, B7, B9, B14, B 15, B16, and the Unit A living room. Baseboard radiators were detaching from the wall in rooms A24 and B24. b. Wall had unrepaired holes or unpainted spackle in rooms A1, A5, A16, B4, B7, B9, B13, B15, B16, B18, B23, and the Unit B hallway near the nurses' station. c. Chair rails were damaged in rooms A24, B3, B4, and B24. d. Furniture, including dressers and side table, had peeled laminate exteriors and/or missing handles in rooms A10, A19, B8, B14, B15, and B25. e. Closets doors loose or missing handles and/or…

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

Based on observation and interview, the facility failed to provide dignity and respect for 4 of 23 sampled residents (Residents #2, #6, #5, and #103) and residents on 1 of 2 units (Unit B). Findings include: 1. Per observation on 8/5/24 at 3:12 PM, Res. #103 was observed being transferred by a Licensed Nurse's Aide [LNA] by pulling their wheelchair backwards from the dining room down the hallway to the resident's room. The resident's feet were dragging and 'bumping' along the floor, and the resident's urine drainage bag and tubing from the suprapubic catheter were also dragging on the floor during the transport. Per interview with the LNA on 8/5/24 at 3:15 PM, The LNA confirmed s/he had pulled the resident backwards in the wheelchair and that the resident's feet and catheter bag were dragging on the floor. The LNA stated [Res.#103] don't pick up [h/her] feet. 2. During an interview with Resident #5 on 8/5/24 at approximately 3:15 PM, s/he stated that s/he is not taken to the bathroom by staff but is told use your pull up to pee or poop. When the Resident was asked how they feel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents or resident representatives received written notification of the facility bed hold policy on residents' discharge to the hospital for 1 of 23 residents sampled. (Resident #5), Findings include: During an interview on 08/06/24 at approximately 8:26 AM Resident #5 stated they s/he had recently been to the hospital however s/he was not able to state the reason s/he was sent to the hospital or how long they s/he were there. Record review revealed that the resident had been sent to the ED [Emergency Department] on 8/1/24 for a potential UTI [urinary tract infection]. There was no evidence of a bed hold notice being sent to the POA [Power of Attorney] in the medical record. Per interview with the Clinical Market Advisor, on 8/7/24 at approximately 4:30 PM s/he could not find a bed hold notification for the resident's transfer to the ED on 8/1/24 but stated s/he would keep looking. On 8/7/24 at 4:45 PM the Clinical Market Advisor stated…

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

Based upon observation, interview, and record review, the facility failed to implement care plan interventions related to catheter care and monitoring for 1 [Res.#103] and failed to identify and implement interventions for an actual urinary tract infection and the use of antibiotic therapy for (Resident #5) for 2 of 2 sampled residents. Findings include: Per record review, Res.#103 medical conditions include a suprapubic catheter. [A suprapubic catheter is a medical device that helps drain urine from your bladder. It enters your body through a small incision in your abdomen.] (https://my.clevelandclinic.org/health/treatments/25028-suprapubic-catheter). Per observation on 8/5/24 at 3:12 PM, Res.#103 was observed being pulled backward in h/her wheelchair from the dining room to his/her room by a Licensed Nursing Aide [LNA]. The resident's urine drainage bag and tubing from the suprapubic catheter were dragging on the floor during the transport. Per interview, the LNA confirmed Res.#103's catheter bag and tubing were both touching the floor while the resident was being moved. Per…

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

Based on observation, interview, and record review the facility failed to revise the care plan for 1 of 23 residents sampled (Resident #16), related to significant medication error and symptomatic eye pain. Findings include: Per record review Resident #16 was admitted to the facility in November of 2023 with diagnoses that include, Pseudophakia OU (artificial lens in both eyes) mild retinopathy (bleeding in the small vessels in the eye), and dry eyes. During an interview with Resident #16 on 8/6/2024 at 2:00 PM s/he stated that s/he received drops for his/her ears to both of his/her eyes. Resident #16 stated It hurt like hell and burned. An emergency room Physician note written on 07/23/2024 states that Resident #16 was seen in the emergency department today for a recent chemical exposure to [his/her] eye . We flushed [his/her] eyes and have started [him/her] on some antibiotic eyedrops to prevent infection . If [she/he] experiences worsening symptoms, especially worsening pain, please return to the emergency room. Per the facility policy titled Person Centered Care Plan revised on…

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

Based upon observation, interview, and record review, the facility failed to implement infection control measures related to catheter care for 1 resident [Res.#103] of 2 sampled residents. Findings include: Per record review, Res.#103 medical conditions include a suprapubic catheter. [A suprapubic catheter is a medical device that helps drain urine from your bladder. It enters your body through a small incision in your abdomen.] (https://my.clevelandclinic.org/health/treatments/25028-suprapubic-catheter). Per observation on 8/5/24 at 3:12 PM, Res.#103 was observed being pulled backward in h/her wheelchair from the dining room to the resident's room by a Licensed Nursing Aide [LNA]. The resident's urine drainage bag and tubing from the suprapubic catheter were dragging on the floor during the transport. Per interview, the LNA confirmed Res.#103's catheter bag and tubing were both touching the floor while the resident was being moved. Per review of Res.#103's Care Plan, the resident is identified as requires suprapubic catheter- resident is high risk for Urinary Tract Infection. Per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to Identify a resident's past history of trauma, and/or triggers which may cause re-traumatization for 3 applicable residents (Residents #22, #31, and #28). Findings include: 1. Per record review, Resident #22, age [AGE], was admitted to the facility on [DATE] with diagnoses that include dementia, anxiety, and depression. Per interview on 2/26/24 at 11:12 AM, Resident #22 said that s/he is very sad. S/He explained that his/her past was hard and at one point was held against his/her will and pressured into religion and became teary. Later in the interview Resident #22 expressed frustration and anger that the facility will not let him/her go outside and said it feels like they keep him/her in his/her room all the time. S/He stated, people here don't give a [explicative] about me. All I do is go to the bathroom, eat, and watch TV. Per review of Resident #22's transfer of care note, his/her active problem list, which was signed by a physician on 9/30/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that records are complete, accurately documented, readily accessible, and systematically organized related to dental records for all residents and medication reviews for 3 of 5 sampled residents (Residents #16, #32, and #31). Findings include: 1. Per interview on 2/26/24 at 10:39 AM, Resident #28, admitted to the facility on [DATE], explained that they had been seen at the facility by a dentist in regard to getting him/her bottom dentures. Per review of Resident #28's medical record, there were no dentist notes that documented that s/he had been seen by a dentist or that a plan was made to get him/her bottom dentures. On 2/28/24 at 3:22 PM, the Administrator showed this surveyor a large binder that contained notes for all the residents seen by the dentist. S/He explained that the Dentist had asked that notes all be kept in the same spot. The Administrator confirmed that all residents' dental records, including Resident #28, were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents' right to be free from sexual abuse by a resident for 2 applicable residents (Resident #31 and #38). Findings include: Per record review, Resident #28 was admitted to the facility on [DATE] with diagnoses that include chronic pain, epilepsy, depression, and anxiety. Resident #28's care plan states s/he has the potential to demonstrate verbal behaviors related to: History of verbal outbursts directed toward others (e.g., use of abusive language, pattern of challenging/confrontational verbal behavior), Ineffective coping skills, i.e., poor anger management, revised 2/11/24, with an intervention to monitor and report any of the following behaviors; verbal outbursts directed toward others (e.g., use of abusive language, pattern of challenging/confrontational verbal behavior), Ineffective coping skills, i.e., poor anger management, revised on 8/8/23. Per a 2/10/24 progress note, Resident #28 was having abnormal behaviors. 2/12/24…

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

Based on interview and record review, the facility failed to ensure that allegations involving abuse are reported no later than 2 hours to the Administrator of the facility and the State Survey Agency for 2 applicable residents (Resident #31 and #38). Findings include: Per interview on 3/1/24 at 10:38 PM, Licensed Nurse #1, explained that s/he witnessed Resident #28 masturbating in Resident #31 and #38's room around 3:00 AM on 2/13/23. See F600 for more information. S/He explained that s/he reported this event to the Unit Manager, the Nurse Educator, and Licensed Nurse #2 (Licensed Nurse #1's replacement at change of shift). Per interview on 3/1/24 at 9:10 AM, the Administrator explained that s/he became aware of Resident #28's sexually inappropriate behavior while investigating while investigating a separate resident to resident altercation involving Resident #28. This statement, taken by Licensed Nurse #2 on 2/13/23, states When I came in this morning to take report form the night nurse, I was told that [Resident #28] was found in another [gender omitted] resident's room…

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

Based on interview and record review, the facility failed to initiate and investigate an investigation of an alleged violation of sexual abuse for 2 applicable residents (Resident #31 and #38). Findings include: Per record review of a facility investigation of an allegation of resident to resident physical abuse, a statement taken on 2/13/23 from Licensed Nurse #2 states When I came in this morning to take report form the night nurse, I was told that [Resident #28] was found in another [gender omitted] resident's room masturbating on the floor between the bed and the window. That [gender omitted] patient did not appear to be aware that [s/he] was in the room according to the night nurse. Per interview on 3/1/24 at 10:38 PM, Licensed Nurse #1 confirmed that s/he found Resident #28 in Resident #31 and #38's room masturbating around 3:00 AM on 2/13/24. S/He explained that while s/he did not know how much Residents #31 or #38 saw of Resident #28's behavior or if Resident #28 had other inappropriate behaviors, s/he is sure that at least Resident #38 was upset and yelling get out, 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 upon observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards for 1 resident [Res.#11] of 34 sampled residents. Findings include: Per record review, Res.#11 was admitted to the facility on [DATE] with diagnoses that include 'Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right dominant side' [complete paralysis and partial weakness after a stroke affecting the right side of the body]. Per review of Progress Notes for Res.#11, on 11/5/23, Res.#11 was evaluated for a blister after burn from coffee spillage on left inner thigh area. Blister is now broken, 2 by 2 centimeters and patient is in burning pain. Res.#11's Care Plan identified the resident as requires assistance/is dependent for Activities of Daily Living care related to: generalized weakness, impaired mobility. After the blistering burn from the coffee spill, the intervention Ensure resident is provided with coffee cup with secured lid was added to the Care Plan 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 interview and record review, the faciliy failed to implement their policy regarding COVID-19 immunizations by failing to obtain vaccine supply and systematically provide education, obtain consents, and offer vaccines in a timely manner to all residents. Findings include: 1. On September 12, 2023, the Centers for Disease Control (CDC) announced the release of the new 2023-24 COVID vaccine and indicated the vaccine would be available later that week. Per facility policy, titled COVID-19 Vaccination, the facility will provide the opportunity to receive COVID-19 vaccinations following Centers for Disease Control and Prevention (CDC) recommendations subject to availability, to patients/residents .unless the immunization is medically contraindicated or the individual has already been immunized. The policy states this will be done under the Medical Director's authorization, with patient consent. Per interview on 1/25/24 at 9:30 AM, the facility's designated Infection Preventionist (IP) stated that the first 2023-24 COVID vaccines were not ordered until the 3rd week of November,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide mental health services and individualized care approaches that address the assessed needs of the resident for 1 applicable resident (Residents #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] with diagnoses that include depression and anxiety disorder. A 10/2/2023 hospital discharge summary indicates Resident #2 was being treated for his/her anxiety and depression during his/her hospital stay. The note explains that s/he was discharged on 75 mg sertraline daily and s/he May ultimately benefit from continued increased dose of 150 mg daily [of sertraline; anti-depressant] due to combined anxiety/depression. Resident #1's care plan, created on 10/3/2023, states that s/he 'is at risk for distresses/fluctuating mood symptoms related to depression, anxiety, PTSD [post-traumatic stress disorder]. Per interview on 1/24/2024 at 11:19 AM, Resident #1's Representative explained that that s/he visited Resident #1…

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

Based on interview and record review, the facility failed to provide pharmaceutical services to meet each resident's needs and the facility failed to collaborate with the pharmacist to assure that effective policies and procedures were established and implemented for one applicable resident (Resident #2). Findings include: 1. Per record review Resident #2 has diagnoses that include schizophrenia and physician order for clozapine [antipsychotic] tablet 100 mg Give 1 tablet by mouth two times a day for schizophrenia, with a start date of 4/7/2023. Per Resident #2's Medication Administration Record (MAR), Clozapine was last administered on 10/5/2023. Resident #2 did not receive pharmaceuticals to treat his/her schizophrenia until risperidone (an antipsychotic) was ordered and administered on 10/13/2023, 8 days after Resident #2 last received an antipsychotic for schizophrenia. The abrupt stop of Clozapine, with no immediate replacement, put Resident #2 at risk for medical complications and increased behaviors. See F760 for more information. Review of the manufacture's Clozapine safety…

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

Based on interview and record review, the facility failed to ensure that residents are free of any significant medication errors for one applicable resident (Resident #2) related to the abrupt stop of a medication that should have been titrated down and the discontinuation of a medication due to the facility's inability to acquire the medication, putting Resident #2 at risk for medical complications and increased behaviors. Findings include: Per record review Resident #2 has diagnoses that include schizophrenia. Resident #2's care plan, created on 9/15/2022, states that s/he is at risk for complications related to the use of psychotropic drugs, antipsychotic, anti-manic, anti-depressant. Record review reveals a physician order for clozapine [antipsychotic] tablet 100 mg Give 1 tablet by mouth two times a day for schizophrenia, with a start date of 4/7/2023. Review of the manufacture's Clozapine safety information packet indicates that the medication is only available through a restricted program called the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program run by the…

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

Based on observation and interview, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 5 residents on A Wing (Residents #2, #3, #4, #5, and #6) as evidenced by not providing access to call lights so that they may make their needs known. Findings include: Based on observation on 11/1/23 at approximately 9:30 AM, Resident #2 was eating breakfast in bed. Their juice had spilled all over their over-bed tray and their legs. When questioned about this, Resident #2 said that they hadn't been able to tell anyone about it because they didn't have their call light. They then pointed to the floor behind their bed where the call light string was laying out of reach. An LNA (licensed nursing assistant) was alerted to the issue and they confirmed the call light string was out of reach. Additional observations at that time revealed that Residents #3, #4, #5, and #6 also had call light strings laying on the floor behind their beds out of reach. Resident #6's call light string did not have a clip to secure the string to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents are free from chemical restraints for one of three sampled residents (Resident #1) as evidenced by administration of medications without proper indication for use and despite experiencing side effects. Findings include: Per record review, Resident #1 was admitted on [DATE] with diagnoses of Traumatic Brain Injury and Dementia. Progress notes and behavior monitoring flowsheets in the record document a steady increase in behavioral incidences throughout admission in which Resident #1 was physically aggressive with staff. Behaviors included punching, kicking, and grabbing at staff. A provider progress note on 10/5/2023 states, Due to continued agitation, [Resident #1]'s scheduled Ativan (an antianxiety medication) will be discontinued and [they] will be started on diazepam (a different antianxiety medication) 10 mg BID (twice a day). A new order for Diazepam Oral Tablet 10mg - Give 10 mg by mouth two times a day for behavioral issues…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and record review, the facility failed to ensure that services provided meet professional standards of quality as evidenced by failing to follow physicians' orders for one of 3 sampled residents (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus without complications and an acquired absence of the right leg above the knee (amputation). On 8/24/23, Resident #1's attending physician ordered the following: Blood sugar checks AC (before meals) and HS (before bed) call if blood sugar less than 70 or greater than 400. Per interview on 10/17/23 at approximately 10:15 AM, Resident #1 stated that their blood sugar levels are not checked at the facility, but at home they have a device they use that constantly monitors their blood sugar levels. Per review of Resident #1's medical record, Resident #1's blood sugar was checked once since admission on [DATE]. There was no evidence 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 staff interview and record review, the facility failed to ensure that all professional staff are licensed, certified, or registered in accordance with applicable State laws for 1 or 4 sampled licensed nurses (RN #1). Findings include: Per record review, Registered Nurse #1 (RN #1) worked at the facility as a Nurse Educator from 7/10/2023 through 8/18/2023. RN #1's employee records revealed an unencumbered license in the state of New Hampshire. There was no evidence that RN #1 had a license to practice as a nurse in the state of [NAME]. According to [NAME] State Licensing and Operating Rules for Nursing Homes, professional staff must be licensed, certified, or registered in accordance with applicable laws. According to the [NAME] Office of Professional Regulation, In order to practice in [NAME], a nurse must possess either an active [NAME] license or multistate license. Per interview on 10/17/2023, at approximately 1:00 PM, the Market Clinical Advisor confirmd that the facility failed to check RN #1's…

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

Based on staff interviews and record review, the facility failed to ensure 1 of 2 applicable residents (Resident #2) was free from abuse. Findings include: Per record review and confirmed via interview, a Registered Nurse (RN) physically abused Resident #2 on 08/14/23. Per review of the facility's own investigation and confirmed by witness statements, an RN removed Resident #2 from the dining room when the resident became agitated during lunch. The RN wheeled the resident in their wheelchair back to their room and RN was observed by staff to be holding the resident's arms down. A skin assessment later conducted on Resident #2, by the Nurse Practitioner found bruising consistent with fingerprints on both arms. Based on corrective actions completed prior to the onsite, this citation is designated as past non-compliance. The following actions were completed by the facility: 1. A report was made to The Agency as required on 08/15/23 and notification was made to Adult Protective Services (APS) on 08/15/23. 2. The Registered Nurse (RN) involved, was immediately suspended, and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and record review, the facility failed to ensure each resident was treated with respect and dignity during personal care so as to not cause pain or discomfort for 3 of 3 sampled residents (Residents #1, #2, and #3). Findings include: 1. Per record review, Resident #1 has a history of chronic right rotator cuff injury and requires assistance of 1-2 staff for mobility needs. Per the Nurse Practitioner's Acute Visit note from 8/9/2023, the note reads that Resident #1 described what happened and why [their] shoulder hurts. Reports last night after being repositioned by lifting [them] under the arms . request for shoulder X-ray. X-ray records show no new injury to the right shoulder. Per review of the facility reported incident investigation documentation, LNA 2 (licensed nursing assistant) notified the Administrator on 8/9/2023 that Resident #1 reported rough handling by LNA 1 during the 8/8/2023 night shift. Resident #1 confirmed, during interview with the Administrator, that the episode of personal care caused them pain in their shoulder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and a review of policies, the facility failed to maintain compliance with Professional Standards related to inaccurate documentation for two of three sampled residents [Residents #1 and #2] Findings include: 1. Per record review, Resident #1 was admitted to the facility on [DATE] with a diagnosis of spinal cord compression due to prostate cancer that has spread to her/his spine and other bones, and a diagnosis of Type 2 Diabetes. S/he was transferred and admitted to the hospital on [DATE] with a diagnosis of sepsis (sepsis is a life-threatening condition in which the body responds improperly to an infection; Sepsis can rapidly progress to septic shock, causing damage to the lungs, kidneys, liver, and other vital organs). A Nursing note dated 7/29/23 indicates the resident was pale in color and they could not obtain an Oxygen Saturation reading (measurement of Oxygen level in the blood) and indicates a foul odor and darkening of the tissue were observed during a dressing change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and record review the facility failed to provide weekly showers and assist with incontinence care as needed for 1 of 3 residents in the applicable sample (Resident #3). Findings include: Per interview with Resident #3 on 8/10/2023 at 2:00 PM the following was communicated: S/He had rung their call light at 11:30 this morning and requested assistance with changing her/his soiled pants. S/he gets up between 5:30 and 6:30 AM every day. S/he had been up since 6:30 AM this morning and has not received help as of 2:00 PM. The resident reports that s/he is incontinent of urine and 8 hours is a long time to be up without being changed. This is not new and happens just about every day. The resident stated that the staff come in, say they need to get someone to help them, shut off the call light, leave, and don't come back. Resident #3 was observed sitting in a wheelchair while s/he explained that staff use a Hoyer (mechanical lift) to put her/him back to bed to change her/him. During this interview, a Licensed Nursing Assistant (LNA) entered the room 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.