Center for Living & Rehabilitation

Based on interview and record review, the facility failed to ensure that a resident with a nutritional problem was given nutritional supplements and appetite stimulants as ordered by a physician for one resident [Resident #106] of 7 sampled residents. Findings include: 1. Per review of Resident #106's medical record, the resident's diagnoses include cancer of the prostate and bone, and difficulty swallowing. Review of the resident's Care Plan reveals the resident is identified as at risk for malnutrition as I have increased nutritional needs with cancer treatment and altered skin integrity, poor appetite and intake, need for protein/nutritional supplement. Care Plan interventions include Provide me with my supplement as ordered: 8oz House Shake, 8oz Boost VHC and provide further nutrition interventions. Review of Physician Orders for Resident #106 include House shake in the afternoon for at risk for malnutrition and Megestrol Acetate Oral Suspension-Give 10 milliliters by mouth in the morning for Appetite stimulant. Review of Resident #106's Medication Administration Record [MAR]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain drug regimen reviews for one out of five sampled residents (Resident #88). Findings include: Per record review, Resident #88 had MRR [Medication Regimen Review] (a monthly review by the pharmacist for any medication recommendations made based on safety and patient specific diagnoses). Resident #88 had medication recommendations made from the pharmacist in June 2024, August 2024, September 2024, October 2024, December 2024, February 2025, and March 2025. Per record review of Resident #88's chart the resident did not have copies of MRRs for the months of June 2024, August 2024, and September 2024. Per record review of Pharmacy Drug Regimen Review-CLR policy [no revised or reviewed date] states, Facility: 1. Shall maintain all Drug Regimen Review recommendations along with prescriber's responses in an easily retrievable location for presentation to surveyors, upon request. 2. Shall file or drug review recommendations with the permanent medical record for each resident after one year. 3. Shall file the findings under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary maintenance services to ensure residents have a safe, clean, comfortable and homelike environment for 4 of 6 resident units. Findings include: An interview was conducted with the facility's Director of Maintenance [DM] on 2/12/25 at 10:26 AM. The DM reported that the facility utilizes a 'TELS' electronic system [TELS is a software program that facilitates maintenance work orders by allowing users to scan, upload, and access related work orders and repair history]. The DM reported that the facility uses the TELS to identify, report, acknowledge, assign, track, and complete facility maintenance issues and repairs. The DM stated that all staff in the facility have access to system and can access it through a computer or phone, and that all staff, including the DM, received education on using the system in the last month [January 2025]. A tour of the facility and interview was conducted with a facility staff member 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 and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice including prevention of complications from the resident's medical condition for 1 of 2 residents in the applicable sample [Resident # 1]. Findings include: Per record review, Res. #1 was admitted to the facility on [DATE] with diagnoses that included diabetic neuropathy [neuropathy is nerve damage that affects the hands and feet, often caused by diabetes or other conditions. Feet and other areas that lack sensation can become injured without the person knowing]. Review of the resident's Care Plan revealed the resident was identified upon admission on [DATE] as having an actual impairment to skin integrity including a right plantar [sole] foot wound. Review of Res.#1's medical record included a 'Clinical Evaluation' dated 12/18/24 which identified the right foot wound as present on admission but now resolved-wound healed and/or closed. Review of 'Skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to provide necessary maintenance services to ensure residents have a safe, clean, comfortable, and homelike environment for 6 of 6 resident units. Findings include: Per observation on 11/20/24 from 12:10 AM to 12:30 PM, all nursing units (Stark, [NAME], [NAME], Frost, [NAME], and [NAME]) needed multiple functional and cosmetic repairs in several resident rooms. * room [ROOM NUMBER]- There was a double electrical outlet receptacle and cover that was broken. One of the top plugs in the receptacle was also broken exposing the electrical wiring. There were two cords plugged into the bottom receptacles. A bulletin board had been removed from the wall and there was a large square of brown paint where the bulletin board had been. There were two pieces of plywood used as a wall covering, both boards were delaminating, exposing splintered wood. * Walls in rooms R6, R13, R11, C4, C5, C6, C7, C8, C10, 102, 103, 113, 115, 120, and 126 had unrepaired holes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and policy review, the facility failed to implement policies for screening employees by not completing the required criminal background checks for 4 out of 5 sampled staff. Findings include: Facility policy titled Background Checks, Arrests, and Conviction Notification, last revised on 3/4/2024, indicates that the facility will conduct criminal background checks for all current employees at least annually. Per review of employee human resource files, 4 of 5 sampled direct care staff who have worked at the facility for over a year do not have annual federal background checks completed. Per interview on 3/20/24 at 11:45 AM, the Human Resource Staff explained that there is no system in place for obtaining annual national background checks for staff that have been here over a year but has worked with the Administrator to implement completing annual background checks in starting in June.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue the drugs for 1 of 5 sampled residents (Resident #13); failed to ensure that there was a specific diagnosis/condition documented in the medical record for psychotropic medications for 1 of 5 sampled residents (Resident #100); and failed to ensure that residents who use psychotropic drugs are accurately monitored for behaviors and medication side effects (Residents # 13, #100, and #30). Findings include: Facility policy titled, Psychotropic Medication Use, last modified on 10/2/2022, states, Psychotropic medications should only be given when necessary to treat a specific diagnoses and documented condition. GDR will be attempted using the following guidelines and limits (unless clinically contraindicated): 1. For all psychotropic medications: within the first year following admission or initiation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and record review, the facility failed to ensure that all residents were treated with respect and dignity by all staff for one of 29 sampled residents (resident #87). Findings include: Per interview on 3/19/24 at approximately 2:00 PM, Resident #87 stated that about a month ago a staff member swore at them during an interaction. They stated that the interaction upset them at the time, but that they worked it out and there is no ongoing concern with the Licensed Nursing Assistant (LNA). Per record review, Resident #87 has a care plan for [Resident #87] can be verbally aggressive, yelling at staff, swearing at staff, and gestures aggressive towards staff r/t Poor impulse control initiated on 5/6/23. Per an MDS assessment on 1/10/24, Resident #87 has a Brief Mental Status Score of 15 (high congnitive function). Per review of the incident documentation from the facility, the LNA confirmed that they swore at the resident during an interaction in which Resident #87 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, interview, and record review, the facility failed to notify the resident's physician of significant weight loss for 1 of 29 sampled residents (Resident #100). Findings include: Record reveals that Resident #100 has diagnoses that include Alzheimer's disease, hypothyroidism, and dementia. Resident #100's nutrition care plan states that s/he remain at risk for malnutrition in view of need for nutrition supplementation, created on 7/29/23 and has the following goal, My weight will be stable within 125-135 lbs, revised on 12/8/23. Interventions include, Monitor my weights and labs as available, created on 7/29/23, and Notify my MD of any significant weight changes PRN [as needed], created on 7/29/2023. Resident #100's care plan includes interventions for monitoring, documenting, and reporting weight changes in relation to hydration status and thyroid medications. Record review shows that Resident #100 weighed 126.4 pounds on 2/5/2024. The next weight documented for Resident #100 was 105.8 pounds on 3/8/2024. This weight loss of 20.6 pounds, over approximately one…

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

Based upon interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 resident [Res.#101] of 2 sampled residents regarding abuse allegations. Findings include: Per review of the facility's Investigation Summary of an incident involving Res.#101 on 2/17/24, the Witness Statement by a Licensed Practical Nurse (LPN) present reveals on 2/17/24, a staff member was witnessed accusing Res.#101 of tampering with their ostomy appliance, causing the resident's eyes to tear up. The resident stated they didn't touch it but the staff member continued as if it were [Res.#101's] fault. The witness statement continues As [Res.#101] lay naked on the bed with poop all over [her/him], [Staff member] berated [her/him]: again, tears welled up in [Res.#101's] eyes. After 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 upon interview and record review, the facility failed to assure that further potential abuse, neglect, exploitation, or mistreatment did not occur after an allegation of abuse for 1 resident [Res.#101] of 2 sampled residents regarding abuse allegations. Findings include: Per review of the facility's Investigation Summary of an incident involving Res.#101 on 2/17/24, the Witness Statement by an LPN present reveals on 2/17/24, a staff member was witnessed accusing Res.#101 of tampering with their ostomy appliance, causing the resident's eyes to tear up. The resident stated they didn't touch it but the staff member continued as if it were [Res.#101's] fault. The witness statement continues As [Res.#101] lay naked on the bed with poop all over [her/him], [Staff member] berated [her/him]: again, tears welled up in [Res.#101's] eyes. After the staff member left the room, Res.#101 told the LPN That [wo/man] has been accusing me all week and stated it makes me feel like crap. The LPN's witness statement is dated 2/17/24 at 11:25 PM. A review of the LPN's Supervisor's statement, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that staff implemented a resident's individualized comprehensive care plan related to fall prevention for 1 of 29 residents in the sample (Resident #266). Findings include: Per observation on 3/18/24 at approximately 3:00 PM, Resident #266 had multiple bruises on their face in varying degrees of healing. Per record review, Resident #266 was admitted to the facility on [DATE] after sustaining a significant fall at their Senior Living facility. Resident #266 sustained a fall on 3/12/24 in their bedroom and a second fall on 3/17/24 in the nurse's station after breakfast. Per Resident #266's care plan, it included a focus for [Resident #266] has had an actual fall with minor injury, to [their] face with bruising prior to admission. An intervention was placed on the care plan on 3/19/24 after the second fall in the facility, which states lay resident down after meals. Per observation on 3/20/24 at 12:15 PM, Resident #266 was being fed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to review and revise Care Plans regarding prevention of future falls for 1 of 29 residents sampled (Res.#62). The facility also failed to ensure that the Resident's comprehensive care plan was reviewed and revised by the interdisciplinary team for one of 79 sampled residents (Resident #79). Findings include: 1.) Per review of Res.#62's medical record, the resident was admitted to the facility with diagnoses that include Parkinsonism, dementia, muscle weakness and a history of falling. Review of the facility's 'Fall Prevention and Protocol' policy [last modified 3/11/22] reads Every resident admitted to [the facility] will have the Fall Risk Evaluation done for the first 24 hours of admission or readmission . and after each fall. Upon admission, Res. #62 scored a '21', with the facility policy listing If the score is 10 or greater, the resident/patient is considered to be at HIGH risk for falls and should be evaluated by the interdisciplinary care team…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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/representative interview, staff interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living without assistance receives the proper level of assistance for one of 29 sampled residents (Resident #100). Findings include: Per record review, Resident #100's care plan states that s/he has potential for impairment to skin integrity [related to] dementia, incontinence, with the intervention to Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short, created on 10/20/23. Per observation on 3/18/24 at 3:44 PM, Resident #100 is in bed, wearing just a brief on his/her lower body. His/her nails are very long nails and appear to have a dark brown substance underneath most of the nails. S/He is tugging at his/her brief and groin area. Per observation and interview on 3/20/24 at 1:40 PM, a Licensed Nursing Assistant (LNA) confirmed that Resident #100's nails were very long and dirty and explained that they should be shorter because s/he scratches himself/herself. S/he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist residents in making audiology appointments for 1 of 29 sampled residents (Resident #71). Findings include: Record reveals that Resident #71 was admitted to the facility on [DATE]. Per his/her care plan, initiated on 9/2/2021, Resident #71 has a communication problem related to a hearing deficit. Per interview on 3/18/2024 at 1:32 PM, Resident #71 requested that this surveyor speak loudly because they are hard of hearing and needs hearing aids. Resident #71 explained that s/he was frustrated because s/he has been trying to get new hearing aids for a while. S/He had an audiology appointment on Friday that was canceled by the provider and s/he hasn't heard any follow up on when it is rescheduled for. Record review reveals a care plan meeting note dated 1/31/2024 indicating that Resident #71 needs an appointment to get new hearing aids. A 3/15/24 progress note confirms that Resident #71 did have an appointment with audiology early that morning but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to ensure an environment free of Accident hazards regarding implementing interventions to reduce hazards and risks and monitoring for effectiveness related to falls for Res.#62, and regarding falls with a possible brain bleed for Res.#266, 2 of of 29 sampled residents. Findings include: 1.) Per review of Res.#62's medical record, the resident was admitted to the facility with diagnoses that include Parkinsonism, dementia, muscle weakness and a history of falling. Review of the facility's 'Fall Prevention and Protocol' policy [last modified 3/11/22] reads Every resident admitted to [the facility] will have the Fall Risk Evaluation done for the first 24 hours of admission or readmission . and after each fall. Upon admission, Res. #62 scored a '21', with the facility policy listing If the score is 10 or greater, the resident/patient is considered to be at HIGH risk for falls and should be evaluated by the interdisciplinary care team for identification 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 interview and record review, the facility failed to ensure that residents maintain acceptable parameters of nutritional status as evidenced by the facility failing to obtain weights as care planned and identify weight loss for 1 of 29 sampled residents (Resident #100). Findings include: Facility policy titled Weight Assessment Monitoring, last modified on 3/11/2022 states, Nursing staff weighs resident/patient per nursing protocol weekly, or as ordered for the first 4 weeks after admission. If resident/patient is identified to be at risk for weight loss/gain, weights may be continued weekly and reviewed by Interdisciplinary Care Team for appropriate intervention. 1. Record reveals that Resident #100 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, hypothyroidism, and dementia. Resident #100's nutrition care plan states that s/he remain at risk for malnutrition in view of need for nutrition supplementation, created on 7/29/23 and has the following goal, My weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 create an individualized person-centered plan to render trauma informed care to a resident with a personal history of trauma for 1 of 29 residents (Resident #30). Findings include: Per observation on 3/18/2024 at 4:18 PM, Resident #30 was seen lying in his/her bed, awake, with the covers pulled to his/her chin. S/He was crying in his/her bed; when asked if s/he was okay, Resident #30 appeared afraid and was weeping while s/he tried to explain concerns s/he had about his/her mother and father and their skin. S/He repeated incoherent phrases about the skin of her father and the skin of her mother and how s/he needed to get it to them and they would not be happy. When asked if s/he would be eating dinner in the dining room, s/he explained that s/he would very much like to go into the dining room. His/her voice was shaky when speaking and continued to weep while she spoke. Per observation on 3/19/2024 at 2:25 PM, Resident #30 was in bed crying. On approach, s/he appeared distressed and was sobbing about his/her…

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

Based on staff interview and record review, the facility failed to ensure that residents are free from significant medication errors for one of 29 sampled residents (Resident #266) as evidenced by administration of an anticoagulant for a resident with a brain bleed. Findings include: Per resident #266's record, Resident #266 sustained a fall on 3/12/24 at approximately 5:40 PM. The fall was unwitnessed, and Resident #266 was sent to the emergency room for evaluation. Per a nursing progress note from 3/13/24 at 7:32 AM, the emergency room nurse called to report that the Resident has a brain bleed that was 3mm in diameter, and that they were unable to determine if it was a result of the fall or not. Per a documented secure conversation note on 3/13/24 at 11:52 AM, Resident #266's physician sent a message at 7:14 AM stating [Resident #266] has a small intracranial hemorrhage (brain bleed), stable on second CT (cat scan) 6 hours later. We'll be holding anticoagulation . In the same documented secure conversation note there is an additional message from the facility NP sent at 11:52 AM…

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

Based on staff interview and record review, the facility failed to ensure that each resident's medical record contains documentation that indicates that the resident or resident's representative was provided education regarding the benefits and potential side effects of the COVID-19 immunization before receiving the vaccine for 1 of 5 sampled residents (Residents #100). The facility also failed to ensure that each eligible resident receives the COVID-19 vaccine for 1 of 5 sampled residents (Resident #6). Findings include: 1. Per record review, resident #100 received the Fall 2023 COVID-19 immunization on 3/20/2024. There is no evidence in the record that Resident #100 or their representative was provided education regarding the benefits or side effects of the immunization. Per interview on 3/20/24 at approximately 4:30 PM, the facility's Infection Preventionist confirmed that no documentation could be located in the record to validate that Resident #100 was provided education regarding the benefits or side effects of the immunization prior to vaccination. 2. Per record review,…

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

Based on staff interview and record review the facility failed to ensure that 1 of 4 residents (Resident #3) in the applicable sample were treated with dignity and respect related to refusal of care. Per record review Resident #3 is frequently resistive and combative, which includes fighting, yelling, screaming, punching, pinching, and kicking staff during episodes of care. Review of nursing progress notes reveals that staff continue to provide care to Resident #3 even when s/he is resisting and refusing care. A care plan focus initiated on 2/11/21 states that the resident is at risk for a behavior problem r/t severe agitation history secondary to Alzheimer's and bipolar disease. [S/He] does threaten to bite staff at times . Can be combative with care . There are no specific interventions for staff to implement related to combativeness with care. A fall risk care plan focus revised on 6/15/23 does reflect an intervention of If [name omitted] is being resistive and or combative with care please make sure [s/he] is safe and leave the room and re approach [him/her]. Review of Progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow a care plan and to revise a care plan for 1 out of 4 Residents sampled (Resident #1). Findings include: Per record review resident #1 has the following medical diagnoses, Alzheimer's Disease, bipolar disorder, and anxiety disorder. A progress note written on 8/5/23 reflects that after lunch Resident #1 was the aggressor in a resident-to-resident altercation. Resident #1 was sitting in the lobby waiting for his/her spouse to arrive. Staff who were assisting another resident witnessed Resident #1 strike another resident. Staff then intervened and redirected them from each other. A current care plan revised on 6/30/2023 reveals that Resident #1 has a behavior problem and requires 1:1 when out of room. The care plan includes the following interventions: 1) Direct monitoring (1:1) when out of room; 2) Deer Oaks (psychiatric services) consult; 3) Avoid lobby prior to meals . Resident #1's August 2023 Medication Administration Record (MAR) reflects an order with the start date of 7/5/23 that states 1:1 close…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and provide mental health services for 2 of 4 residents sampled (Residents #1 and #2). Findings include: 1. Per record review on 08/05/23, Resident #1 was involved in a resident-to-resident altercation as the aggressor in the altercation. A review of the care plan revealed Resident #1 had an intervention in place for a consult with Social Services and psychiatric services as indicated for a behavior modification plan, and another intervention for Deer Oaks services (Mental Health Counseling service) for support. Upon further review, Resident #1 did not have a physician order for Deer Oaks services and there was no documentation found that Resident#1 had received these services. Per interview with the facility social worker on 9/25/23 at 1:00 PM, it would be expected that there would be a Physician order for Deer Oaks and then a referral would be made. Social Services confirms that Resident # 1 does not have an order for Deer Oaks and the services have not been initiated. Per interview on 9/25/23 5:40 PM…

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