St. Johnsbury Health & Rehab

Based on the interview and record review, the facility failed to provide a sufficient number of Licensed Nursing Assistants (LNAs) and Registered Nurses (RN) for 8 consecutive hours a day to provide nursing services, considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. This is a repeat deficiency cited during a facility Recertification Survey on 12/11/24. Findings include:Per interview on 7/16/2025 at 12:19 PM, the Assistant Director of Nursing (ADON) revealed that she frequently works overtime to provide the facility with RN coverage. She is one of the two staff members who are trained to draw blood for labs. The facility has 30 outstanding labs that were ordered between 6/30/25 and 7/14/25 that have not been processed. She states she cannot keep up with them as there are not enough staff.Per record review, a Missed Medications Report between the dates of 5/17/25-7/17/25 revealed 2,177 pages of missed medications and treatments.Per review of the late medication report provided on 7/17/25, contained 6,017…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it used the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 18 days from 5/1/2025 to 7/13/2025. Findings include:A review of the facilities' staffing schedules from 5/1/25 to 7/13/25 revealed 8 days with no RN scheduled [6/21, 6/28, 6/29, 7/4, 7/5, 7/6, 7/12, 7/13] and 10 days [6/24, 6/30, 7/1, 7/2, 7/3, 7/7, 7/8, 7/9, 7/10, 7/11], where there were not 8 consecutive hours of RN services.Per interview with the Administrator on 7/17/2025 at 4:09 PM, where she confirmed that the facility did not have a Registered Nurse scheduled or present in the building for a minimum of 8 consecutive hours daily as required by regulation on the 18 days above.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure that residents were free from significant medication errors by not administering all medications as prescribed, and in a timely manner. This issue was determined to be widespread, potentially impacting all residents in the facility. Findings include: 1.Review of Resident #'1's diagnosis list revealed s/he had a diagnosis of diabetes mellitus. The Resident's hospital Discharge summary dated [DATE] revealed that the Resident was a long-term user of insulin and Insulin dependent diabetes mellitus: Status: Chronic. The hospital discharged the Resident to this facility with a medication list titled, Home Medication List that included insulin glargine [Lantus Solostar U-100 Insulin] 28 unit subcutaneous every morning. Last Taken: [DATE] 07:57 28 units. This Home Medication List consisted of 13 medications with dose and instructions/orders. Next to each medication was a check mark and on page #1 handwritten Entered PCC [Point…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed have a functioning system to obtain laboratory services which has the potential to impact all residents and failed to obtain laboratory services to meet the needs of its residents for 4 of 14 sampled residents (Residents # 3, #5, #6, and #7). Findings include:1.) Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic neuropathy, unstageable pressure ulcer to the right heel, and history of repeated falls. A transfer of care note (TOC) dated 4/30/25 reveals that Resident #6 had a fall on 4/24/25. A fall assessment included in the 4/30/25 TOC indicated that s/he is a fall risk, scored at 10 (a score of 4 or more is considered a risk for falling) based on 3 or more diagnosis, prior history of falls within 2 months, incontinence, visual impairment, impaired functional mobility, environmental hazards, poly pharmacy, pain affecting level of functioning, and cognitive impairment. 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, it was determined that the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to deficiencies that resulted in immediate jeopardy (F600 and F841). In addition, there are several repeat deficiencies. The identified failures by the lack of administrative oversight for a large amount of regulatory requirements in multiple areas of compliance put all residents at risk for more than minimal harm. Findings include:1.Interviews with the Medical Director; past and present, VP of Clinical Services, Administrator, and facility staff reveal that Resident #1 did not receive quality care and services specific to their long-standing diagnosis of Diabetes Mellitus, and they did not receive insulin although they had been a chronic user of insulin per their hospital discharge summary, ED (Emergency Department) notes/documentation, and interview with the Resident's son. See F655 for additional information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview of the facility's Quality Assurance and Performance Improvement Program (QAPI), the facility failed to address all systems of care in a comprehensive manner by identifying problems and opportunities for improvement in the areas of treatment/services specific to meeting required regulatory visits; appropriate staffing levels: ensuring there was an RN in the building for 8 consecutive hours 7 days/week; residents care supervised by a physician to include required regulatory visits; laboratory orders were performed timely; neglect (cited at immediate jeopardy level); administration; and Medical Director (cited at immediate jeopardy level). The identified failure to have an effective Quality Assurance and Performance Improvement Program to identify problems and provide system oversight has the potential put all residents at risk for more than minimal harm. Findings include:During a complaint investigation with 3 complaints the facility was found to have deficient practices that resulted in 2 citations at immediate jeopardy level and 15 deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview it was determined that the facility failed to report 2 allegations of abuse of a resident to the State Survey Agency in a timely manner. Findings include:1. Per review of complaint #24087 regarding Resident #13, received on 5/29/25 from a provider who stated in their complaint that Resident #13 had alleged abuse by a facility staff member. The complaint also stated that the allegations of abuse were reported to the facility Director of Nursing (DON) on 5/28/25 by the provider over the phone. During an interview on 6/4/25 at approximately 1:00 PM the Director of Nursing confirmed that she had been contacted by the provider, however, was not provided with specific details and did not think she needed to report the allegation to the State agency. The facility Administrator filed a report on 6/4/25 after learning of this incident from the survey team. 2. Per record review, Resident #12's physician progress notes dated 6/21/25 revealed the resident had mentioned to the provider an allegation of staff to resident abuse where a CNA slapped (pronoun…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a baseline care plan that includes the instructions needed to provide effective and person-centered care that includes communication, behavioral symptoms, psychotropic medication drug use, activities, dental care, pressure ulcers, falls, and diabetic care needs for 6 of 14 residents in the sample (Residents #1, #2, #3, #4, #6, and #8). Findings include: 1.) Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic neuropathy, unstageable pressure ulcer to the right heel, and history of repeated falls. A transfer of care note (TOC) dated 4/30/25 reveals that Resident #6 had a fall on 4/24/25. A fall assessment included in the 4/30/25 TOC indicated that s/he is a fall risk, scored at 10 (a score of 4 or more is considered a risk for falling) based on 3 or more diagnosis, prior history of falls within 2 months, incontinence, visual impairment, impaired functional mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans for 2 residents of 14 (Residents #1 and #8). This is a repeat deficiency for this facility, with the violation cited during the previous complaint survey, dated 11/19/24. Findings include:1.) Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic neuropathy, unstageable pressure ulcer to the right heel, and history of repeated falls. A transfer of care note (TOC) dated 4/30/25 reveals that Resident #6 had a fall on 4/24/25. A fall assessment included in the 4/30/25 TOC indicated that s/he is a fall risk, scored at 10 (a score of 4 or more is considered a risk for falling) based on 3 or more diagnosis, prior history of falls within 2 months, incontinence, visual impairment, impaired functional mobility, environmental hazards, poly pharmacy, pain affecting level of functioning, and cognitive…

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

Based on record review and interview the facility failed to update comprehensive care plans in a timely manner for 6 of 14 sampled residents. (Resident ID #'s 2, 3, 4, 5, 9, and 10). Findings include: Per record review on 7/21/25 of Resident #2's current care plan revealed the review due date was 7/3/25 and the target completion date was 7/10/25. Per record review on 7/21/25 of Resident #3's current care plan revealed the review due date was 6/25/25 and the target completion date was 7/7/25.Per record review on 7/21/25 of Resident #4's current care plan revealed the review due date was 6/24/25 and the target completion date was 7/1/25.Per record review on 7/21/25 of Resident #5's current care plan revealed the review due date was 6/24/25 and the target completion date was 7/8/25.Per record review on 7/21/25 of Resident #9's current care plan revealed the review due date was 6/5/25 and the target completion date was 6/12/25.Per record review on 7/21/25 of Resident #10's current care plan revealed the review due date was 7/1/25 and the target completion date was 7/8/25.Interview 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 record review and interview, it was determined that the facility failed to notify ordering physician's when ordered lab draws had not been performed and provider's were not notified when laboratory results had been received for 3 of 14 residents (Residents #5, #6, and #7) . This is a repeat deficiency from the recertification survey on dated on 12/11/24. Findings include: Per record review, Resident #6 has a diagnosis of diabetes. S/He had the following labs drawn, per physician order for “BMP, BNP, CBC, TSH, Vit D, A1C” on 5/23/25 which revealed that Resident #6 had a blood glucose on 330 (range 74-106) in addition to multiple other test results to be found out of range. The lab results in Resident #6 did not include a result for A1c values. Per review of a 6/26/25 Nurse Practitioner follow up note, the NP when discussing the resident and their blood sugar, the A1c results were still “pending.” Per an email dated 6/23/25, a Licensed Practical Nurse confirmed that the A1c value drawn on 5/23/25 was not in Resident #6’s medical record. She indicated that the A1c result from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide safe and effective skin and wound care consistent with facility policy and professional standards of practice for preventing and treating existing pressure ulcers for 1 of 1 sampled residents (Resident #6). As a result, a resident with an admitting diagnosis of an unstageable pressure ulcer was sent to the emergency room related to cellulitis of the right foot requiring antibiotic treatment, and a stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister) right foot ulcer. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 12/11/24. Findings include:Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic neuropathy, unstageable pressure ulcer to the right heel, and history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement relevant, consistent, and individualized interventions to prevent falls from occurring for 1 applicable resident at risk for falls (Resident #6). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 12/11/25, and cited at a harm level during a complaint survey dated 3/28/25. Findings include:Based on interview and record review, the facility failed to develop and implement relevant, consistent, and individualized interventions to prevent falls from occurring for 1 applicable resident at risk for falls (Resident #6). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 12/11/25, and cited at a harm level during a complaint survey dated 3/28/25. Findings include:Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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' care is supervised by a physician for 1 of 14 sampled residents (Resident #6) by not ensuring a plan was in place to manage the resident's diabetes or pressure ulcer. As a result, a resident with an admitting diagnosis of an unstageable pressure ulcer was sent to the emergency room related to cellulitis of the right foot requiring antibiotic treatment, and a stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister) right foot ulcer. Findings include:Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic neuropathy, an unstageable pressure ulcer to the right heel, and history of repeated falls. A transfer of care note (TOC) dated 4/30/25 reveals that Resident #6 has Accu-Chek Glucometer and Freestyle Libre (both are used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to ensure all regulatory provider visits were completed for 1 of 14 residents. (Resident #8). Findings include:Per record review for Resident #8 revealed that the resident was admitted on [DATE] with diagnosis of Unspecified Atrial Fibrillation, Hypokalemia, Acute on [sic] Chronic Diastolic (Congestive) Heart Failure, Hypomagnesemia, Urinary Tract Infection, Sepsis, Pain in left Shoulder, COPD, OSA, Major Depressive Disorder, Recurrent Severe Psychotic Features and Unspecified Open Wound of Lower Back and Pelvis without Penetration into retroperitoneum, Presence of Prosthetic Heart Valve, Severe Sepsis without Septic Shock, Chronic Respiratory Failure with Hypoxia, and Dependence on Supplemental Oxygen. Review of practitioner notes revealed the first physician visit occurred on 6/27/25, this does not meet the regulatory requirement of a 30 days physician onsite visit. Interview on 7/23/25 at approximately 4:10 PM, the current DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 resident [Resident #1] of 3 sampled residents did not self-administer medications despite physician orders forbidding this. Findings include: Review of Physician orders for Resident #1 dated 4/14/25 include Resident MAY NOT administer own meds. Further review of medication orders for Resident #1 includes Zenpep Oral Capsule Delayed Release Particles-give 5 capsules by mouth before meals for pancreatic enzymes. Start date 5/1/25. The scheduled administration times are 7:30 AM, 11:30 AM, & 4:30 PM. Review of Resident #1's Medication Administration Record [MAR] for May 2025, also includes an order for the Zenpep Oral Capsules- Give 3 capsules by mouth as needed for PM with snacks, 21 max caps a day, starting 5/1/25. There were no entries documented for the as needed for PM dose from the start dated of 5/1/25 to the day of the survey 5/14/25. Per observation and interview with Resident #1 on 5/14/25 at 9:37 AM, the resident stated [s/he] was in possession of the prescribed medication Zenpep Oral Capsule…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for1 of 3 sampled residents [Resident #1], that prior to transfer to an Emergency Department, appropriate information was communicated to the receiving health care institution or provider, and before a nursing facility transfers a resident to a hospital the nursing facility must provide written information to the resident or resident representative that specifies the nursing facility's policies regarding bed-hold periods, during which the resident is permitted to return and resume residence in the nursing facility. Findings include: Review of Resident #1's medical record reveals the resident has diagnoses that include: Diabetes mellitus [a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose in the blood and urine] due to a underlying condition with hyperglycemia [high blood sugar], a history of a pancreatectomy [surgical procedure involving the removal of the pancreas]- [Your pancreas makes hormones (like insulin) that help control 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 all drugs and biologicals were safely stored and accessible only by authorized personnel for 1 resident [Resident #1] of 3 sampled residents. Findings include: Review of Physician orders for Resident #1 dated 4/14/25 include medication orders for Zenpep Oral Capsule Delayed Release Particles-give 5 capsules by mouth before meals for pancreatic enzymes. Start date 5/1/25. Review of Resident #1's Medication Administration Record [MAR] for May 2025, also includes an order for the Zenpep Oral Capsules- Give 3 capsules by mouth as needed for PM with snacks, 21 max caps a day, starting 5/1/25. Per observation and interview with Resident #1 on 5/14/25 at 9:37 AM, the resident stated [s/he] was in possession of the prescribed medication Zenpep Oral Capsule Delayed Release Particles and proceeded to show the surveyors multiple capsules in a clear plastic medicine cup. The resident stated this was the only medication [s/he] was allowed to keep by [h/herself], and that all the other medications were kept by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that the medical director fulfilled her/his responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility regarding the surveillance of, and development of policies that reflect current professional standards of practice to prevent the spread of potential COVID-19 infection, and coordinate care of residents. This has the potential to impact all residents. Finding include: Per review of the facility documented COVID-19 outbreak line listing for residents revealed that 12 tested positive for COVID-19 during the period of 1/14/25 and 1/26/25. There were no deaths or hospitalizations that resulted from this outbreak. Per interview with an Licensed Nursing Assistant (LNA) on 3/5/25 at 1:00 PM, she/he stated that they were given direction to pull all precaution carts, and to stop testing the residents and staff for COVID-19. She/he stated that these directives came from the DON (Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to impact all residents. Findings include: 1.) Review of the facility documented COVID-19 outbreak line listing revealed that 12 residents tested positive for COVID-19 between 1/14/25 and 1/26/25. Review of an email dated 1/23/25 from VDH ([NAME] Department of Health) to this facility, which confirmed VDH's receipt on 1/23/25 of the facility notification of a COVID-19 outbreak with the first onset of symptoms being on 1/14/25. The facility reported to VDH that residents who were COVID-19 positive had mild cold symptoms. On 1/23/25, the VDH nurse included a copy of a blank line listing and requested the facility fill it in with as much detail as possible and send it back to me. On 1/27/25 a second email from the VDH nurse…

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

Based on interview and record review, it was determined that that facility failed to ensure the staff member designated as the facility's Infection Preventionist (IP) had obtained specialized Infection Prevention and Control training beyond initial professional training. This has the potential to impact all residents. Findings include: During an interview with the Director of Nursing (DON) on 3/5/25 at approximately 2:45 PM, s/he stated that s/he was working as the DON and the Infection Preventionist until they found a replacement for the Infection Preventionist. S/he was working on her/his Centers for Disease Control (CDC) Infection Prevention and Control certification. S/he confirmed that the facility did not currently have a qualified designated Infection Preventionist for this facility. S/he stated that the corporate DON was providing oversight once per week of the infection prevention program. Per interview with the Administrator and the VP (Vice President) of Operations on 3/5/25 at approximately 5:00 PM, it was confirmed that the Infection Preventionist position was being…

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

Based on observation, resident and staff interviews, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs, such as timely medication administration, as required by the resident's diagnoses, medical condition, or plan of care, potentially impacting all residents of the facility. Findings include: 1. Per review of the facility's Medication Administration and Documentation-General policy, the responsibility of the licensed is nurse is listed as Administers medications within one hour before or after prescribed time. Per record review of Resident #3's Medication Administration audit report from 12/1/24 to 12/10/24 there were 52 medications that were given past the allotted time specified in the policy. The medications included Clonzaepam (medication used to treat anxiety), Topiramate (medication used to treat seizures), Eliquis (a medication to prevent strokes), Sertraline (a medication used to treat depression),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate supervision to prevent accidents/incidents for one of 9 residents in the applicable sample (Resident #81). Findings include: Per interview conducted on 12/9/24 at 11:11 AM, Resident #192 said Resident #81 has entered his/her room without permission on several occasions, once climbing into Resident #192's bed, and once holding a fork in her/his hand. During an interview on 12/9/24 at 2:30 PM, Resident #80 said Resident #81 climbed onto his/her bed while s/he was in it and grabbed his/leg, causing pain. Resident #80 also said it frightens him/her when Resident #81 enters their room as it is often in the middle of the night. During an interview with Resident #84 on 12/9/24 at 2:57 PM, Resident #84 said that Resident #81 often enters his/her room without permission. Resident #84 feels that this is an invasion of his/her privacy and has complained about it. Per record review, Resident #81 was admitted to the facility with…

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

Based on interview and record review, the facility failed to provide behavioral treatment and services to residents who display or are diagnosed with mental disorder or psychosocial adjustment difficulty in order to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 5 of 9 (sampled residents (Residents #67, # 8, 74, #73, & #2). Findings include: Review of the facility's 'Behaviors: Management of Symptoms policy' [Policy NSG206 Revised 7/1/24] reveals Based on the comprehensive assessment, staff must ensure that a patient: who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Under 'Practice Standards', the policy includes Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial wellbeing. 1. Per review of Res.67's Care Plan, Res. #67 is identified as exhibits verbal and physical behaviors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident's choice regarding his/her advance directives (wishes regarding life sustaining treatment) were properly documented, ordered, and care planned for 1 of 39 residents sampled (Resident #192). Findings include: Per record review Resident #192 has an Advance Directive dated [DATE] which states the Resident does not want CPR (Cardiopulmonary Resuscitation) if my heart stops, does not want a breathing machine for any length of time, and does not want a feeding tube for any length of time. Per interview with Resident #192, s/he has an Advanced Directive and does not want CPR if his/her heart stops, does not want a breathing machine for any length of time, and does not want a feeding tube for any length of time as stated in the Resident's Advanced Directives form. The Resident also showed this surveyor a Do Not Resuscitate bracelet that was applied during a recent hospitalization that they were still wearing stating that s/he had left it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident received scheduled showers based on resident preference and care plan for 1 of 2 residents in the applicable sample (Resident #49). Findings include: Review of Resident # 49's care plan revealed a focus that was last revised on 11/20/2024 related to resident preferences that stated It is important for me to choose between a tub bath, shower, bed bath or sponge bath. I prefer a shower as of now. Another care plan focus last revised on 10/31/24 related to resident activities of daily living states Provide opportunity for bathing preference: shower, tub bath, bed bath based on my tolerance. Tuesday/Friday, PRN [as needed]. use of bath bench with one assist. The Licensed Nursing Assistant (LNA) Care [NAME] (a tool that reflects the Resident care needs that is based off the Resident care plan) reflects that Resident #49 should be offered on Tuesdays and Fridays. Review of LNA documentation in the November and December 2024 in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care necessary to prevent an in-house acquired pressure ulcer for 1 of 4 residents in the applicable sample (Resident #192). Findings include: Per record review, Resident #192 was admitted on [DATE] for short term rehab with diagnoses that include type 2 diabetes with diabetic neuropathy (nerve damage caused by diabetes). cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked), muscle weakness, absence of right foot (toes), absence of left leg below the knee, and hemiparesis (partial paralysis on one side of the body). During an interview on 12/9/24 at 11:15 AM Resident #192 presented a copy of her/his care plan that the facility had given to her/him and began to review several interventions that s/he alleged were not being implemented. The Resident stated that the care plan intervention to assist patient with turning and repositioning was not being performed. The Resident also stated that 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 provide or obtain laboratory services when ordered by a physician for 1 of 3 sampled residents (Resident # 36). Findings include: Per record review, Resident #36 has diagnoses of anemia (a lack of healthy red blood cells to carry oxygen to the body's tissues), chronic kidney disease stage 5 (end-stage disease, the kidneys have lost nearly all of their ability to function and can no longer filter waste for the body). A progress note written by an on-call provider, contacted by the facility after Resident #36 had fallen, with a date of 12/1/2024, reads Recommendations: on-call provider [name omitted] gave orders for a BMP ( basic metabolic panel, a panel that measures substances in blood that reflect the body's chemical balance and metabolism), a CBC ( a complete blood count measuring red blood cells and clotting factors) and a PT/INR ( a prothrombin time/international normalized ratio, a test to help to determine if blood is clotting normally). A lab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews, the facility failed to maintain proper bookkeeping procedures on transactions involving personal funds that included information on when transactions occurred, what type of transaction, and ongoing balances, and failed to provide a receipt for such transactions for 1 of 3 the applicable sample, (Resident # 2). Findings include: Per record review of a Facility Reported Incident (FRI), Resident # 2 reported to the facility that s/he was missing money. Per a record review of the medical file, Resident # 2 is legally blind and has a Brief Interview for Mental Status (BIMS) score of 15, indicating a high level of cognitive functioning. S/he has resided at the facility since 7/19/2023. Per Interview on 11/18/24 at approximately 11:30 AM, Resident # 2 conveyed that when s/he was admitted to the facility, s/he had a wallet containing $2,800.00. The facility removed the wallet to put it in a safe place. S/he has asked for and received money a few times to pay bills. Earlier this year, s/he asked for money to pay a bill and discovered approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident [Resident #1] of two sampled residents remained free from physical abuse. Findings include: The facility policy OPS Abuse Prohibition [last revised 10/24/22] states, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. An interview was conducted with Resident #1 on 11/18/24 at 1:30 PM. Resident #1 stated that on 8/14/24 at approximately 3:00 PM, Resident #1's roommate, who has a diagnosis of Alzheimer's Disease (a brain disorder that causes problems with memory, thought processing, and behavior) urinated on Resident #1's shoes and floor. The roommate then went through Resident #1's belongings. Resident #1 asked him/her to stop, and the roommate approached him/her and hit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Care Plan interventions were implemented for one resident [Res.#3] of 8 sampled residents Findings include: Per record review, Res.#3 was admitted to the facility with diagnoses that included osteomyelitis [bone infection caused by bacteria or fungi], diabetes, acute kidney disease, myocardial infarction [heart attack], hypertension [high blood pressure], and coronary artery disease [blood vessels supplying blood to the heart are blocked] and neuropathy [nerve pain]. Review of Res.#3's Care Plan reveals the resident was identified as: - Has an actual infection and is at risk for sepsis, has a history of sepsis [an infection of the blood stream] related to osteomyelitis of left foot -at risk for cardiovascular symptoms or complications related to atherosclerotic heart disease, hypertension. -At risk for fluid volume excess as evidence by acute kidney failure, chronic kidney failure -Has a diagnosis of diabetes -Exhibits alterations in comfort related to chronic knee infection, amputation of toes, diabetic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews, the facility failed to assure that residents are free from misappropriation of resident property related to personal funds for one resident (Resident #1) out of three residents sampled. Findings include: Per record review on Resident #1 has diagnoses of Atrial Fibrillation (a condition that causes the heart to beat irregularly), Cellulitis (a serious bacterial infection of the skin), Hypothyroidism (a disease that causes your thyroid to release too little thyroid hormone), and Metabolic Encephalopathy (a disease that causes brain impairment). Per report from APS (Adult Protective Services) received on 7/12/24, Resident #1 gave $400 to LNA #1 (Licensed Nursing Assistant) to fix his/her vehicle that had a broken back window. An internal investigation was supplied to the surveyor. Per the investigation and witness statements, LNA #1 was approached by Resident #1 once and declined the $400. Resident #1 approached LNA #1 a second time with $400 in an envelope. LNA#1 accepted the $400 from Resident #1. A police report was made by the Adminsitrator 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 record review and interviews, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (Resident #1) of three sampled residents. Findings include: Per report from APS (Adult Protective Services) received on 7/12/24, Resident #1 gave $400 to LNA #1 (Licensed Nursing Assistant) to fix his/her vehicle that had a broken back window. An internal investigation was supplied to the surveyor. Per the investigation and witness statements, LNA #1 was approached by Resident #1 once and declined the $400. Resident #1 approached LNA #1 a second time with $400 in an envelope. LNA#1 accepted the $400 from Resident #1. The alleged misappropriation was overheard by a Unit Manager and was reported to APS and the state agency on 7/12/24. On 7/19/24 LNA #1 repaid Resident #1 the $400 she had accepted in an envelope. LNA #1 was terminated on 7/19/24 following the completion of the internal investigation. A police report was filed on 7/12/24. Per witness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents admitted with mental disorders are screened prior to admission to a nursing facility to determine the appropriateness of admission and the need for specialized services for one of four sampled residents (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] with diagnoses of major depressive disorder and unspecified mental disorder. Resident #1 was also prescribed an antipsychotic medication (Lurasidone) prior to admission and continued receiving it while admitted to the facility. A pre-assessment screening and resident review (PASRR) Level 1 assessment was not filled out by the discharging hospital. The exemption reason was documented as Resident #1 would be unlikely to need admission greater than 30 days. Per progress note review, Resident #1 expressed suicidal ideation to facility staff on 4/11/24 and 4/17/24. Resident #1 also eloped from the facility on 4/17/24. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure that each resident had a comprehensive, person-centered care plan that meets their psychosocial needs for one of 4 sampled residents (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] with diagnoses of major depressive disorder and unspecified mental disorder. Resident #1 was also prescribed an antipsychotic medication (Lurasidone) prior to admission and continued receiving it while admitted to the facility. Per progress note review, Resident #1 expressed suicidal ideation to facility staff on 4/11/24. A social services note from this day states, This writer spoke with resident . [they] told this writer that [they] wanted to 'kill [themselves]. I can't do this anymore .' .This writer and resident discussed [their] past attempts of killing [themselves] via overdosing. Resident stated again [they] wanted to die and requested to go to the hospital. Resident #1 expressed suicidal ideation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview, the facility failed to protect residents' rights to be free of misappropriation of property related to medication for one applicable resident (Resident # 1). Findings include: Per review of the facility-reported investigation documentation, on 12/30/23, the facility was running low on the Oxycodone prescription for Resident #1 and was attempting to reorder the medication. The pharmacy reported they could not fill the prescription. Their records indicated the facility had received a 30-day supply on 12/11/23, which consisted of 180 tablets. Per record review of the Controlled Substance Logbook on B wing, it was revealed that an entry on 12/11/23, page 143, at 12:55 PM, Oxycodone, was signed by Licensed Practical Nurse #1 (LPN) and LPN #2. The number entered appears to be 90. However, this number is overwritten to indicate an amount of #120. The following four entries are overwritten to suggest that on 12/11 at 12:55 PM, #120 was entered instead of the original #90. Through an…

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

Based on Record review and interviews, the facility failed to implement its policy and thoroughly investigate the work history of prospective staff. Findings include: Per a record review of a facility-reported incident (FRI), a Licensed Practical Nurse (LPN) was found to be involved in an incident on 12/11/23 in which 60 tablets of Oxycodone were unaccounted for. The FRI also reveals another incident in March 2024 in which the same LPN was named as a person of interest and investigated by a different facility for discrepancies in narcotic administrations. The LPN was terminated from employment as a result. A policy titled PS 300 Abuse Prohibition, page 4, #3 states, The center will screen potential employees for a history of abuse, neglect or mistreating patients, including attempting to obtain information from previous employers and /or current employers and checking with appropriate licensing boards and registries. Per interview with the Clinical Marketing Advisor on 3/19/2024 at approximately 3:30 PM, s/he confirmed the facility did not know about the LPN's involvement with 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 record review and staff interviews, the facility failed to implement a system to reconcile controlled medications consistently and accurately for one applicable resident (Resident #1). Findings include: Per review of the facility-reported investigation documentation, on 12/11/23, the facility was running low on the Oxycodone prescription for Resident #1 and attempted to reorder the medication. The pharmacy reported they could not fill the prescription. Their records indicated the facility had received a 30-day supply of 180 tablets on 12/11/23. Per record review of the Controlled Substance Log Book on B wing, it was revealed that an entry on 12/11/23, page 143, at 12:55 PM, Oxycodone, was signed by Licensed Practical Nurse #1 (LPN) and LPN #2. The number entered appears to be 90. However, this number is overwritten to indicate an amount of #120 and signed by LPN #3. The following four entries are overwritten to suggest that on 12/11 at 12:55 PM, #120 was entered instead of the original #90. Those…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and review of facility policy, the facility failed to establish a grievance policy that ensures written grievance decisions meet documentation requirements, potentially impacting all residents in the facility. Findings include: Review of facility policy titled OPS204 Grievance/Concern, last revised 7/19/23, reveals that the policy does not address the documentation requirements for written grievance decisions. Although the policy does discuss the initiation of documenting the receipt of a grievance, it does not address that all written grievance decisions include the following: • date the grievance was received, • a summary statement of the resident's grievance, • the steps taken to investigate the grievance, • a summary of the pertinent findings or conclusions regarding the resident's concerns(s), • a statement as to whether the grievance was confirmed or not confirmed, • any corrective action taken or to be taken by the facility as a result of the grievance, • and the date the written decision was issued. 2 of 2 grievance forms sampled do…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement a comprehensive care plan in relation to wandering and elopement for 1 of 3 sampled residents (Resident #1). Findings include: Record review reveals that Resident #1 was admitted to the facility on [DATE] with diagnoses that include Wernicke's encephalopathy (a neurological disorder that presents with confusion, muscle movement coordination disorder, and vision problems), dementia, orthostatic hypotension (low blood pressure after standing that can cause dizziness or lightheadedness), and history of falling. Progress notes reveal an elopement assessment on 8/31/2023 which determined that Resident #1 is at high risk for elopement and a Wanderguard (a monitoring device that utilizes an alarm system) would be implemented for safety. Progress notes reveal Resident #1 has repeated behavior of wandering, success with removing his/her WanderGuard, exit-seeking behavior, and a history of an actual elopement with injury resulting. A 9/3/23 note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that the facility has sufficient nursing staff to provide nursing services to maintain the highest practicable well-being. The lack of sufficient direct care staff has the potential to affect all residents residing in the home. Findings include: 1. Per record review, Resident #1 was admitted to the facility on [DATE] for therapy and care management related to a stroke and cardiac conditions. Resident #1 was transferred to the hospital on 9/25/23 and passed away on 9/27/23. Per Resident #1's care plan created on 9/23/23, s/he requires extensive assistance from staff for transferring, bed mobility, dressing, toileting, hygiene, and bathing. Per interview on 10/19/23 at 4:01 PM, Resident #1's Representative indicated that Resident #1 was neglected care while at the facility because staff did not attend to Resident #1's needs. The representative explained that s/he visited the facility multiple times during Resident #1's stay for extended periods…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were provided with a clean and comfortable environment as evidenced by debris-covered floors in resident rooms for days in a row. Findings include: Per observation on 8/28/23 at approximately 12:30 PM, the floors in resident rooms A3 and A6 were visibly dirty with copious amounts of dust, dirt, and old food crumbs. The amount of debris on the floor was indicative of several days' worth of buildup. There was a dried, crusted, dark brown stain from spilled liquid in front of A6 Bed 1's nightstand. Per observation on 8/28/23 at approximately 1:00 PM, the floors underneath the beds in room B22 had accumulated dust and debris under them. When the resident in Bed 1 was interviewed about the dirty floor at the time of the observation, the Resident stated, I've asked them to clean under my bed many times, but they won't! Per observation on 8/28/23 at approximately 4:30 PM, the floors in rooms A3, A6, and B22 were in the same state as earlier in the day. Per observation on 8/29/23 at approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement Care Plan interventions related to diagnoses, weight monitoring, and medications for 1 resident [Res.#36] of 27 sampled residents. Findings include: Res.# 36 was admitted to the facility on [DATE] with diagnoses that include Chronic Kidney Disease, Morbid (Severe) Obesity, Retention of Urine, and Congestive Heart Failure [Congestive Heart Failure (CHF) occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs]. (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142),. Review of Physician Orders for Res.#36 includes an order for Furosemide Oral Tablet 80 milligrams- Give 1 tablet by mouth two times a day for CHF. [Furosemide belongs to a group of medicines called loop diuretics (also known as water pills). Furosemide is given to help treat fluid retention (edema) and swelling that is caused by congestive heart failure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assure that weights were monitored per physician orders regarding a resident identified as at risk related to diagnoses and medications for 2 residents [Res.#36 and #10] of 27 sampled residents. Findings include: 1.) Res.# 36 was admitted to the facility on [DATE] with diagnoses that include Chronic Kidney Disease, Morbid (Severe) Obesity, Retention of Urine, and Congestive Heart Failure [Congestive Heart Failure (CHF) occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs]. (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142),. Review of Physician Orders for Res.#36 includes an order for Furosemide Oral Tablet 80 milligrams- Give 1 tablet by mouth two times a day for CHF. [Furosemide belongs to a group of medicines called loop diuretics (also known as water pills). Furosemide is given to help treat fluid retention (edema)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the physician reviewed the pharmacist's medication regimen review recommendations, took action to address the recommendations, and documented the rationale in the resident's medical record for two of five sampled residents (Residents #6 and #13). Findings include: 1. Per review of Resident #6's record, the pharmacist identified irregularities and made physician recommendations during the months of October 2022, January 2023, April 2023, July 2023, and August 2023. There is no documentation or evidence of physician acknowledgement of the recommendations, actions taken, or a rationale for the recommendations made for the months of October 2022, January 2023, or April 2023. Per interview on 8/30/23 at approximately 10:30 AM, the Market Clinical Lead confirmed that no documentation or evidence of physician response could be found for the 3 months in question. 2. Per review of Resident #13's record, the pharmacist identified irregularities and made physician recommendations during the months of August 2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain accurate physician orders to provide necessary care and services on admission for 1 of 7 newly admitted (within 30 days) sampled residents (Resident #10). Findings include: Facility policy OPS424 Medication Reconciliation, effective 9/1/2022, states, The patient's medication orders will be reconciled at each transition of care. Medication reconciliation is the process of comparing a patient's existing medication orders to all the previous medications the patient has been taking. The process involves obtaining and maintaining a complete and accurate list of current medication use across all healthcare settings. Medication reconciliation involves collaboration with the patient representative and multiple disciplines including admission liaisons, physicians/advanced practice providers (APP), licensed nurses, and pharmacy. For patients admitted from the hospital: obtain and review copies of Medication Administration Records (MARs), Treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise a comprehensive care plan to include interventions and achievable goals to reach or maintain the highest practicable well-being for 2 of 27 sampled (Residents #43 & #10). Findings include: 1. The care plan for Resident #43 was not updated to include a resident-centered goal based on individual strengths, weaknesses, and personal goals regarding mental health. Resident #43 was admitted to the facility in August 2022 with diagnoses including bipolar disorder, Aspergers Syndrome, and anxiety disorder. Per record review, Resident #43 has expressed feeling tired or having little energy as well as feeling down, depressed, or hopeless during MDS (Minimum Data Set, a Federal system collecting periodic comprehensive resident data) assessments done on November 16, 2022, February 6, 2023, March 12, 2023, and May 26, 2023. During an interview with Resident #43 on August 28, 2023, when asked if they attend activities they responded no and clarified when asked why I just don't like to. The care plan initiated on August 16, 2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received care related to symptoms, including assessment, monitoring, and testing, for 1 of 27 sampled residents (Resident #30). Findings include: Per interview on 8/28/23 at 1:40 PM, Resdeint #30's Representative revealed that a few weeks earlier, Resident #30 had a bad cough and had lost his/her sense of taste and smell. S/He stated that when s/he inquired with staff about testing Resident #30 for COVID 19, staff told him/her that Resident #30 did not get tested because everyone in the building has a cold right now. Review of Resdeint #30's physician orders reveals an order for Guaifenesin (cough medicine) extended release every 12 hours for 7 days for chest congestion starting on 8/10/23. There are no nursing assessments, provider assessments, or change of condition assessments documented regarding Resident #30's symptoms requiring cough medicine. There are no vital signs for monitoring Resdeint #30's condition, including temperature, respiratory rate, heart rate, and oxygen saturation, in 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 observations, interviews, and record review the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 27 residents sampled (Resident #43). Resident #43 was not provided with behavioral health care services despite their displayed depressed behavior and assessments indicating depression. Resident #43 was admitted in August 2022 with diagnoses including bipolar disorder, Aspergers syndrome, and anxiety disorder. Resident #43 was observed on 8/28/23 at 9:30 AM, 11:30 AM, and 2 PM sitting in a wheelchair at the bedside in their room with their head down on folded arms resting on the over-bed table. On 8/29/23 Resident #43 was observed in the same place with their head down on folded arms at 9 AM and 3 PM. At 3:15 on 8/28/23 two Licensed Nursing Assistants who were familiar with Resident #43 stated [s/he] always sits like that. On 8/30/23 Resident #43 was again observed in the same place in the same position at 9:45 AM. During an interview with Resident #43…

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