Springfield Health & Rehab

Based on interview and record review the facility failed to inform in advance of the risks and benefits of the proposed care, the treatment alternatives or other options for 1 of 5 sampled residents (Resident #1). This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25. Findings include:Per record review Resident #1 was admitted with physician's orders for an antidepressant, Protriptyline (Vivactil) 10 mg twice daily, and an antipsychotic medication, Aripiprazole (Abilify) 15 mg daily. A consent form for antipsychotic medications was completed on and signed by the Resident's Guardian on 8/15/2025 listing the Aripiprazole as a prescribed medication. Further record review revealed a Consent for Antidepressant Medication form which was blank, it did not list the Protriptyline, and it was not signed by the Guardian. There was no documented evidence that the facility obtained informed consent for the Protriptyline. A physician's order dated 9/13/2025 for Quetiapine (Seroquel, an antipsychotic) 600 mg daily was initiated. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the resident representative of a change in condition related to laboratory results and treatment options for one of three residents in the sample (Resident #1). This is a repeat deficiency for this facility, with the violation cited during a partial survey dated 3/3/25. Findings include:Based on record review Resident #1 had a court appointed guardian with the guardian's spouse listed as emergency contact #2 on their information sheet. A progress note dated 10/8/2025 states The nurse received a fax from the [NAME] lab of a urine culture. The nurse sent the culture results to the [Nurse Practitioner]. The Resident was evaluated by OT [occupational therapy] and determined the resident is not safe to take anything orally other than a [tablespoon] of water every so often for comfort. Based on OTs evaluation the nurse attempted to call the [guardian] to talk about the results of the culture and talk about options regarding [antibiotic] treatment. 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 interview and record review the facility failed to ensure that one of five nurses, an agency nurse in the applicable sample had received training and competencies needed to provide care for the residents who reside in the facility. This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25. Findings include: Per review of 5 nurse's education and training files to determine if they had the training and skill set to perform an admission the facility was unable to locate the employee training and competency files of an agency staff nurse. Per interview with the facility Administrator on 11/4/2025 at approximately 4:00 PM the agency nurse no longer works there, and they had a recent change in the education department. The Administrator confirmed that they were not able to find the agency nurses file that consists of training and competencies required to provide care to the residents who live there.

Based on observation, interview, and record review of facility policy, the facility failed to establish a grievance policy that contains the correct information to support the residents' rights to file a grievance for seven of the seven residents in the sample (Resident #62, #15, #51, #19, #30, #46, and #35). This has the potential to affect all residents in the facility. Findings include: A review of the Grievance /Concerns Policy & Procedure, posted in the lobby of the facility, contained information pertaining to the previous owners and named the current Administrator as the Grievance Officer, providing the wrong email address for the Administrator. A review of document Patient Concern/Grievance Policy, revised on 1/2024, reads: 1) The grievance officer is the Director of Social Services, and her name, extension, and location are posted throughout the facility. 2) If a resident/family member has a concern, they can approach /contact any facility staff member, or a resident concern form can be filled out . 6) There will be a follow-up with the residents and/or family member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the interview and staff education record review, the facility failed to ensure that 2 of 3 sampled licensed nursing assistants (LNAs) were assessed for the competency and skill sets needed to provide care and respond to each resident's individualized needs. This is a repeat deficiency for this facility, with violations cited during a previous complaint survey, dated 4/16/24, and has the potential to affect all residents. Findings include: Per review of 3 LNA education records, 2 of the 3 sampled LNAs currently working at the facility did not have documentation of the competency evaluation required to demonstrate that they had the necessary skills to provide the care needed. Per interview on 3/26/24 at approximately 3:30 PM, the Director of Nursing (DON) indicated that she is responsible for assessing competencies. She is currently developing a system that has not been implemented yet. Per interview with the Regional Director of Nursing on 3/26/2024 at approximately 4:59 PM, she indicated the facility does not have hard copies of employee files that were also employees 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 the record review and staff interview, the facility failed to ensure that monthly pharmacist drug regimen reviews, recommendations, and attending physician responses were completed and documented in the resident record Medication Regimen Review (MRR) process for 10 of 10 Residents in the applicable sample (Residents #12, #13, #20 #22 #23# 26#29 #54 #61, and #64). This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/10/24. Findings include: 1. Per record review Resident #54 has diagnoses that include dementia with mood disturbances. A Care Plan focus initiated on 1/19/2024 states that the Resident exhibits or has the potential to exhibit physical and verbal behaviors toward others. Per review of facility investigation reports, the Resident has had a recent history of aggressive physical behaviors toward other residents on 12/23/2024, 12/29/2024, and 1/8/2025. Review of Resident #54's Physician's orders revealed a physicians order for…

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

Based on interview and review of employee training records, the facility failed to develop a system to document the minimum 12 hours of nurse aide training per year required to ensure the continuing competence of the LNAs ( Licensed Nursing Assistants). Findings include: Per review of the training records for 3 sampled staff members, there was no documented evidence of the 12 hours of training per year required to meet identified staff or resident needs. On 3/26/25 at approximately 3:00 PM, an LNA revealed she did not know how the facility tracked training records and relied on the facility to determine if she met the minimum standard hours. During an interview with the Regional Director of Nursing on 3/26/25 at approximately 4:55 PM, she stated the facility did not have complete access to the prior owner's employee records and had not yet developed a tracking system for current employees.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify residents and/or their representative in writing of a transfer/discharge for 3 out 3 sampled residents (Residents #14, #22, and #26). Findings include: Per facility Transfer or Discharge Policy reviewed 1/2024, The Resident and/or their representative will be notified in writing of the following information: a. Reason for transfer/discharge. b. Effective date of transfer/discharge. c. The location to which the resident is being transferred/discharged d. A statement of the resident's right to appeal the transfer/discharge e. The facility bed hold policy f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman Record review shows that Resident #14 was hospitalized on [DATE]. There is no record that a transfer/discharge notice was provided to the resident and/or their representative. Record review shows that Resident #22 was hospitalized on [DATE], 6/24/24, 9/9/24, and 7/25/24. There is no record that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify residents and/or their representative in writing of the bed-hold and returns policy for 3 out 3 sampled residents (Residents #14, #22, and #26). Findings include: Per facility Bed-holds and Returns Policy, reviewed 1/2024, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. 1. Record review shows that Resident #14 was hospitalized on [DATE]. There is no record that a Bed-hold Notice was provided to the resident and/or their representative. On 3/25/25, at 3:34 PM, this was confirmed by the facility Administrator. 2. Record review shows that Resident #22 was hospitalized on [DATE], 9/9/24, and 7/25/24. There is no record that a Bed-hold Notice was provided to the resident and/or their representative. On 3/26/25, at 9:03 AM, this was confirmed by the Regional Director of Nursing. 3. Record review shows that Resident #26 was hospitalized on [DATE] and…

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

Based on interview and record review the facility failed to ensure that residents are effectively assessed for past trauma experiences and address the needs of trauma survivors by identifying and minimizing triggers and/or re-traumatization and developing an idevidualized care plan related to trauma for 4 of 4 residents in the applicable sample (Resident #22, #26, #28, and #51). Findings include: 1. During an interview with Resident #51 on 3/25/25 (date) at 10:31 AM s/he stated that she has had several traumatizing events throughout her/his life. These events include multiple sexual assaults and two fetal abortions, one with and one without consent. Per record review a Psychosocial Evaluation completed by the consultant Licensed Clinical Social Worker (LICSW) on 5/13/2024 Resident #51 has a history of trauma, anxiety, and SI (suicidal ideation). The Resident discussed severadl past traumatic events that occured throughout her/his life and the impact that they have had on them. A Comprehensive Trauma Screening completed as part of the 5/13/2024 Psychosocial Evaluation states: Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician failed to ensure that the onsite review of the resident's total program of care included necessary lab testing, treatment, and medication orders for 3 of 27 residents sampled (Resident #13, #26, and Resident #322). Findings include: 1). Per record review Resident #322 was admitted on [DATE] after an acute hospital stay related to a fractured right hip repaired on 3/13/25. Per his/her discharge summary/orders written by sending Physician on 3/20/25, Resident #322 was being admitted to rehabilitation therapy, and pain control. Per further review of his/her discharge summary, s/he had been receiving oral dilaudid for pain 4 times a day in addition to acetaminophen for pain. S/he was also experiencing constipation and was ordered to continue receiving medications to treat the symptoms. Resident #322 was also noted to have swelling in his/her right hip after surgery and was being treated with aspirin 81 mg for prevention of deep vein thrombosis (DVT) as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 2 out of 10 applicable residents (Resident #20, #23) remained free from unnecessary medications. Findings include: 1). Per record review, Resident #23 was readmitted to the facility on [DATE] status post fractured hip with surgical repair, and a history of Alzheimer's dementia. Resident #23 had the following medication orders written by the Provider on 3/14/25: Oxycodone 2.5 mg every 4 hours as needed for hip fracture post-op pain, start 3/14/25 with no evidence of stop date. Morphine 0.5 mls every 2 hours as needed for Hip fracture; post -op pain; Comfort measures, with no evidence of a stop date. A record review indicates a note entered by the Consulting Pharmacist on 3/13/25 indicating the submission of a New admission Medication Regime Review (MMR) with the following recommendations: Currently receiving Oxycodone PRN (as needed) without a stop date. Please evaluate the duration of therapy. Consider adding a stop date of 14 days, if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free from unnecessary psychotropic medications for 5 of 10 Residents in the sample (Resident #12, #20, #29, #54, and #61). The facility also failed to implement 14 day stop dates on prescribed as needed (PRN) psychotropic medications for 3 of the 5 residents in the sample (Residents #12, #20, #54). Findings include: 1. Per record review Resident #54 has diagnoses that include dementia with mood disturbances. Review of the Resident's Care Plan reflects that s/he was admitted to Hospice services on 8/7/2024 due to the diagnosis of congestive heart failure. A Care Plan focus initiated on 1/19/2024 states that the Resident exhibits or has the potential to exhibit physical and verbal behaviors toward others. Per review of facility investigation reports, the Resident has had a recent history of aggressive physical behaviors toward other residents on 12/23/2024, 12/29/2024, and 1/8/2025. During meal observations on 3/24/2025 at 12:40 PM and 3/25/2025 at 12:15 PM, Resident #54 was observed sitting in a…

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

Based on observation and interview, the facility failed to maintain a clean kitchen environment, which has the potential to impact all residents in the facility. Findings include: On 3/24/25, at 10:24 AM, it was observed that shelves under the main cooking counter/steam table were very dirty with dried food and crumbs. Clean pots and pans were stacked directly on the dirty shelves. Other shelves around the kitchen had dirty, food-stained paper under clean pans, cups and kitchen tools. The dietary manager confirmed shelves were not clean at this time. On 3/25/25, at 11:34 AM, in the first-floor kitchenette, a staff member picked up the ice scoop from inside the ice chest with bare hands and put the scoop back into the ice chest. This surveyor noted that the ice scoop was directly on the ice, with the handle touching the ice. There was a container on the counter to store the ice scoop. It was empty. On 3/25/25, at 12:15 PM, the ice scoop was still inside the ice chest. At this time, a Dietary Aide confirmed that the ice scoop should not be stored inside the ice chest, but rather in…

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

Based on interviews and record review the facility failed to ensure that the binding arbitration agreement was explained in a form or manner the resident or resident's representative acknowledges that he/she understands for 2 out of 3 residents sampled, (Resident #31 and Resident #43). Findings include: 1. Per record review, Resident #43's Minimal Data Set (MDS) states that he/she had a Brief Interview for Mental Status (BIMS) done on 3/11/25, with a score of 8, indicating that he/she is moderately cognitively impaired. Resident #43's representative, a sibling, signed this resident's Arbitration Agreement on 3/8/25. During an interview on 3/27/25, at 10:38 AM, Resident #43's representative stated They (the facility) emailed me a bunch of paperwork to sign but never explained it. I live in another state and work full time. They told me it was just routine admission paperwork that needed to be signed so [Resident #43] could be admitted He/she did not realize what arbitration was. He/she stated he/she would not have signed an arbitration agreement if he/she knew what it meant. 2. Per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the 1 of 27 residents in the sample (Resident #23) or his/her representative was informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment alternatives or treatment options, and to choose the alternative or option he or she prefers. Findings include: Per record review, Resident #23 has a diagnosis of Alzheimer's and is no longer able to make his/her own medical decisions. S/he was recently treated for a fractured hip, that was surgically repaired on 3/6/25. Resident #23 was readmitted to the facility on [DATE]. Resident #23 has a Power of Attorney (POA) who makes his/her medical decisions. The following orders were written by the Physician on 3/14/25 Morphine Sulfate (concentrate) oral solution 20 mg/ml, give 0.5 milliliters (mls) by mouth every 2 hours as needed for hip fracture, post op pain; Comfort measures. Per interview with Resident #23's Representative 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 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 [Resident #324] of one sampled resident regarding abuse allegations. Findings include: Per interview with Resident #324 on 3/24/25 at 1:25 PM, Resident #324 stated that Licensed Nurse #1 was withholding his/her pain medication as well as not treating his/her wounds and had inserted a silicone catheter when the resident had a potential allergy to silicone. Resident #324 was interviewed on 3/26/25 at 12:10 PM. Resident #324 stated s/he reported it to other nurses and Licensed Nurse #1 was moved to a different unit. However, the next day the nurse was seen outside his/her door and on the unit. Resident #324 stated s/he felt intimidated. Per interview with the Administrator on 3/24/25 at 2:13 PM, the Administrator stated s/he filed the concerns in a grievance. The Administrator confirmed that Licensed Nurse #1 was working…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 27 sampled residents (Resident #322). Findings include: 1). Per record review, Resident #322 was admitted on [DATE] after acute hospitalization, related to a fractured right hip, that was repaired on 3/13/25. Per his/her discharge summary and orders written by the hospital Physician on 3/20/25, Resident #322 was being admitted to rehabilitation for therapy, and pain control. Per further review of the discharge summary, Resident #322 had been receiving oral dilaudid for pain 4 times a day in addition to acetaminophen. Resident #322 was also noted to have swelling in his/her right hip after surgery and was being treated with aspirin 81 mg for prevention of deep vein thrombosis as recommended by a orthopedic surgeon. Per the discharge instructions the aspirin was to continue until 4/13/25. Per review of Resident #322's Discharge summary dated [DATE] 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.

Based on interview and record review, the facility failed to ensure pain management was provided for 1 of 27 sampled residents (Resident #28). This is a repeat deficiency for this facility, with violations cited during a previous complaint survey, dated 10/18/24. Findings include: Per the record review, the staff failed to ensure adequate pain control and administer pain medications per provider orders for Resident #28. During the survey, the Resident was observed calling out in pain on multiple occasions. Per record review of Resident #28's care plan, s/he entered hospice care on 3/29/2024 due to end stage diagnosis of chronic obstructive pulmonary disease (COPD; irreversible lung and airway damage that obstructs airways). Per interview with the resident on 3/25/2025 at approximately 12:30 PM, Resident # 28 indicated pain almost every day, particularly in between scheduled pain medications. Per observation on 3/25/2025 at 1:00 PM and on 3/26/2025 at 2:00 PM and 2:29 PM, Resident # 28 was heard from the hall, calling out in pain. A review of the MAR (Medication Administration…

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

Based on observation, interview, and record review the facility failed to ensure medication error rates were not 5% or greater. The total error rate for all observations was calculated at 12%. There were 25 observations and three medication errors. Findings include: Per observation of LPN #1 on 3/25/25 at 10:12 AM, LPN #1 administered Resident #50 one Omeprazole Oral Tablet Delayed Release 20 mg [milligram] tablet (a medication used for acid reflux), 2 puffs of Dulera Inhalation Aerosol 100-5 MCG/ACT [micrograms per actuation] (a medication used to treat asthma), and 31 units of Basaglar KwikPen Subcutaneous Solution Pen injector 100 units/mL [units per milliliter] (insulin used to treat high blood sugar) for a blood glucose reading of 333. Per record review of Resident #50's MAR [Medication Administration Record] for March 2025, the Omeprazole was due to be administered at 7:00 AM. The insulin and Dulera inhaler were due to be administered at 9:00 AM. Per record review of the facility's Administering Medications policy [last reviewed/revised 2/25/25] states, 4. Medications must be…

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

Based on interview and record review, the facility failed to promptly provide routine and emergency dental services to meet the residents' needs related to dental pain for one of 16 residents in the applicable sample (Resident #61). Findings include: An interview was conducted with Resident #61 on 3/24/25 at 11:56 AM. Resident #61 discussed that s/he has not seen a dentist since being at the facility since 8/7/24. S/he stated s/he was having dental pain. Per interview with Resident #61 on 3/26/25 at 10:25 AM, s/he stated s/he was in 10 out of 10 pain at times due to upper and lower right dental pain. Resident #61 stated, I have a lot of teeth that need to be pulled .I feel like I don't matter and that my health isn't being taken care of. Per record review of the facility's Dental Services policy [no last revised\reviewed date] states, Centers will provide or obtain an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient .When necessary or if requested, Center staff will assist the patient in making dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was sufficient staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population. This deficient practice had the potential to impact all residents who reside in the facility. This is a repeat deficiency for this facility, with violations cited during a partial survey, dated 4/16/24. Findings include: 1. During an interview with the Director of Nursing on 1/22/2025 at 12:03 PM, he stated that he is often working the medication cart due to short staff. Per interview with the designated Infection Preventionist, she was not able to complete training or follow up with the COVID-19 outbreak mitigation plan due to being out with COVID-19 and also working as a staff nurse. See F882 for more information. During an interview on 1/23/25 at 5:48 PM with the facility Administrator, 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 interview and record review the facility failed to ensure that residents were free from significant medication errors for 2 of 3 residents in the applicable sample (Resident #10 and #11). Findings include: 1. Per record review, Resident #10 tested positive for COVID-19 on 1/10/2025. A Physician's order dated 1/10/2025 states Paxlovid (300/100) Oral Tablet Therapy Pack 20 x 150 MG & 10 x 100 MG (Nirmatrelvir-Ritonavir) Give 3 tablet by mouth two times a day for COVID-19 treatment for 5 Days until finished . Review of Resident #10's Medication Administration Record (MAR) revealed that the start date was to be 1/10/2025 at 9:00 PM and end date on 1/15/2025 for a total of 10 doses. The MAR reflects that the first dose of Paxlovid was not administered until 1/13/2025 at 9:00 PM. The MAR revealed that Resident #10 only received 4 doses of the Paxlovid between 1/13/2025 - 1/15/2025. Review of the Order Audit Report confirms that the Paxlovid was not dispensed by the pharmacy until 1/13/2025. Further review of Resident #10's revealed a Physician's order with a start date of…

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

Based on interview and record review the facility failed to ensure that resident's medical records contained nurse progress notes, complete and accurate assessments, and wound care consultant notes to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 2 of 15 sampled residents (Resident #9 and #7). This is a repeat deficiency for this facility, with violations cited during a partial survey, dated 6/12/24, and the previous recertification surveys, dated 1/10/24. Findings include: 1. Review of the facility policy titled Charting and Documentation, The Policy Statement says All services provided to the residents, progress toward the care plan goals, or any changes in the resident's medical, physical. functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the facility policy titled Wound Care last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that an allegation of resident to resident abuse was reported to the State Licensing Agency for 1 of 3 sampled residents (Resident #4) within 2 hours of the incident and failed to submit an investigation of the findings to the State Agency within 5 days. Findings include: A facility investigation submitted to the State Agency on 1/9/25 of an allegation of physical abuse related to a resident-to-resident altercation that occurred on 1/8/25 at approximately 5:12 PM, revealed that Resident #1 entered the room of Resident #4 and threw a can of soda at his/her arm causing a skin tear to the left forearm, and a bruise to his/her forehead Per nursing documentation and risk management notes there is no evidence of how the bruise occurred to Resident #4's forehead. The facility failed to report the incident to the State Agency within 2 hours of the occurrence. According to the State Agency the facility filed the report on 1/9/25 at 4:30 PM, over 23 hours after the facility was aware of the allegation, and the 5 day…

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

Based on observation, interview, and record review the facility failed to revise the care plan for 1 of 15 residents in the sample (Resident #4) related to resident to resident physical abuse and wounds. Findings include: A facility investigation submitted to the State Agency on 1/9/25 of an allegation of physical abuse related to a resident-to-resident altercation that occurred on 1/8/25 revealed that Resident #1 entered the room of Resident #4 and threw a can of soda at his/her arm causing a skin tear to the left forearm and a bruise to his/her forehead. Review of Resident #4's care plan reveals there is no documented evidence that the facility revised the care plan to add interventions to monitor Resident #4 for complications related to resident to resident physical abuse resulting in injury. See F689 for more information. Per interview on 1/22/25 at approximately 10:00 AM with Resident #4 stated that s/he is afraid to sleep because [s/he] is worried that [Resident #1] will come back in [his/her] room. Per Resident #4's care plan dated on 6/27/24 [Resident #4] is at risk for 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.

Based on observation, interview and record review the facility failed to provide quality care to 1 out of 15 residents in the sample (Resident #4) related to wound care that is not pressure. Findings include: Per observation on 1/23/25 at approximately 10:00 AM, Resident #4 had a dressing on his/her left forearm dated 1/17/25. Per interview with Resident #4 at that time s/he stated that s/he had an injury to his/her left arm and that the nurses had placed a dressing to the area. Resident #4 further stated that a nurse had not changed the dressing in several days and pointed to the date on the bandage which was dated on 1/17/25. Review of the facility policy titled Wound Care last reviewed/revised in 1/2024 states the following information should be recorded in the resident's medical record 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in the resident's condition. 6. All assessment date (i.e., wound bed color, size…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 2 residents in the sample were free from physical abuse (Resident #3). Findings include: Per record review a Nursing Note for Resident #3 dated 10/31/2024 reads This RN (Registered Nurse) was called to the dining room on dementia unit by an LNA [license nursing assistant]. Who stated that [S/he] witnessed [Res #1] put [his/her] hands on another residents [Res #3] neck. While the resident was sitting at the table causing the resident to yell out. Per the facility investigation summary dated 10/31/2024 Staff reported that resident [Res #3] stuck [his/her] tongue out at the resident [Res #1]. [Res #1] then put [his/her] hands around [Res #3] neck . Review of the facility investigation confirmed that the altercation between Residents #1 and #3 did occur and was witnessed on 10/31/2024. Per interview with the Administrator on 11/19/2024 at approximately 10:00 AM the following interventions were implemented on 10/31/2024. The facility Identified all residents at risk on the 2nd floor for abuse, initiated a 1:1 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Per interview and record review the facility failed to revise the comprehensive care plan related to a resident elopement from the facility for one sampled resident [Res.#1]. Findings include: Review of the medical record for Resident #1 reveals h/she is a [AGE] year-old admitted on [DATE] with diagnoses that include alcohol abuse, vascular dementia, psychotic disturbance, mood disturbance and anxiety. An interview was conducted on 6/12/24 at 12:48 PM with Resident #1's assigned Licensed Practical Nurse [LPN] during events on 5/25/24. The LPN stated on the morning of 5/25/24, Resident #1 had the wander guard present, and had triggered the alarm, then exited the building. The LPN stated that staff observed via the camera that Resident # 1 was outside and s/he was just sitting there. The LPN reported later We didn't realize [s/he] had left. We were in the process of searching for [h/her] for approximately 30 minutes when police called and reported picking up the resident. Per record review, on 5/25/24 at 9:28 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a discharge plan for a resident who attempted to leave against medical advice for 1 sampled resident [Resident #1]. Findings include: Review of the medical record for Resident #1 reveals the resident is a [AGE] year-old admitted on [DATE] with diagnoses that include alcohol abuse, vascular dementia, psychotic disturbance, mood disturbance and anxiety, along with difficulty in walking, abnormalities of gait and mobility, and a history of falling. Review of the facility's Discharge Against Medical Advice [AMA] policy includes: If the patient continues to insist on discharge AMA and refuses a safe planned discharge: A Discharge Transition Plan will be provided to the patient or patient representative. Per further record review and confirmed during interviews with Resident #1 Unit Manager [UM], the Director of Nursing (DON) and the Administrator, there is no documentation that a Discharge Transition Plan was created for Resident #1 or that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to ensure that each resident receives adequate supervision to maintain safety and prevent accidents regarding elopement and leaving the facility Against Medical Advice for 1 sampled resident [Res.#1]. Findings include: Review of the medical record for Res.#1 reveals the resident is a [AGE] year-old admitted to the facility on [DATE] with diagnoses that include alcohol abuse, vascular dementia, psychotic disturbance, mood disturbance and anxiety, along with difficulty in walking, abnormalities of gait and mobility, and a history of falling. Interviews with staff familiar with Res.#1 were conducted on 6/12/24. Staff, the Director of Nursing [DON] and the facility's Administrator [ADM] described the resident as cognitively delayed and has a dementia diagnosis, stating the resident .is tricky. My first impression is this [person] is out of [h/her] mind .some of the things [s/he] says are not realistic. The ADM reported I talk to [h/her] every day. [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 upon interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 sampled resident [Res.#1]. Findings include: Per review of the [NAME] Police Report to Adult Protective Services- Intake Report #0016 -5/25/24 9:45 AM: On 05/25/2024 I was on duty as a Police Officer in the town of [NAME]. I was called to a report of an elderly [person] walking on [NAME] Rd. It was later found to be the victim [Res.#1] who had left the [NAME] Health and Rehab facility without their knowledge. The victim made comments that [s/he] was going to walk to [NAME], which is approximately 37 miles away .It should also be noted the victim did not know which town [s/he] was currently in. An interview was conducted on 6/12/24 with Res.#1's Licensed Practical Nurse [LPN] from 5/25/24. The LPN stated We didn't realize [s/he] had left. We were in the process of searching for [h/her] for approximately 30 minutes when police called reporting picking up the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and record review, the facility failed to ensure that there are a sufficient number of skilled nurse aides to provide care and services to attain the highest practicable well-being for each resident and in accordance with each resident's plan of care. Findings include: 1. Per record review, Resident #2 was admitted to the facility on [DATE] following surgical intervention for diverticulitis (a chronic issue with the intestines) that resulted in a colostomy (when the intestines exit through a hole in the abdomen). As a result of this, Resident #2 receives all their care in bed. Per review of the care plan, Resident #2 requires substantial to total assist in bed for toileting, incontinence care, bathing, and grooming/hygiene. The care plan also states that Resident #2 is incontinent of urine. Per interview on 4/16/24 at approximately 9:30 AM, Resident #2 stated that they have had to wait hours on several occasions in order to have their urine-soaked brief changed 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.

Based on interview and record review, the facility failed to ensure that licensed nurses have the specific competencies necessary to care for Residents' needs as identified through resident assessments and the plan of care. Findings include: Per record review, Residents #1 and #2 both had colostomies while admitted to the facility. A colostomy is when the intestines are surgically diverted to exit out of an incision in the abdomen. Stool is then collected in a bag that must be emptied periodically. The bag must also be changed periodically. Per interview on 4/16/24 at approximately 11:00 AM, the facility Nurse Educator stated that they were not sure if ostomy care was part of the annual competencies that nurses have to complete, or if the competencies are completed as needed based on the current patient population. The facility Wound Nurse stated that they have shown some of the nurses who provided ostomy care to Residents #1 and #2 how to do it, but that they have not completed a competency checklist for each nurse for ostomy care that outlines the facility's procedure for ostomy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with colostomies receive care and services consistent with professional standards of practice and the comprehensive care plan for 2 of 2 sampled residents (Residents #1 and #2). Findings include: 1. Per record review, Resident #1 was admitted to the facility on [DATE] with a diagnosis of Diverticulitis (a chronic condition of the intestines), Failure to Thrive, and Colostomy Status (a colostomy is when the intestines are surgically diverted to exit out of an incision in the abdomen). Per review of a provider admission note entered on 4/5/24, the note states, Patient had recent colon resection for bowel obstruction approximately 2 and half weeks ago. [They were] sent back to the ER after having acute abdominal pain and having inability to care for [themselves]. Resident #1 was discharged to the hospital on 4/10/24 and did not return. Per further record review, Resident #1 was never ordered for any colostomy care, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat the resident with respect and dignity and failed to provide an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 (Resident # 334). Findings include: Per record review, Resident #334 was admitted to the facility on [DATE] with the following diagnoses: spinal stenosis, rheumatoid arthritis, morbid obesity, and end-stage renal disease. An activities of daily living (ADL) care plan initiated on 12/29/23 reflects that the resident requires assistance/is dependent for ADL care related to limited mobility. Her/his Brief Interview for Mental Status ( BIMS) score is 15, suggesting that s/he is cognitively intact. Per interview on 1/9/2024 at 8:30 AM, Resident # 334 indicated s/he had back pain and painful joints due to their arthritis, making it challenging to move around and care for her/him self. S/he feels limited in mobility and thinks that the Licensed Nursing…

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

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 life sustaining treatment was updated on their COLST (clinician's order or orders for treatment or limitation of treatment such as intubation (insertion of a tube through a person's mouth or nose, then down into their trachea to open the airway and allow passage of air), mechanical ventilation (a machine that takes over the work of breathing when a person is unable to breath on their own), transfer to hospital, antibiotics, artificially administered nutrition, or other medical intervention) for one of 23 residents (resident #9). Per record review Resident #9 has a COLST that was signed on 12/13/2022 that reflects that Resident #9 would want a trial course in intubation and ventilation treatment if s/he were in respiratory distress. On 10/27/24 Resident #9 requested a change to their COLST to remove their previous choice to trial intubation and ventilation. A care plan meeting note written on 10/27/2023 that…

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

Based upon observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for 1 resident [Res.#40] of 32 sampled residents. Findings include: Review of Res.#40's Care Plan reveals the resident is assessed as exhibits or has the potential to exhibit physical behaviors such as hitting and banging the wall, rearranging furniture, related to: Cognitive Loss/Dementia with psychotic features and primary open-angle glaucoma, bilateral, severe stage [damage to the Optic nerve that leads to vision loss]. Care Plan interventions for this include Have minimal decorations in resident's room due to resident behavior/glaucoma along with Facility will secure dresser to the wall [marked as Resolved on 1/2/24]. Per observation of Res.#40's room on 1/8/24, the room contained a single bed, a chair, and a nightstand located across the room from the bed with 4 books stored on a shelf below the nightstand drawer. There was no dresser in the room. The walls in the room were bare, with no artwork, posters, personal items, or activity calendar. There was no…

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

Based on observations, interview, and record review the facility failed to develop a comprehensive care plan related to the communication needs of one hearing impaired resident (Resident #6) in the sample. Findings include: During interview with Resident #6 on 1/9/24 at 10:10 AM s/he stated loudly I can't hear you. When asked if s/he had hearing aids, Resident #6 stated I don't read lips. Resident #6 smiled, shrugged her/his shoulders, and shook her/his head. Per record review Resident #6 was admitted to the facility with a significant hearing impairment. Activities care plan initiated by the Director of Recreation on 10/16/23 states would benefit from accommodation for hearing loss by using communication board, placement near speaker/leader, use of amplifiers/headphones and written instructions/gestures. On 1/10/24 the care plan was updated to reflect impaired communication as evidenced by impaired hearing. Intervention included Ensure that resident has [his/her] hearing aids in ears during day time hours, as [s/he] allows. Speak in normal tone voice clearly and slowly. Reduce…

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

Based upon observation, interview, and record review, the facility failed to provide appropriate activities per the resident's plan of care for 1 resident [Res. #40] of 32 sampled residents. Findings include: Per review of Res.#40's medical record, the resident was admitted to the facility with diagnoses that include Glaucoma [damage to the Optic nerve that leads to vision loss] and Adjustment Disorder with Depressed Mood. Per observation, the resident resides in a room by themselves with a single bed and no roommate. Review of Res.#40's Care Plan reveals the resident is assessed as While in the facility, [Res.#40] states that it is important that [they] have the opportunity to engage in daily routines that are meaningful relative to [their] preferences, with the Care Plan Goal that the resident should attend/participate in activities of choice 3 times weekly. Care Plan interventions include I enjoy listening to music and prefer country, 60's, 70's, 80's on the radio, CD player, and live entertainment, I keep up with the news by discussions with another person, group discussions and…

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

Based on staff interview and record review, the facility failed to ensure that irregularities noted during monthly pharmacist medication regimen reviews are documented in a written report for one of 5 sampled Residents (Resident #5). The facility also failed to ensure that the attending physician reviewing the report documents a rationale for not changing the medication according to the pharmacist's recommendations for one of 5 sampled Residents (Resident #5). Findings include: 1. Per record review, Resident #5's medication regimen was reviewed by the pharmacist on 2/1/2023. The Pharmacist Medication Regimen Review note states Comment/recommendations noted - see report. Per review of pharmacist recommendation reports for Resident #5, no report for February of 2023 could be located. 2. Per record review, the pharmacist recommended an increase in Resident #5's Basal Insulin order on 12/1/2023 through the pharmacist recommendation report. The attending physician marked disagree on the report and signed it. Per review of the record, no documented rationale could be found as to why the…

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

Based on staff interview and record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the drugs for one of 5 sampled residents (Resident #5). Findings include: Per record review, Resident #5 receives the following psychotropic medications: - Clonazepam (an antianxiety medication) 1mg three times a day - Trazodone (an antidepressant) 50mg before bed - Duloxetine (an antidepressant) 120mg once a day - Latuda (an antipsychotic) 60 mg in the morning and 20mg at bedtime - Divalproex Sodium (an anticonvulsant used to treat mood disorders) 25 mg once a day Resident #5 has been on all of these psychotropic medications for over a year. The doses of these medications have either remained the same or have increased over the last year. There is no evidence in Resident #5's record to indicate that the physician has attempted a gradual dose reduction for any of these medications. There is also no documentation from the physician explaining why a gradual dose reduction of…

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

Based on staff interview and record review, the facility failed to ensure that required documentation and medical records are readily accessible. Findings include: 1. Per observation on 1/8/24 at approximately 2:15 PM, Resident #32's toenails were very long, extending approximately 1/3-1/2 inch out from the top of their toes. One of Resident #32's middle toes had grown down and around the top of the toe. Resident #32 stated that this toe was painful. Per record review, a podiatry request for nail care had been ordered in May of 2023, to be addressed during the Podiatrist's scheduled June 2023 visit to the facility. There are no records to confirm that Resident #32 had been seen that June or at any point after June up until the present. Per interview on 1/10/24 at approximately 12:00 PM, the Market Clinical Lead confirmed that no records could be located to indicate that Resident #32's toenails had been cut in June of 2023 or any point thereafter, though they believed that evaluations did take place. They confirmed that the records were not currently accessible in the facility 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 observation, resident interview, and staff interview, the facility failed to ensure residents have a clean and comfortable environment as evidenced by a dirty and unsanitary resident environment. Findings include: Unit observations and interviews occurring on 12/20/23 between approximately 9:00 AM and 9:30 AM on both resident care units with the following findings: -The floor in room [ROOM NUMBER] had multiple, large drops of a sticky substance where dried dirt had been tracked in by shoes and stuck to the floor. There were also many muddy footprints that had dried on the floor (the most recent muddy day in the location of the facility was two days prior). -The floor in room [ROOM NUMBER] had multiple dried, muddy footprints and old stains of a colored liquid. The bathroom toilet had an over-toilet commode that was caked in layers of creams and powders. The toilet bowl had large, dried feces splatters and mold growing in the bowl below the water line. At this time, the Resident in Bed #2 stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure that care plans were reviewed by the interdisciplinary team within 7 days after completion of the comprehensive assessment for two of three sampled residents (Resident #1 and #2). Findings include: 1. Per record review, Resident #1 was admitted to the facility on [DATE]. Per Minimum Data Set (MDS) records, comprehensive assessments were performed for Resident #1 on 5/10/23, 8/10/23, and 10/11/23. Records of care plan revision history show that the care plan was created on 5/16/23 and reviewed on 8/18/23 and 10/19/23. Per review of care plan meeting progress notes, a care plan meeting took place on 5/11/23 and consisted of members of the interdisciplinary team, including Resident #1 and their family. There are no other progress notes to date documenting any interdisciplinary team meetings to discuss reviewing/revising the care plan for Resident #1. Per interview on 12/20/23 at approximately 2:00 PM, the Administrator confirmed that no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to implement a system for reporting and controlling communicable diseases as evidenced by insufficient reporting of new COVID-19 cases and insufficient transmission-based precautions for the care of residents with COVID-19. Findings include: 1. Per review of the facility-provided line list [a tool that tracks positive test results for staff and residents] for all positive COVID-19 staff and residents, 8 residents and 4 staff members had tested positive during the facility's COVID-19 outbreak at the time of investigation. The first positive case was discovered on 8/31/23 and the most recent case was discovered on 9/8/23. Per interview on 9/11/23 at approximately 10:00 AM, the [NAME] Department of Health Epidemiologist assigned to assist in the management of the facility's COVID-19 outbreak confirmed that, as of that time, the facility had only made them aware of 6 residents and 3 staff members who tested positive as part of this…

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