Vernon Green Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure professional standards were maintained regarding delegation of nursing duties for one of four sampled residents (Resident #5). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 10/30/24 and 12/4/23.Findings include: Review of Prescribed Orders for Resident #5 include Lidocaine External Patch 4 % (Lidocaine patch is a topical anesthetic used to stop pain,) Apply to left and right hip topically at bedtime on 12 hours. off 12 hours. and remove per schedule.Review of the Medication Administration Record [MAR] for Resident #5 for Jan. 12, 2026, reveals licensed nursing staff initialing as completed the application of Lidocaine patches to the left and right hip of Resident #5 at 8:00 PM on Jan. 12, 2026.An interview was conducted with the Staff Nurse for Resident #5 on Jan. 13 at 9:11 AM. The Staff Nurse stated the LNAs [Licensed Nursing Assistants] take off 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 residents were free from accidents and hazards for two of 11 sampled residents (Residents #14 and #37). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 10/30/24 and 12/4/23. Findings include: 1.Per record review, Resident #14 has a Care Plan which identifies the resident as at risk for falls related to decreased cognition, poor safety awareness, requiring encouragement to sit or rest. The four interventions listed in Resident #14's Care Plan to prevent future falls are all dated 12/5/2025. Review of Progress Notes for Resident #14 dated 1/4/26 reveal at 9:20 AM the resident was Sleeping in chair, leaning forward and fell to the floor hitting their right frontal head on floor. The resident sustained a quarter sized bump on right lateral forehead - ice applied. Further review of Resident #14's Care Plan revealed no new intervention added to prevent future falls for the resident. Further review of Progress Notes for Resident #14 reveals 2 days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions were implemented after a significant weight loss for one of two sampled residents (Res #6).This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 10/30/24. Findings include:Per a record review, Resident #6 has diagnoses that include anemia, GERD (gastro esophageal reflux disease), non-pressure chronic ulcer of the left foot, and other malaise, all indications that present a risk for weight loss.Per a record review, Resident #6 weighed 123.6 pounds on 12/7/25. Resident #6's next recorded weight of 114.4 pounds. was taken on 12/22/25. The weight loss of 9.2 pounds. or 7.4% in a 15-day period between 12/7/25 and 12/22/25 is a significant weight loss, per MDS (Minimum Data Set) guidelines. According to CMS (Centers for Medicare & Medicaid Services) for long-term care residents, a significant weight loss is defined as a loss of 5% or more of body weight in the last 30 days or 10% or more of body weight in the last 180 days (6 months).Per 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 ensure the facility was free from medication errors greater than 5% with 2 errors in 32 opportunities [6.25%]. Findings include: Review of the facility's Medication Administration/Medication Errors Policy and Procedure [Document ID: VACH-PP-1-6-623, Reissued 11/29/23] reveals Medications shall be administered in a safe and timely manner and as prescribed, in accordance with good nursing principles and practices .1). Review of Prescribed Orders for Resident #5 include Lidocaine External Patch 4 % (Lidocaine patch is a topical anesthetic used to stop pain,) Apply to left and right hip topically at bedtime- on 12 hours, off 12 hours and remove per schedule.Review of the Medication Administration Record [MAR] for Resident #5 for Jan. 12, 2026, reveals licensed nursing staff initialed as completed the application of Lidocaine patches to the left and right hip of Resident #5 at 8:00 PM on Jan. 12, 2026.Per interview with the Staff Nurse for Resident #5 on Jan. 13 at 9:11 AM, the Staff Nurse stated I have no concern signing off [on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement 14 day stop dates on prescribed as needed (PRN) psychotropic medications for 3 out of 5 residents in the sample (Resident's #24, #205 and #45). Findings include 1. Per record review, Resident #24 was admitted with a diagnosis of Alzheimer dementia and had the following medication orders written by the facility Provider on 10/7/2024: Quetiapine tablet; 25 mg; amt: 1 tab; oral .Twice A Day - PRN There was no documented evidence in the orders of a stop date for the antipsychotic medication as required or rationale by the Provider to extend the medications. 2. Per record review, Resident #205 was admitted on [DATE] with a diagnosis of lewy body dementia. S/He had the following PRN medication orders written by the facility Provider on 10/22/2024: Trazodone tablet; 50 mg: 1/2 tablet PRN three times a day without a stop date and Risperidone 0.25 mg, 1 tablet as needed without evidence of a stop date. Per interview with the Director of Nursing [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 upon interview and record review, the facility failed to ensure one resident [Res. #35] of 21 sampled residents remained free from physical abuse. Findings include: Per record review of Progress Notes for Res. #35 dated 7/22/24 Other resident was in [h/her] room when [Res.#35] tried to enter the room. [Res.#35] asked the person to leave [h/her] room and they got agitated and would not let [h/her] in [h/her] own room. They took [Res.35's] glasses off and threw them across the room, poured a soda on [h/her] head and then was moving [h/her] wheelchair from side to side until [s/he] ultimately fell out of the wheelchair. [Res.#35] did call for help and staff arrived as soon as heard [h/her]. Per review of the facility's investigation of the incident, the investigation concluded the allegation was verified by evidence collected during the investigation and was witnessed by staff. Per review of corrective actions taken by the facility after the incident, the residents were immediately separated after the incident and assessed for injuries. Close supervision was provided. Care plans…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement care planned interventions for 2 of 29 Residents in the sample (Resident # 30) related to positioning, and (Resident #25) related to pressure ulcer prevention, pain control, and nutritional risks. Findings include: 1. Per recd review Resident #25 has advanced dementia. S/he developed an in house acquired stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an open/ruptured serum-filled blister) pressure ulcer on her/his left heel and has experienced a significant weight loss of 11.84% over 3 months. A Nurses Progress note dated 9/10/2024 12:12 PM reads a fluid-filled blister was noted at outer edge of left heel found this AM during therapy session; resident c/o discomfort when blister was pushed on; the skin over the blister is dry/calloused; the right heel is slight pink . A Care Plan Problem with a start date of 2/19/2022 stated that Resident #25 has the potential for skin breakdown related to incontinence 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 observations, staff interviews and record reviews, the facility failed to revise the comprehensive care plan for two of twenty nine Residents in the sample (Resident #9 and Resident #15) as the Residents' plans of care changed related to Activities of Daily Living (ADLs) and Nutritional Status for Resident #9, and a fall with major injury at the facility for Resident #15. Findings include: 1. Per Observation on 10/28/24 and 10/29/2024, Staff were seen assisting Resident #9 with eating a meal. This surveyor observed the need for total assistance. Per record review, Resident #9's current Care Plan Problem category Nutritional Status states I have a history of weight loss. I continue to be at risk for weight loss and altered fluid status due to my variable meal intake at times, related to my cognitive/ mood state, as well as possible medication side effects. This Problem category has an Approach dated 12/04/2023 that states I am dependent on you to assist me with my meal to help me have sufficient intake. I will occasionally feed myself a drink. There is another Approach,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards related to a Licenced Nursing Assistant (LNA) acting outside his/her scope of practice by administrating medications to one resident in the sample (Resident # 205). Findings include Per observation at approimately 2:00 PM on 10/28/2024 the LNA was observed administrating medications to Resident #205 while at the nurse's station. Per Interview with a Licensed Nurse on 10/28/2024 at approximately 2:05 PM s/he stated that s/he or the other Nurse were unable to administer the medication to the Resident. S/He stated that they delegated the task to the LNA because s/he had a good rapport with Resident #205. Per Interview with the LNA on 10/28/2024 at 3:40 PM s/he confirmed that s/he gave Resident #205 his/her medications crushed in ice cream. The LNA stated that this was not the first time s/he has been delegated by nurses to give medications. The LNA stated that s/he has not been trained by the facility to give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide adequate supervision to maintain safety for one (1) resident (Resident #15) out 2 sampled residents. Findings include: Per record review Resident #15 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation (an irregular heartbeat), depression, hypertension (high blood pressure), and dementia. Resident #15's care plan states I am at risk for falling R/T [related to] my decreased activity tolerance, as well as my decreased safety awareness. This was last edited on 9/5/24. Per record review, on 9/28/24 at approximately 7:54 PM Resident #15 had an unwitnessed fall in his/her room. Resident #15 was transported to the hospital by EMS [Emergency Medical Services]. Per record review of physician documentation, Resident #15 was admitted to the hospital for Left Hip fracture with small extraperitoneal pelvic hemorrhage (a left broken hip with some internal bleeding). S/he had surgery to fix his/her broken hip. Per the facility's…

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

Based on interview and record review the facility failed to ensure that recommendations made by the Registered Dietician were implemented to support wound healing and deter weight loss for 1 of 29 Residents in the sample (Resident #25). Per record review Resident #25 had experienced a significant weight loss of 11.48% over 3 months, and had a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an open/ruptured serum-filled blister) facility acquired pressure ulcer. A Registered Dietician's Progress Note dated 9/11/2024 states Recommend increase in supplement to TID [three times per day] to provide 750 cal/27 gm pro., and Centrum silver QD [every day] to support wound healing and deter weight loss . Further review of the record revealed a Dietician Progress Notes dated 10/28/2024 that states that Resident #25 had not started centrum tab or had any increase in her/his dietary supplement; this [was] recommended by dietician to support wound healing; sent fax to Doctor [name omitted] r/t [related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview the facility failed to store and prepare food in accordance with professional standards for food safety. Findings include: During a tour of the facility kitchen accompanied by the Food Service Manager (FSM) on 11/27/23 at 11:00 AM the canned food shelf was noted to contain two dented cans of tomatoes. The FSM removed the dented cans and confirmed that they should not have been placed on the shelf for use. In the walk-in freezer there was a tray of bowls filled with scoops of ice cream that was unlabeled. The FSM stated that they were from yesterday and they should be dated. There was a tray of birthday cakes on the shelf that was not covered or wrapped, the FSM confirmed that the cakes should be covered and stated that they will not be used. In the walk-in refrigerator there were 3 open containers of cottage cheese that were not dated, the FSM removed them. Other open food items with no labels were a can of beef base and Italian dressing. There was a large block of butter that was half used and open on top shelf with no date or wrap. There…

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

Based on observations, interviews, and review of facility records, policies, and procedures, the facility Administration failed to use its resources efficiently to attain or maintain the highest practicable well-being of each resident. Findings include: During the extended recertification survey conducted from 11/27/23 through 12/4/23 the survey team determined that the facility provided substandard care, including a concern that rose to the level of immediate jeopardy, and identified numerous other patterns of ineffective management of the facility. The survey team determined that the facility had failed to ensure the resident environments were free from the risk of serious harm related to water temperatures, failed to ensure residents were free from abuse and neglect, failed to provide behavioral health services to residents requiring these services, and failed to ensure that the facility had a complete Infection Prevention and Control Program. Additionally, the facility failed to have proper systems in place to ensure that all residents had appropriate care plans and drug regimen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a governing body that is responsible for implementing policies regarding the management and operations of the facility and that holds the facility Administrator accountable for the management of the facility. Findings include: The facility's Governing Body is made up of a Board of Directors (BOD). Per review of a member list for the facility's Board of Directors, the BOD consists of a Chair, a [NAME] Chair, A Treasurer, a Clerk, a President/COO, and 7 other elected members. A Board of Directors Policies and Procedures document was provided dated 2/4/2011. No more-recent version of the policy could be found or provided by the facility. The policy includes the following: Vision, Values, and Mission Procedures: Responsibility: Chairperson, President, Board of Directors Action: Oversees implementation, receives regular reports of progress, determines corrective action, celebrates success. Policy Oversight Process . It is the role of the board to review and approve a policy development process, ensure 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 on staff interview and record review, the facility failed to have written arrangements with agencies outside the facility that furnish laboratory and behavioral health services. Findings include: Per review of all written arrangements with outside services provided by the facility, written arrangements for behavioral health services and laboratory services could not be found. Per review of the facility assessment, psychiatric/mood disorders is among the list of Types of diseases and conditions that are common to [the facility's] residents and the care that is provided. The Facility Resources section also includes laboratory services in the Services subsection. Per interview on 12/4/23 at approximately 11:30 AM, the Administrator confirmed that they receive laboratory services from a local hospital that supplies the facility with lab equipment and processes their lab samples. The Administrator also confirmed that they were receiving behavioral health services through an outside agency up until 2022 when the agency stopped sending staff in to provide those services. Per…

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

Based on staff interview and record review, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs that meets requirements of the regulation. Findings include: During entrance conference on 12/4/23 at approximately 9:45 AM, the facility's written transfer agreement with a local hospital was requested. Per interview on 12/4/23 at approximately 11:30 AM, the Administrator stated that the facility has never had a written transfer agreement with a hospital.

Based on staff interview and record review, the facility failed to maintain an infection control program that is reviewed/updated annually and includes a system for preventing and tracking infections and communicable diseases for residents and staff as evidenced by lack of an infection surveillance system or water management program. The facility failed to ensure staff uses proper Personal Protection Equiptment (PPE) and hand hygiene for 1 of 25 residents sampled (Resident #14). Findings include: 1. Per review of the facility's policy and procedure manual titled Infection Prevention and Control, the issue date on the manual reads 10/25/21. This is the policy/procedure manual used by the facility as the foundation for their Infection Prevention and Control Program. Per interview on 11/28/23 at approximately 1:45 PM, the Director of Nursing (DON) was asked to provide evidence that the Infection Prevention and Control Program has been reviewed and updated (as necessary) since 10/25/21. On 11/29/23 at approximately 11:30 AM, the DON confirmed that the facility's Infection Prevention 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 establish an antibiotic stewardship program that includes antibiotic use protocols. Findings include: Per review of the facility's policy and procedure manual titled Infection Prevention and Control, it states the following: The Infection Prevention and Control Program includes: 4. an antibiotic use program that includes antibiotic use protocols and a system to monitor antibiotic use. Elements of the program include: - Antibiotic Stewardship and review including reviewing data to monitor the appropriate use of antibiotics in the resident population. Per review of the facility provided antibiotic tracking documents, there is evidence that the facility had been running monthly reports on all residents who were receiving antibiotics and the reasons for antibiotic use. However, no policy or procedure manual was provided by the facility for the Antibiotic Stewardship Program. There was no evidence provided of a formalized program for Antibiotic Stewardship with protocols for antibiotic use, participating staff and their…

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

Based on observation, resident interview, staff interview, and record review, the facility failed to provide a respectful and dignified dining experience that enhances residents' quality of life as evidenced by failure to serve meals to residents at a table at approximately the same time, and the facility failed to ensure care was provided to residents with respect and dignity as evidenced by the failure to assist with care related to toileting for one 1of 25 sampled residents (Resident #33). Findings include: 1. Per record review, Resident #33 has resided at the facility since 10/17/2022 with diagnoses that include Depression, muscle weakness, and a BIMS of 12 (A cognitive screening measure that evaluates memory and orientation indicating moderately impaired cognition). Per interview with Resident # 33 on 11/27/2023 at approximately 2:10 PM, Resident # 33 expressed feeling humiliated about being incontinent of urine and feces. S/He is not offered the bedpan, urinal, or bathroom but is instructed to go in my underwear, and they will clean me., stating I know I'm a lot of work, and I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the comprehensive care plan as the resident's plan of care changes for 2 of 21 sampled residents (Resident #3, and #11). Findings include: 1. Per record review Resident #3 was admitted to the facility on [DATE] with diagnoses that include heart failure, atrial fibrillation (an irregular, often rapid heart rate), and peripheral vascular disease (PVD) (circulation disorder). An admission Nursing Assessment completed on 9/12/23 reflects that there were no pressure or vascular wounds identified and the resident only required routine skin care. An admission Physicians Progress Note dated 9/13/2023 reflects dermal stasis changes consistent with PVD . decreased sensation to feet. A Nursing Progress Note written on 11/23/2023 states During hs [hour of sleep] care LNA [licensed nursing assistant] noted heel leaking. When LPN [licensed practical nurse] took a look. It appears to be an old wound. It has a scab on it. The area around is very dry 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 record review and staff interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and therefore could not provide the requiered in-service education based on the outcome of the reviews, for 3 of 3 in the applicable sample. Findings include: A review of three Licensed Nursing Assistants (LNA) revealed there was no evidence that annual evaluations had been conducted; additionally, there was no evidence of yearly competencies in any of the five employee files. An interview on 11/29/2023 at approximately 4:39 PM with the Administrator and the Director of Nursing confirmed they could not produce documentation of either performance reviews or competencies related to the performance review.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess for and provide residents with the necessary behavioral health care and services to maintain the highest practicable, mental, and psychosocial well-being for 1 of 25 residents sampled. (Resident #48). Findings include; During a telephone interview on 11/27/23 at 3:04 PM conducted with Resident #48's Representative, the family is working with the facility regarding the resident's history of mental illness and trauma. The Representative has communicated the resident's history of growing up in an extremely abusive environment to the facility. Per record review there is no mental illness other than anxiety listed on the resident diagnosis/problem list, and a history of trauma is not reflected on the resident's diagnosis/problem list. The resident's care plan does not address a history of trauma. Review of Physician orders included an order for psychiatric evaluation/consult as needed (PRN). Resident #48 also has a physician's 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 staff interview and record review, the facility failed to ensure that monthly pharmacist drug regimen reviews, recommendations, and attending physician responses are completed and documented in the resident record for 3 of 5 sampled residents (Resident #11, #27, and #19). Findings include: 1. Per Resident # 11 record review, two progress notes from the facility's pharmacist consultant on 9/26/23 and 10/25/23 state, Medication regimen reviewed: see report for recommendations. Both reports were requested from the Director of Nursing (DON). Per interview on 11/29/23 at 4:00 PM, the DON confirmed that the documented reports containing the pharmacist's recommendations and any physician response taken could not be located or verified as having been completed. 2. Per record review Resident #27 receives Seroquel 25 milligrams (mg) once a day. Seroquel is an antipsychotic medication that requires the Abnormal Involuntary Movement Scale testing (AIMS) which is a rating scale that was designed to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder 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 on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals are kept in locked compartments only accessible to authorized personnel as evidenced by medication carts being left unlocked and unattended. Findings include: 1. Per an Adult Protective Services (APS) report filed in June of 2022 and forwarded to the State Agency, an Licensed Practical Nurse (LPN) abandoned their shift on 6/15/2022, leaving the medication cart keys with the medication cart, unattended. Per interview on 11/29/23 at approximately 11:00 AM, the Administrator confirmed that this incident occurred. They also provided a copy of an email from the former Director of Nursing confirming that this had occurred. 2. Per observation on 11/28/23 at approximately 12:00 PM, an RN was seen leaving their medication cart to administer a resident's medication in their room. The cart was unlocked and a drawer of resident medications was open. The RN confirmed that the medication cart should not be left like this. 3. Per observation on 11/29/23 at approximately 8:20 AM, an LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all alleged violations of neglect and/or misappropriation of resident property are reported immediately but not later than 24 hours after the allegation is made to the State Agency and Adult Protective Services. Findings include: Per an Adult Protective Services (APS) report filed in June of 2022 and forwarded to the State Agency, an Licensed Practical Nurse (LPN) abandoned their shift on 6/15/2022 and was suspected of taking narcotics from the medication cart. The LPN was an agency staff member, and the report was made by the LPN's travel agency. Per interview on 12/29/23 at approximately 11:00 AM, the Administrator confirmed that they remember this incident vaguely and that they were made aware of it by the Director of Nursing (DON) employed at the time. All they could provide was a copy of an email sent to them by the DON at the time, confirming that the LPN had left their shift early without handing off care to, or counting off the narcotics with, another nurse. There was an incorrect count on one 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 all alleged violations of neglect and/or misappropriation of resident property are thoroughly investigated, and all findings are reported to the State Agency within 5 days of the allegation. Findings include: Per an Adult Protective Services (APS) report filed in June of 2022 and forwarded to the State Agency, an Licensed Practical Nurse (LPN) abandoned their shift on 6/15/2022 and was suspected of taking narcotics from the medication cart. The LPN was an agency staff member, and the report was made by the LPN's travel agency. Per interview on 12/29/23 at approximately 11:00 AM, the Administrator confirmed that they remember this incident vaguely and that they were made aware of it by the Director of Nursing (DON) employed at the time. All they could provide was a copy of an email sent to them by the DON at the time, confirming that the LPN had left their shift early without handing off care to, or counting off the narcotics with, another nurse. There was an incorrect count on one of the narcotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a comprehensive person-centered care plan that addresses preventative measures related to skin care for 1 of 25 residents in the sample (Resident #3) and a resident's communication needs for 1 of 25 residents (Resident #52). Findings include: 1. Per record review Resident #3 was admitted to the facility on [DATE] with diagnoses that include heart failure, atrial fibrillation (an irregular, often rapid heart rate), and peripheral vascular disease (PVD) (circulation disorder). An admission Nursing Assessment completed on 9/12/23 reflects that there were no pressure or vascular wounds identified and the resident only required routine skin care. An admission Physicians Progress Note dated 9/13/2023 reflects dermal stasis changes consistent with PVD . decreased sensation to feet. Review of Resident #3's care plan does not identify dermal stasis changes or interventions related to the risks related to decreased sensation to feet such 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 staff interview and record review, the facility failed to provide services related to nutritional maintenance that meet professional standards for one of 5 sampled residents (Resident #18). Findings include: Per record review, Resident #18 was admitted to the facility on [DATE] with a diagnosis of Dementia. The record did not show any documented weights in the last 3 years for Resident #18. Per review of the care plan, there is a care plan problem that states, I am at risk for weight loss and altered fluid status. I have variable meal intake related to my decline in visual function and variations in my cognitive mood state. I am dependent on staff for all meal and fluid consumption. My Weight monitoring was discontinued 5/29/18. There is no weight monitoring order in Resident #18's chart. Per interview on 11/28/23 at approximately 3:00 PM, the Minimum Data Set (MDS) nurse confirmed that weights have been discontinued for Resident #18. They stated that the reason the weights were continued is for comfort…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide care for a resident with bilateral necrotic (death of cells or tissue through disease or injury) wounds as identified in physician's progress notes. Findings include: Per record review Resident #3 was admitted to the facility on [DATE] with diagnoses that include heart failure, atrial fibrillation (an irregular, often rapid heart rate), and peripheral vascular disease (circulation disorder). A Physicians Progress note dated 11/29/23 states [Name omitted] has PVD [peripheral vascular disease] and has had dermal stasis changes (caused by poor circulation and blood flow) to hands and feet since admission. [S/he] has thickened skin and red/purple discoloration to hands and feet. [S/he] has several small scabbed over necrotic areas that are present and have been being monitored without any signs of infection. One of those areas is on her left ring finger where had necrotic area to fingertip and today was noted to have lifted up nail…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review the facility failed to ensure the resident maintained or did not experience an avoidable decline in nutritional status related to the resident's oral/dental condition for 1of 4 residents sampled. Findings include: Per observation on 10/04/23 at 11:21 A.M. Resident #1 was seen sitting in the common area of the unit. The Licensed Nurse Assistant (LNA) set a lunch tray in front of Resident #1, uncovered the food, and left the resident to eat his/her meal. The resident was observed to sit back in his/her chair not attempting to eat his/her lunch. During interview at 11:30 A.M. Resident #1 was asked how his/her meal was, and the resident stated, I am not hungry. Resident #1 confirmed at this time that he/she had lost his/her dentures and stated, I don't know what happened to them. Resident #1 was asked if he/she was getting new dentures and the resident stated, I don't know. When asked if he/she had difficulty eating without his/her dentures Resident #1 stated, Well yes. Per record review, a Nutrition Weight loss follow-up 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.

Based on observation, interview, and record review the facility failed to ensure that a resident who lost the dentures were referred to dental services within 3 days and failed to ensure the resident could still eat adequately while awaiting dental services for 1 of 4 residents sampled. Findings include: Per observation on 10/04/23 at 11:21 a.m. Resident #1 was seen sitting in the common area of the unit. The Licensed Nurse Assistant (LNA) set a lunch tray in front of Resident #1, uncovered the food, and left the resident to eat his/her meal. The resident was observed to sit back in his/her chair not attempting to eat his/her lunch. During interview at 11:30 A.M. Resident #1 confirmed that he/she had lost his/her dentures stating, I don't know what happened to them. Resident #1 was asked if he/she was getting new dentures and stated, I don't know. When asked if she had difficulty eating without his/her dentures Resident #1 stated, Well yes. Per record review, a Nutrition Weight loss follow-up note dated 7/28/23 states After maintaining relatively stable weight from 2/6-7/11/23,…

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