Pine Ridge Post Acute

Based on observation, interview, and record review, the facility failed to provide services to maintain hearing methods to carry out the Activities of Daily Living (ADL) for 1 of 1 resident (Resident 4), reviewed for communication. This failure placed the resident at risk of not being able to hear and/or communicate and a diminished quality of life.Findings included.Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed that Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Review of the admission Minimum Data Set (an assessment tool), dated 12/30/2025, showed that Resident 4 used hearing aids.Review of Resident 4's hearing care plan, revised on 01/05/2026, showed the intervention to apply hearing aid to both ears. It further showed, Ensure hearing aid or other hearing appliance is in place and in working order.Observation on 03/19/2026 at 11:58 AM showed Resident 4 was not wearing their hearing aids. Resident 4…

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 feeding assistance was provided for 1 of 1 resident (Resident 8), reviewed for activities of daily living. This failure placed the resident at risk of unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition. The policy further showed that the appropriate care and services would be provided to residents in accordance with their plan of care including dining.Review of Resident 8's ADL care plan revised on 02/28/2026, showed an intervention for Eating: 1:1 [one to one] Feeding Assist.Observation on 03/23/2026 at 8:30 AM, showed Staff S, Certified Nursing Assistant, assisted Resident 8 set up their breakfast tray on their bedside table. At 8:32 AM, Staff S was no longer in Resident 8's room and Resident 8 was eating unsupervised. At 8:46…

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 clinical records were complete and accurate for 1 of 4 residents (Resident 13), reviewed for advance directives. This failure placed the resident at risk for medical complications and unmet care needs.Findings included.Review of the facility's policy titled, Advance Directives, reviewed in [DATE], showed a definition for Physician Orders for Life-Sustaining Treatment (POLST) that stated, This document, signed by an authorized health care professional, is a medical order that records residents' treatment wishes so that emergency personnel know what treatments to provide in the event of a medical emergency.Review of Resident 13's POLST form dated [DATE], showed Resident 13's code status (instructions to their medical team about what to do if a resident had no pulse and was not breathing) was Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation-emergency lifesaving procedure performed when the heart stops beating).Review of Resident 13'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was offered and/or provided for 2 of 5 residents (Residents 9 & 32), reviewed for immunizations. This failure placed the residents at risk for contracting the COVID-19 virus and related complications.Findings included.Review of the facility's policy titled, SARS-CoV-2 (COVID-19), dated 08/01/2024, showed, Center residents are offered recommended COVID-19 vaccinations upon admission and as eligible per CDC [Centers for Disease Control and Prevention] recommendations.Review of the CDC online document titled, Staying Up to Date with COVID-19 Vaccines, dated 11/19/2025, recommended a 2025-2026 COVID-19 vaccine for people ages 6 months and older. It further showed that getting the 2025-2026 COVID-19 vaccine is especially important if you.are living in a long-term care…

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 a fall incident was thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, showed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy further showed, The individual conducting the investigation as a minimum: .d. interviews the person(s) reporting the incident; . f. interviews the resident (as medically appropriate) or the resident's representative; . h. interviews staff members (on all shifts) who have…

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 revise an elopement care plan for 1 of 1 resident (Residents 1), reviewed for care plan revision. This failure placed the resident at risk for additional elopements, unmet care needs, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set assessment (MDS-a required assessment) dated 01/16/2025 showed Resident 1 admitted to the facility on [DATE]. The MDS assessment further showed the resident had moderately impaired thinking and used a wheelchair for mobility. Review of the admission elopement risk assessment dated [DATE] showed the resident was at risk of elopement. Review of the facility's investigative report dated 02/24/2025 showed that on 02/24/2025 at 3:00 AM, the local law enforcement called the facility and informed the nurse on shift that Resident 1 was found at a store approximately 1½ miles away from the facility in a gown and with a wheelchair that had the name of the facility on it.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary supervision resulting to an elopement for 1 of 1 resident (Resident 1), reviewed for accident hazards. This failure placed the resident at risk for additional elopements, injuries and pain. Findings included . Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool), dated 01/16/2025 showed Resident 1 admitted to the facility on [DATE]. The MDS assessment further showed the resident had moderately impaired thinking and used a wheelchair for mobility. Review of the admission elopement risk assessment dated [DATE] showed the resident was at risk of elopement. Review of the care plan dated 10/15/2024 showed Resident 1 was at risk of elopement/exit seeking/wandering related to mild thinking impairment, a history of elopement attempts, mood or behavior disorders and noncompliance. Review of the facility's investigative report dated 02/24/2025 showed that on 02/24/2025 at 3:00 AM, the local law enforcement called the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring were conducted for use of diuretics (medications that help move extra fluid and salt out of the body) for 2 of 7 residents (Residents 3 & 26), anticoagulants (medication that prevent blood clot) for 3 of 7 residents (Residents 26, 28 & 10), and antibiotic (medication that treats infections) for 1 of 7 residents (Resident 11), reviewed for unnecessary medications. These failures placed the residents at risk for receiving unnecessary medications, adverse side effects, and related complications. Findings included . A review of the facility's policy titled, Medication Administration General Guidelines, revised in January 2023, showed the last step in the process was to observe residents for medication actions/reaction and record in the nurse's notes as appropriate. The policy further showed that any noted adverse consequence should be reported to the prescriber and/or attending physician. A review of the facility's policy titled,…

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 the dishwasher temperature was checked and the sanitizing solution was tested routinely in accordance with professional standard for food service safety for 1 of 1 kitchen, reviewed for food services. These failures placed the residents at risk for food borne illness and a diminished quality of life. Findings included . Review of the facility policy titled, Dishwashing, adopted on 08/01/2024, showed, It is the policy of this center that dishes and other multi-use eating, preparation and serving items are cleaned and sanitized properly after each use. The policy further showed to log and check for proper temperatures. In an interview and joint observation on 12/16/2024 at 10:39 AM with Staff I, Dietary Director and Staff K, Dietary Aide, stated that they checked the dishwasher temperature and the sanitizer ppm [or PPM- parts per million - unit of measure for concentration] three times a day [breakfast, lunch and dinner]. Staff K stated that they logged daily the dishwasher temperature and the sanitizer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) was followed for Resident 119 and failed to ensure clean linen were handled properly for room [ROOM NUMBER]. In addition, the facility failed to properly disinfect glucometers (a device to measure how much sugar is in the blood) for 2 of 2 residents (Residents 121 & 114) and sanitize medical equipment for 2 of 2 residents (Residents 211 & 3), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility policy titled, Enhanced Barrier Precautions, revised in March 2024, showed EBPs were used to reduce the transmission of MDRO to residents. EBPs required gown and glove use during high contact resident care activities dressing 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 interview and record review, the facility failed to inform the resident and/or their representative before administering psychotropic (mind altering) medications for 1 of 5 residents (Resident 10), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their medications. Findings included . Review of the facility policy titled, Psychotropic Medication Use, revised in July 2022, showed: Residents will not receive medications that are not clinically indicated to treat a specific condition . The policy further showed that when determining whether to initiate, modify, or discontinue medication therapy, the IDT [Interdisciplinary Team] conducts an evaluation of the resident. The evaluation will attempt to clarify whether: other causes for symptoms (including symptoms that mimic a psychiatric disorder [disturb thinking and altered mood and behavior]) have been ruled out;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable bed sheet was provided for 1 of 1 resident (Resident 10), reviewed for accommodation of needs. This failure placed the resident at risk for unmet care needs, insufficient sleep or discomfort, and a diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed that appropriate care and services would be provided for resident who were unable to carry out ADLs independently. Review of the admission Minimum Data Set (an assessment tool) dated 11/10/2024 showed Resident 10 required maximum physical assist for bed mobility and total assist for transfers. On 12/12/2024 at 10:16 AM, Resident 10 stated, they [the facility] do not have fitted sheets, that they wake up at night sweaty with their back lying on the cold [mattress] vinyl [water proof synthetic material], the flat sheet slips behind my back, it is uncomfortable, 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.

Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care-a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so) was obtained and completed for 1 of 10 residents (Resident 4), reviewed for advance directives. This failure placed the resident and their representative at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility policy titled, Advance directives, revised in September 2022, showed that prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and /or his or her legal representative, about the existence of any written advance directives. The policy further showed that if the resident or representative indicated that they had not established an advance…

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 written transfer/discharge notice to the resident and/or their representative for 1 of 1 resident (Residents 27), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . Review of the facility policy, titled, Notice of Transfer or Discharge, reviewed in April 2020, showed, It is the policy of this center to provide written notice of transfer/discharge in accordance with state and federal regulations. Review of Resident 27's discharge Minimum Data Set (an assessment tool) dated 10/03/2024 and 11/06/2024, showed Resident 27 was discharged to an acute hospital on [DATE] and on 11/06/2024. Review of the nursing progress notes dated 10/03/2024 and 11/06/2024, showed Resident 27 had a change in condition and was transferred to an acute hospital. Review of Resident 27's Electronic Health Record…

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 bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered/provided for 1 of 1 resident (Resident 27), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital. Findings included . Review of the facility policy, titled, Bed Hold, revised on 04/07/2023, showed, It is the policy of this facility that upon transfer to offer the resident and/or resident representative the option to hold the bed. The policy further showed, Upon transfer or discharge the nursing department will provide the resident and/or resident representative a copy of the bed hold policy. Review of Resident 27's discharge Minimum Data Set (an assessment tool) dated 10/03/2024, showed Resident 27 was discharged to an acute hospital on [DATE]. Review 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 interview and record review, the facility failed to accurately assess 2 of 21 residents (Residents 10 & 11), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding antibiotic (medication to treat infection) use and surgical wound care treatment placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable.…

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 the Preadmission Screening and Resident Reviews (PASARR-an assessment to ensure individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) Level I was completed for 1 of 7 residents (Resident 11), reviewed for PASARR screening. This failure placed the resident at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, PASRR Process, reviewed in March 2019, showed that upon admission to the facility the Admissions Coordinator, Medical Records Director or designee will ensure that a PASRR Level I was included in the admission paperwork . If there is no PASRR Level I, the Medical Records Director or designee will contact the hospital to obtain a Level I PASRR . If a Level II Evaluation is indicated the Social Worker will ensure within a timely period that a LMHP…

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 State PASARR (Pre-admission Screening and Resident Review-an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facility for long term care) Coordinator after a significant change in status occurred for 1 of 7 residents (Resident 27), reviewed for PASARR. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . A review of the facility's policy titled, PASRR Process, reviewed on March 2019, showed, If there is a significant change in condition that could affect their diagnosed need for a PASARR II, staff should refer for a NEW PASRR Level II. The policy showed, The Level I evaluator will determine if the resident's current care needs are able to be met at the NF [nursing facility]. The policy further showed to follow-up as needed 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 observation, interview, and record review, the facility failed to develop and/or implement care plans for 2 of 19 residents (Residents 11 & 20), reviewed for care planning. The failure to develop person-centered care plans for skin impairment, antibiotic (medication that treats infection) use, urostomy (a surgical procedure that creates an [ostomy-artificial opening] to drain urine), vision, pain, and nail care placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning - Interdisciplinary Team, revised in March 2022, showed that the interdisciplinary team was responsible for the development of resident care plans. Comprehensive, person-centered care plans were based on resident assessments and developed by an interdisciplinary team. RESIDENT 11 Resident 11 admitted to the facility on [DATE]. Review of Resident 11's admission Minimum Data Set (MDS- an assessment tool) dated 12/01/2024 showed 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 observation, interview, and record review, the facility failed to provide necessary assistance with nail care for 1 of 1 resident (Resident 20), reviewed for Activities of Daily Living (ADL) care. This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living, Supporting, revised in March 2018, showed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Resident 20 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the body cannot properly regulate blood sugar levels) and legal blindness (loss of vision). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician orders were implemented and followed in accordance with professional standards of practice for 1 of 1 resident (Resident 11), reviewed for quality of care. This failure placed the resident at risk for not receiving necessary care services, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Orders, revised in November 2014, showed that the facility established uniform guidelines in the receiving and recording of medication orders. Orders must be written and maintained in chronological order. When recording treatment orders, specify the treatment, frequency and duration of the treatment. Review of the face sheet printed on 12/12/2024 showed Resident 11 admitted to the facility on [DATE]. Review of the hospital discharge orders dated 11/25/2024 showed Resident 11 discharged with abdominal (stomach area) drains (tubes placed near surgical incisions to remove pus, blood…

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 maintain, label/date, and properly store oxygen tubing, nasal cannula (flexible tubing that sits inside the nose and delivers oxygen), and nebulizer (device used to administer medication in the form of a mist that is inhaled into the lungs) mask for 3 of 7 residents (Residents 5, 32 & 120), reviewed for respiratory care. In addition, the facility failed to follow Resident 120's physician orders for oxygen use. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included . A review of the facility's policy titled, Respiratory Treatment, revised in 08/21/2024, showed residents received respiratory treatments and monitoring per their physician orders, standard of practice and care plan. It showed that oxygen cannula and tubing would be changed as needed if soiled or damaged. It showed that when the nasal cannula and/or the nebulizer mask were not in use, they would 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a required assistive device (use of gait belt) and hands on contact were provided during therapy for 1 of 3 residents (Resident 1), reviewed for falls. This failure placed the resident at risk for fall with injury, unmet care needs, and a diminished quality of life. Findings included . Review of a nursing progress notes dated 03/20/2024, showed Resident 1 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones), a hyperextension injury (disruption of the spinal column) of the back that was surgically repaired, and history of falls. Further review of the nursing progress notes showed Resident 1 was able to make needs known and required assist of one person for activities of daily living. Review of a nursing progress note dated 03/22/2024, showed Staff B, Assistant Director of Nursing, was notified of a witnessed fall while Resident 1 was in the therapy gym and worked with a therapist. The 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 allegations of abuse were thoroughly investigated for 4 of 4 residents (Residents 4, 5, 6 and 7), reviewed for abuse investigations for misappropriation of property. Residents 4, 5, 6, and 7 who had impaired thinking and lacked the ability to provide information about their bank accounts or purchases made using their accounts, had representatives responsible for their finances were not included in the facility's abuse investigations. This failure placed the residents at risk for financial exploitation. Findings included . Review of the facility policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting and Protection, dated 01/2023, showed it is the policy of this center to prevent and prohibit all types of abuse and misappropriation of property, protect our residents from abuse. RESIDENT 4 Review of the 5-day admission Minimum Data Set assessment (MDS-an assessment tool) dated 12/07/2023, showed Resident 4 was readmitted…

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 implement written abuse policies and procedures related to misappropriation of resident property for 1 of 3 residents (Residents 1), reviewed for abuse investigations. This failure caused Resident 1 to lose a substantial amount of money when staff used their financial accounts for personal gain and placed other residents at risk for misappropriation of property. Findings included . Review of the facility policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting and Protection, dated 01/2023 showed, it is the policy of this center to prevent and prohibit all types of abuse and misappropriation of property, protect our residents from abuse. Further review of the facility policy showed, Misappropriation of residents property is defined as the illegal or deliberate use of resident's resources for the personal profit or gain of another person; or spending resident funds without the resident's consent, or if the resident is not capable of consenting, spending resident funds for items or services from…

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

Based on observation, interview, and record review, the facility failed to ensure food items in the refrigerator were labeled and dated. Additionally, the facility failed to ensure the kitchen thermometer was properly sanitized between use for 1 of 1 kitchen. These failures placed the residents at risk for cross contamination, food borne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life. Findings included . Review of the facility's policy titled, Discard date, reviewed in February 2019, showed food will be dated and prepared for storage to prevent deterioration, dehydration [lack of total body water, which could cause physical and mental deterioration] or food borne illness. All leftover food will be labeled with the discard date to include month and day. Review of the facility's policy titled, Thermometer-Cleaning and Sanitizing, reviewed in February 2019 stated, Sanitize thermometer before and in between each food item being temped. Sanitize using an approved food-contact surface sanitizing solution, such as alcohol swabs,…

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 allegation of abuse was reported to the State Agency within the required timeframe for 1 of 3 residents (Resident 35) reviewed for abuse. This failure placed the resident at risk for potential unidentified mistreatment and lack of protection due to unrecognized abuse. Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), a nursing home employee (or other mandated reporter) is required to make a report if they had reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. It also showed, Federal law requires the facility to report all allegations of abuse or neglect. This would include taking seriously any allegation from residents or others with a history of making allegations. Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify abuse allegation and failed to ensure the abuse allegation was thoroughly investigated for 1 of 3 residents (Resident 35) reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting and Protection, revised in January 2023, showed that it is the policy of the facility to prevent and prohibit all types of abuse, neglect, misappropriation of property and exploitation. It also showed that they would investigate allegations of abuse. Resident 35 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool) dated 07/23/2023, showed Resident 35 had moderately impaired cognition and required extensive assist with activities of daily living. On 08/21/2023 at 10:40 AM, Resident 35 stated that an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 2 of 6 residents (Resident 40 and 4) reviewed for Minimum Data Set (MDS- an assessment tool). The failure to ensure accurate assessments regarding vision and discharge status placed the residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019 showed, accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, Quarterly, Annual, Significant Change in status). The RAI manual also states that the observation period (also known as the Look-back period) is the time-period over which the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive care plans for 2 of 11 residents (Residents 2 & 308) reviewed for comprehensive care plans. The failure to develop and implement comprehensive care plans placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . RESIDENT 2 Resident 2 admitted to the facility on [DATE] with a diagnosis of legal blindness (vison is significantly impaired). Review of Resident 2's admission Minimum Data Set (MDS-an assessment tool), dated 08/11/2023, showed Resident 2's vision was severely impaired. On 08/23/2023 at 12:25 PM, Resident 2 stated they were legally blind and that they can only see outlines. Resident 2 stated that staff provided orientation of their meal using the clock position and that if there were new staff, they would need to be informed to orient Resident 2 with their meals. Review of Resident 2's care plan, printed on 08/24/2023 at 12:23 PM, showed there was no care plan…

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 services provided met professional standards of practice for Lidocaine 4% patch (pain medication) administration for 1 of 3 residents (Resident 3) observed for medication administration. This failure placed the resident at risk for medication errors and adverse outcomes. Findings included . Review of the facility's policy titled, Medication Administration General Guidelines, dated January 2023, showed, Medications are to be administered at the time they are prepared. Observation and interview on 08/25/2023 at 8:23 AM, showed Staff F, Registered Nurse, prepared medications for Resident 3. Staff F took one Lidocaine patch that was already open and dated from the medication cart. Further observation showed a Lidocaine box filled with opened patches dated 8/25. Staff F stated that they prepared the Lidocaine patches ahead of time and that a lot of residents used Lidocaine patches in the morning. Staff F stated that they opened all the packages in the box, dated them, placed them back in the box and 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 interview and record review, the facility failed to ensure physician orders (POs) were checked for drug allergies/contraindications prior to medication administration for 1 of 5 residents (Resident 7) reviewed for unnecessary medications. This failure placed the resident at risk for allergic reactions, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Administration General Guidelines, dated January 2023, showed, Note any allergies or contraindications the resident may have prior to medication administration. Resident 7 admitted to the facility on [DATE]. Review of Resident 7's electronic health record under the Allergy tab, dated 06/16/2023, showed the resident had an allergy to Acetaminophen (or Tylenol, medication that treats minor aches and pains) that could cause rash of body [rashes]. Review of Resident 7's August 2023 Medication Administration Record (MAR), showed an order dated 08/11/2023 for Acetaminophen oral tablet,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard infection prevention and control precautions were implemented to prevent the transmission of a highly transmissible disease, Methicillin-Resistant Staphylococcus Aureus (MRSA, a bacteria resistant to many of the antibiotics [used to treat infections]) by not implementing appropriate Transmission Based Precautions (TBP, safe guards put in place to help prevent the spread of disease) for 1 of 1 resident (Resident 27) reviewed for infection control. Additionally, the facility failed to ensure proper hand hygiene practices were followed during pressure ulcer dressing change for 1 of 1 resident (Resident 309) reviewed for pressure ulcers. These failures placed the residents, visitors, and staff at an increased risk for infection, related complications, exposure to a highly transmissible disease, and a diminished quality of life. Findings included . Review of the facility's policy titled, Transmission Based Precautions, revised…

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.