Life Care Center Of Mount Vernon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a dignified and homelike experience and promote the rights of 1 of 1 resident reviewed for dignity (266), 2 of 3 (Residents 12 and 44) reviewed for urinary catheter use, 1 of 1 (Residents 4 and 11) dining observations and concerns voiced in resident council meeting (Residents 8, 11, 18, 24, 54, 214 and 265) residents reviewed for dignity when staff failed to interact with residents in a dignified manner, and failed to cover urinary bags, These failures placed residents at risk for feelings of emotional distress, frustration, humiliation, embarrassment, diminished self-worth and or quality of life, and a potential decline in nutritional status. Findings included . Review of the facility policy titled Preservation of Residents' Rights, reviewed 09/26/2024, showed each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff, or volunteers will…

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

Based on observation, interview and record review, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the health records for 20 residents (Residents 7, 33, 35, 40, 44, 45, 46, 48, 51, 56, 57, 58, 59, 60, 114, 115, 119, 120, 121 and 165) on 1of 3 units reviewed for privacy and confidentiality. This failure placed residents at risk for violation of a resident's right to privacy and/or confidentiality, unwanted dissemination of personal health information, emotional distress and a diminished quality of life. Findings included . Review of the facility's policy titled, Confidentiality of Information approved 02/04/2025, documented, Associates are responsible and accountable for the integrity and protection of business information and protected health information. They must protect information entrusted to them and must not inappropriately disclose, modify, or destroy such information. Associates who inappropriately disclose confidential information (either purposefully or through casual…

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 and interview, the facility failed to ensure the facility was maintained in a clean, comfortable, homelike and safe environment, for 2 of 3 halls including resident rooms (315, 102, 106, and 114). Failure to ensure the facility was free from dust, kept clean, and had laundered privacy curtains placed residents at risk for decreased quality of life, compromised dignity and potential infection control issues. Findings included . <room [ROOM NUMBER]- Bed 1> In an observation on 04/02/2025 at 9:56 AM, three large areas of brown matter were on the bottom portion of the outside of the privacy curtain. <room [ROOM NUMBER]- Bed 2> In an observation on 04/02/2025 at 2:45 PM, heavy dust was noted in the ceiling vent, around the privacy curtain rail and the hooks. <room [ROOM NUMBER]- Bed 2> In an interview on 04/03/2025 at 8:51 AM, Resident 46 stated their bathroom needs to be cleaner. The resident stated they share a bathroom with the room on the other side and often there was bowel movement on 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 have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of concerns for 3 of 3 resident council's (January, February and March 2025), who verbalized complaints during a Resident Council (RC) meeting. The facility's failure to initiate, log, investigate verbalized concerns, inform residents of the facility's findings and the actions taken, if any, prevented the facility from identifying care trends and determining if actions taken to resolve grievances were effective. These failures led to residents repeatedly reporting the same care issues without resolution and placed them at risk for feeling frustrated, unimportant, with diminished self-worth and decreased quality of life. Findings included . Review of the facility policy, Grievance Program (Concern and Comment) revised 01/07/2025 documented the resident has the right to, and the facility must make prompt efforts by the facilty to resolve grievances the resident may have. 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 interviews, and record reviews, the facility failed to conduct thorough investigations for 3 of 3 allegations of abuse and/or neglect for (Residents 117, 164, and 216), 3 of 4 falls (Residents 46, 115, and 218), and 1 of 1 medication error (Resident 24) whose investigations were reviewed for thorough investigations. The failure to conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred. These failures placed residents at risk for repeated incidents and injuries. Findings included . Review of the facility policy titled, Incident and Reportable Event Management, reviewed 09/25/2024 stated the facility would provide an environment free from accident hazards by identifying hazards and risk, evaluating and analyzing, implementing interventions, and monitoring the effectiveness and modification of interventions if necessary . to prevent recurrence the facility should evaluate what happened,…

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 resident's care plan was reviewed, updated, and implemented for 1 of 4 residents (Resident 218) for falls and failed to ensure residents who engaged in smoking were assessed for adequate supervision to prevent injury from burns for 2 of 2 residents (Residents 24 and 54) reviewed for accidents. These failures placed all residents at risk for lack of consistent interventions, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy titled, Fall Management, revised 03/11/2025 documented the facility will assess residents upon admission/readmission, quarterly and with change in condition, and with any fall event for risks and will identify appropriate interventions to minimize the risk of injury related to falls, facility was required to provide adequate supervision to prevent accidents. <FALLS> Resident 218 was admitted to the facility on [DATE] with diagnoses that included the history 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 observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in resident (Residents 14, 46, 5, 116, and 216) and resident council group interviews. The facility had insufficient staff to ensure residents received Restorative Nursing Program (RNP) services as evidenced by Restorative Nursing staff removed from restorative nursing duties to cover direct care duties impacting 2 of 4 residents (Residents 4, and 25) reviewed for limited ROM and restorative nursing services. These failures placed residents at risk for a delay in repositioning and toileting assistance, a decrease in resident safety and health needs and a diminished quality of life. Findings included . Review of the facility assessment dated [DATE], showed the facility assessment did not address the staffing needs specific to the resident population and acuity of the facility. <RESTORATIVE NURSING SERVICES> <Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 5 of 8 residents (Residents 5, 8, 11, 24 and 54) reviewed for medically related social services. Failure to assure resident safety, ensure residents were informed of their care, treatment and services available to them, and continuously monitor, thoroughly assess, and advocate for resident's rights placed residents at risk for harm, diminished quality of life and unmet care needs. Findings included . According to the facility's Director of Social Services (SSD) job description, dated 12/06/2016, the primary purpose of the SSD was to plan, organize, develop, and direct the overall operation of the facility's Social Services Department in accordance with applicable laws, regulations and company standards. The facility's established policies and procedures were to ensure that medically related social 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 observation, interview and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in the facility kitchen. This failure placed residents at risk for cross-contamination and foodborne illnesses. Review of document titled 'Sanitation and food safety' with a revision date of 09/08/2022 documented under Procedure that: Staff will wash their hands. * After handling raw or unwashed foods * After handling dirty dishes, soiled equipment or utensils * During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. * Before donning gloves to initiate a task that involves working with food. During an observation on 04/02/2025 at 12:47 PM, Staff EE, Food Service Director (FSD), entered the kitchen from his office, did not wash his hands, put on gloves, and prepared chicken for the residents. During an observation on 04/02/2025 at 2:24 PM, Staff DD, dietary aid, placed dirty dishes into the dishwasher. Once the dishwasher had completed its cycle, the clean dishes…

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 document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Findings included . Review of the facility assessment provided by the facility dated 07/30/2024, included the names of the prior facility Administrator and Director of Nursing Services. The facility assessment only included a Part I template and failed to include the following required elements: - The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; - The staff competencies that are necessary to provide the level and types of care needed for the resident population; - The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; The facility's resources, including but not limited to, all buildings and/or other physical structures…

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 the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings included . Review of the facility QAPI plan/policy dated 01/21/2025 documented the facility's QAPI committee was responsible for ensuring compliance with state and federal requirements and for continuous improvement in quality of care and customer satisfaction. Review of the facility [NAME] 3 facility report showed the following repeat deficiencies from Statement of Deficiencies dated 08/06/2024: F - 0550 - 483.10(a)(1)(2)(b)(1)(2) - Resident Rights/exercise Of Rights S-S= E F - 0610 -…

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 the physical environment accommodated resident needs for 2 of 2 residents (Residents 4, and 15) reviewed for accommodations of needs. This failure placed residents at risk for falls and unmet care needs. Findings included . <Resident 4> Resident 4 was a long-term resident of the facility with diagnoses that included traumatic brain injury (TBI) (an injury to the brain caused by an external force) and a voice and resonance disorder (functional speech deficits). Review of Resident 4's Care Plan on 04/03/2025 documented the following: - Resident 4 had a soft-touch pad call light. - Staff were to ensure the call light was within reach and respond promptly to all requests for assistance. During an observation on 04/03/2025 at 2:03 PM, Resident 4's call light was a push button style call light. Resident 4 pushed the call light a few times, and it was observed not to turn on. An unknown staff member entered the room, checked to see if 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 the recommendation of the Level II Preadmission Screen and Resident Review (PASARR) evaluation were incorporated into the plan of care upon receiving recommendations for 1 of 6 sampled residents (Resident 24) reviewed for coordination of PASARR and assessments. This failure placed residents at risk of not receiving the necessary mental health services and a diminished quality of life. Findings included . Review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR), reviewed 09/26/2024 the Level II PASARR determination and evaluation report specify services to be provided by the facility .the recommendations are then incorporated into the person-centered care plan. Resident 24 admitted to the facility on [DATE] with diagnoses that included bipolar disorder (mental illness with extreme mood shifts), anxiety and post-traumatic stress disorder (PTSD). The admission Minimum Data Set assessment dated [DATE], the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 3 of 6 residents (Residents 15, 46, and 114) reviewed for pre-admission screening and resident review (PASRR), received the required screening for necessary services. This failure placed the residents at risk for unidentified mental health needs. Findings included . Review of the facility policy titled, Pre-admission Screening and Resident Review, reviewed 09/26/2024 documented the facility will ensure that potential admissions are be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASRR Level I and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual by the state designated authority, known as PASARR Level…

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 review and revise care plans for 2 of 6 residents (Residents 30 and 114) reviewed for care planning. These failures placed the residents at risk for unmet care needs, adverse health effects and a diminished quality of life. Findings included . Review of the facility policy titled, Comprehensive Care Plans and Revisions, revised 08/22/2023, showed the facility would ensure the timeliness of each resident's person-centered, comprehensive CP, and that the comprehensive CP was reviewed and revised by an interdisciplinary. The policy showed the facility would monitor residents over time to identify changes in condition and update the CP as warranted to reflect goals and interventions. <RESIDENT 114> Resident 114 admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease. In an interview and observation on 04/02/2025 at 3:20 PM, Resident 114 was observed to have edema bilaterally with their shoes indenting into the…

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

Based on observation, interview, and record review, the facility failed to provide 1 of 1 resident (Resident 4) access to a communication device. This failure placed the resident at risk for unmet care needs by decreasing the resident's ability to participate in daily living activities. Findings Included . <Resident 4> Resident 4 is a long-term resident of the facility. Resident 4's diagnosis includes traumatic brain injury (TBI, an injury to the brain caused by an external force), voice and resonance disorder (functional speech deficits). During a joint interview on 04/03/2025, at 4:04 PM, Collateral Contact 2 (CC2) and Collateral Contact 3 (CC3) stated that the facility is no longer using Resident 4's Tobii communication device. They stated that they were told staff had not been trained on the device, which had resulted in staff members not knowing how to operate it. A review on 04/04/2025 of the document named 'Care Plan' documented that Resident 4 could see, hear, and understand well but was unable to speak. Resident 4 could answer 'yes' or 'no' questions with a thumbs 'up or…

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 there was an activity program to meet individual resident needs for 3 of 4 residents (Residents 4, 15, and 25) reviewed for activities. This failure placed residents at risk of becoming bored and depressed when not provided meaningful engagement throughout the day, and a diminished quality of life. Findings included . RESIDENT 25 Resident 25 admitted [DATE] with diagnoses which included history of a stroke and vascular dementia and required total assistance for activities of daily living and participation in activities. Review of the Annual Minimum Data Set (MDS, a required assessment tool) dated 12/29/2024, documented that Resident 25 did not participate in the activity interview and staff responded to the questions on behalf of the resident. The MDS identified the resident activity preferences as: listening to music, being around animals/pets, doing things with groups, participating in favorite activities, going outside when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure of 2 of 6 residents (Residents 4 and 114) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. These failures placed residents at an increased risk of adverse health events, discomfort and unmet care needs. Findings included . <EDEMA MANAGEMENT> <RESIDENT 114> Resident 114 admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease. Review of the admission note on 03/11/2025 at 3:48 PM showed Resident 114 had a history of hyperlipidemia (high cholesterol) and hypertension (high blood pressure). There was no mention of edema (swelling). Review of the residents diagnoses list in the clinical record showed they had no known cardiac related diagnoses including hyperlipidemia and hypertension. In an interview and observation on 04/02/2025 at 3:20 PM, Resident 114…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services to prevent pressure ulcers for 2 of 3 residents (Residents 15 and 46) reviewed for pressure ulcers. The facility failed to implement a turning/repositioning program for residents with decreased mobility and decreased functional ability resulting in the development of stage II pressure ulcers. Resident 46 did not receive thorough and ongoing skin assessments that included observing for change in risk factors, pressure points, and evaluating effectiveness of interventions. These failures placed Resident 15 and 46 and other residents at risk for the development of a pressure ulcer. Findings included . The National Pressure Ulcer (also known as a pressure injury) Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages included: - A pressure injury (PI) was a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can…

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 treatment and services were provided to increase, maintain and/or prevent a decline in Range of Motion (ROM) mobility for of 2 of 4 residents (Resident 4, and 25) reviewed for limited ROM and restorative nursing services. The facility's failure to ensure assessment and implementation of restorative nursing services placed residents at risk for functional decline and increased dependence on staff for activities of daily living. Findings included . <RESIDENT 25> Resident 25 admitted [DATE] with diagnoses which included history of a stroke and vascular dementia and bilateral contractures of the shoulders, elbows and hands. Resident 25 was wheelchair bound and required total assistance for activities of daily living and participation in activities. In an observation on 04/03/2025 at 3:22 PM, Resident 25 was in their room sitting up in a tilt in space wheelchair. Resident 25's lower body was turned toward the left with one leg dangling 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate hydration for 2 of 2 residents (Residents 15 and 266) reviewed for hydration. These failures placed residents at risk for inadequate intake and dehydration and for a decreased quality of life. Findings Included . <RESIDENT 266> Resident 266 was admitted to the facility on [DATE]. Resident 266 was severely cognitively impaired and had a diagnosis of dementia (a syndrome that typically leads to deterioration in cognitive functioning). A review of the document named 'Nutrition: Assessment/Nutritional Data Collection' dated 04/07/2025 documented that Resident 266's daily fluid needs are 1386-1438 milliliters. During observations on 04/03/2025 at 1:59 PM and 3:22 PM, Resident 266 was resting in bed with no fluids at the bedside. During an observation on 04/04/2025 at 9:38 AM, Resident 266 was in bed with breakfast on the bedside table, which included a 4-ounce cup of juice that they had already drunk. No other fluids were…

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 pain management was provided in accordance with the resident's physician's orders for one of three residents (Resident 164) reviewed for pain management. Failure to ensure prompt delivery and administer medications per the provider orders resulted in Resident 164's dissatisfaction with their care contributing to discharge against medical advice from the facility and placed residents at risk for diminished quality of life. Findings included . Resident 164 admitted [DATE] with diagnoses which included aftercare for a total hip arthroscopy following a complicated hospital stay. Resident 164 discharged against medical advice on 03/19/2025. Review of a grievance form left by the resident on 03/19/2025 stated my pain medication seemed to be a problem for them to let me have every time I was put off for 15-30 minutes and by the time I received it I hurt so bad it wasn't enough to help. The grievance form was escalated to a reportable allegation 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 observation, interview and record review, the facility failed to ensure mental and psychosocial health needs were identified and met for 2 of 2 residents (Residents 30 and 114) reviewed for behavioral-emotional health. Failure to identify mental health needs and utilize person-centered interventions developed by an interdisciplinary team placed residents with behavioral needs, at risk for unidentified behavior triggers, unmet behavioral needs, refusal of care, self-neglect, lack of behavioral services and support, loss of dignity, loss of autonomy and diminished quality of life. Findings included . <RESIDENT 114> Resident 114 was admitted to the facility on [DATE] with diagnoses to include depression, anxiety disorder and cognitive communication deficit. Review of the admission Minimum Data Set (MDS-an assessment tool) assessment on 03/14/2025 showed Resident 114 was taking an antidepressant. The mood interview showed the resident reported that they had little interest or pleasure in doing things, felt…

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 act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner for 2 of 5 residents (Residents 14, and 30) reviewed for unnecessary medications. Failure to act timely on the pharmacist's recommendations placed all residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of the facility policy titled, Medication Regimen Review, revised 06/01/2024, the provider should address the consultant pharmacist's recommendations no later than their next scheduled visit. <RESIDENT 14> Resident 14 admitted to the facility on [DATE] they have diagnoses that include hyperlipidemia (high levels of fats in blood), diabetes, and history of heart attack. In a review of Resident 14's MRR recommendations dated 11/21/2024 the pharmacist documented a fasting lipid panel (blood test to check the levels of fats in the blood) was ordered on 08/07/2024…

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 2 of 5 sampled residents (Residents 41 and 46) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for the use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors, updating care plans and complete consents. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse side effects, and diminished quality of care. Findings included . <RESIDENT 41> Resident 41 was admitted to the facility on [DATE] with diagnoses which included dementia without psychosis, anxiety and major depression. Review of Resident 41's physician's orders documented that the resident had orders for two different medications classified as antipsychotics (Quetiapine, for…

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

Based on interview and record review, the facility failed to consistently offer and/or provide a nutritional snack when ordered or requested for 4 of 6 resident's (5, 11, 54, and 265) residents reviewed for dining preferences. This failure to provide nutritional snacks at non-traditional times and meet resident choices placed residents at risk for inadequate nutrition. Findings included . <REVIEW OF RESIDENT COUNCIL MINUTES> Review of the resident council meeting minutes on 01/28/2025 documented the concern of residents wanting more snacks and different snack options. <RESIDENT COUNCIL> In an interview with resident council representatives on 04/07/2025 at 11:36 AM, Resident's were asked do you received snacks at bedtime or when you request them? Residents responded. Resident 5 stated they asked for snacks and staff tells them there are only saltine crackers available. Resident 11 stated the staff fill the snack bins after breakfast and lunch and will give you graham crackers. Resident 11 stated they would like a snack at 10:30 at night since they are up late but staff report 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 2 of 3 units. The facility failed to ensure the staff used appropriate hand hygiene practices during personal care, and disposal of soiled garbage in accordance with infection control standards of practice. This failure placed all residents and staff at risk of potential infection. Findings included . Review of the facility polity titled, Hand Hygiene, revised 12/04/2020, documented hand hygiene should be completed before and after any resident contact, before applying gloves (donning), after removal of gloves (doffing), contact with potential contaminated personal protective equipment and after any potential contact with infectious materials i.e., blood, bodily fluids, or contaminated surfaces. Review of the facility policy titled, Clostridium Difficile reviewed 06/04/2024 documented the facility would care for residents with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident records were completed accurately for 3 of 3 residents (Residents 1, 2, and 3) reviewed for accurate electronic medical record documentation related to the route of medication administration of residents who were to have nothing by mouth (NPO). These failures placed residents at risk to receive inaccurate routes of medications, harm, and diminished quality of life. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing) and malnutrition. Review of Resident 1's current physician orders, dated 03/10/2025, showed they were to have NPO and had an enteral feeding tube (feeding tube in stomach or intestine). Review of Resident 1's care plan showed their diet order was NPO, and had an enteral feeding tube, dated 03/10/2025. Review of Resident 1's medication administration record (MAR) dated March 2025 showed the resident's diet was NPO, and had the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure resident rights were being followed for 2 of 3 (Resident 1 and 2) residents when a scheduled appointment was canceled for Resident 1 without their knowledge, and the facility did not answer phone calls and Resident 2's guardian was unable to speak with staff or Resident 2. These failures placed residents at risk for unmet care needs, delays in communication or care, and decreased quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD- lung disease that causes breathing problems and restricted air flow), coronary artery disease (a condition affecting the heart that causes damage or disease in the heart's major blood vessels), and left foot pain. Review of Resident 1's admission progress note dated 05/23/2024 at 7:44 PM, showed Staff C, Licensed Practical Nurse (LPN) admission Nurse, documented Resident 1 was alert and oriented and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a thorough investigation was completed for 1 of 3 residents (Resident 3) reviewed for investigations. This failure placed residents at risk for new or continued abuse, possible harm, and a decreased quality of life. Findings included . Resident 3 admitted to the facility on [DATE] with diagnoses to include right hip fracture, history of falls, and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 3's admission Minimum Data Set (MDS- assessment tool), dated 05/27/2024, showed the resident was cognitively intact. Review of Resident 3's progress note dated 6/27/2024 at 5:07 PM, showed Staff E, Registered Nurse (RN) Care Manager, documented that Resident 3 reported that a staff member had acted angry during repositioning the night before. Review of the facilities investigation showed there was no statement from Staff F, Nursing Aide Certified (NAC), related to the abuse allegation.…

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 the environment was clean, comfortable, and homelike for 3 of 3 halls with stained carpet and failed to provide maintenance for resident rooms with broken blinds. These failures placed residents at risk for diminished dignity, and diminished quality of life. Findings included . <BROKEN BLINDS> In an observation on 04/22/2024, room [ROOM NUMBER] was observed to have broken blinds in the window. In an observation on 04/23/2024 at 9:08 AM, room [ROOM NUMBER] was observed to have broken blinds in the window. In an observation on 04/30/2024 at 2:18 PM, room [ROOM NUMBER] was observed to have broken blinds in the window <CARPETS> Observation of the facility carpeting on 05/01/2024 at 1:35 PM, showed: - A dark stained area extending approximately two feet in a semicircle at the residents' doorways in Rooms 101, 102, 103, 104, 205, 404. - A grapefruit sized dark stained area near room [ROOM NUMBER]. - Two cantaloupe sized areas of staining…

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 1 of 3 sampled residents (Resident 55) was free from physical abuse by a cognitively impaired resident (Resident 57) who had a known history of unwanted touching and sexual aggression towards other residents (Resident 13 and 52). Failure to consistently provide supervision, and prevent unwanted touching by Resident 57, placed residents at risk for abuse, feeling safe, injury, and a potential decrease quality of life. Findings included . Review of the facility's policy titled, Abuse Prevention updated 07/18/2023, stated it is the policy to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. The facility staff were to identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as verbally aggressive behavior, sexually aggressive behavior, wandering into other's rooms/space and residents with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of allegations of potential abuse or neglect for 3 of 3 sampled residents (Resident 69, 5 and 55) reviewed for allegations of abuse and/or neglect and injuries of unknown source. The failure of staff to identify, report, and initiate an investigation for allegations placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations. Findings included . Review of the facility policy titled, Abuse - Reporting and Response, dated 10/13/2023, showed the facility would report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source .and report within the required timeframes. <RESIDENT 69> Resident 69 admitted on [DATE] with diagnosis which included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument (RAI - an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments, - a systematic process to interpret the triggered information from the Minimum Data Set assessment to assess the potential problem and determine if the area should be care planned), to holistically analyze the plan of care for 3 of 6 sampled residents (Residents 5, 29 and 121) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, showed the RAI consists of three basic components: the Minimum Data Set (MDS - and assessment tool) assessment, the CAA process, and the RAI Utilization…

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 resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 8 sample residents (Residents 47, 55, 32, 5, 29, and 121) whose CPs were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, Comprehensive Care Plans and Revisions, revised 08/22/2023, showed the facility would ensure the timeliness of each resident's person-centered, comprehensive CP, and that the comprehensive CP was reviewed and revised by an interdisciplinary. The policy showed the facility would monitor residents over time to identify changes in condition and update the CP as warranted to reflect goals and interventions. <RESIDENT 47> Resident 47 admitted on [DATE] with cancer, hip fracture, anxiety, and protein calorie malnutrition. In an interview and observation on 04/22/2024 at 2:22 PM, Resident 47 said they…

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 complete required annual performance reviews for 3 of 3 sampled Nursing Assistant Certified (Staff W, X, and Z) reviewed for annual performance review after one year of employment. Failure to complete annual performance evaluations, and ensure these staff members were adequately trained, placed all residents at risk for unmet care needs. Findings included . Staff W, Nursing Assistant Certified (NAC), was hired 01/31/2023. Review of Staff W's requested employee file information showed no Annual performance review was provided for the prior year. Staff X, NAC, was hired 08/10/2022. Review of Staff X's requested employee file information showed no Annual performance review was provided for the prior year. Staff Z, NAC, was hired 10/14/2021. Review of Staff Z's requested employee file information showed no Annual performance review was provided for the prior year. In an interview on 04/23/2024 at 3:40 PM, Staff B, Registered Nurse/Director of Nursing Services stated the annual performance evaluations were not done. Refer to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability or Related Condition and a Serious Mental Illness prior to admission to a Medicaid-certified nursing facility or a significant change of condition) assessments were completed timely for all residents following significant change in status for 3 of 5 sampled residents (Resident 10, 51 and 57) reviewed for possible serious mental disorders and related conditions. This failure resulted in a potential inability to receive and benefit from Level II PASSR services for Resident's 10, 51 and 57, and other residents at risk for a decreased quality of life. Findings included . Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR), revised 09/05/2023, showed the facility will ensure that potential admissions are screened for possible serious mental disorders or intellectual…

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 implement a baseline care plan for 1 of 2 sampled residents (Resident 121) reviewed for baseline care plans. The failure to develop an effective and person-centered baseline care plan for falls placed the resident at risk for health complications, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Baseline Care Plan, revised in 08/17/2022, showed, A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. Resident 121 admitted to the facility on [DATE] with diagnosis to include a stroke, vascular dementia, and unspecified protein calorie malnutrition (not consuming enough protein and calories). Review of Resident 121's care plan, dated 04/16/2024, showed the resident was at risk for falls related to their history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 7 sampled residents (Resident 47, 59 and 121) reviewed for comprehensive care planning. The failure to ensure the comprehensive care plan was person-centered to maintain or attain the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Findings included . <RESIDENT 47> Resident 47 admitted on [DATE] with cancer, hip fracture, anxiety, and protein calorie malnutrition. Review of the Significant Change Minimum Data Set (MDS - an assessment tool) assessment, dated 04/06/2024, showed Resident 47 had a condition that may result in a life expectancy of less than six months. In an interview on 04/22/2024 at 2:27 PM, Resident 47 said they were unsure about the plans for them. The resident stated they had a lot going on and they never stop worrying. The resident said I am…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain oral health for 1 and 3 sampled residents (Resident 29) and communication devices in functional order for 1 of 1 sampled resident (Resident 5) reviewed for activities of daily living. This failure placed residents at risk for a decrease ability to communicate, maintain oral health, have unmet care needs, and a diminished quality of life. Findings included . <COMMUNICATION> RESIDENT 5 Resident 5 admitted to the facility on [DATE] with diagnoses that included intracranial injury with loss of consciousness (brain injury), unspecified convulsions (involuntary contraction of muscles), unspecified voice and resonance disorder (inability to communicate with voice), contracture left ankle and left upper arm. In an interview, on 04/22/2024 at 2:06 PM, Collateral Contact 1 (CC1), Resident 5's family member, stated the Tobii DynaVox (a speech generating device) was broken and remained in the corner of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of the facility's policy, Fall Management, reviewed on 12/04/2023, showed the facility would assess residents upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and identify appropriate interventions to minimize the risk of injury related to falls. Resident 121 admitted to the facility on [DATE] with diagnosis to include a stroke, vascular dementia (a general term for problems with reasoning, planning, memory, and other thought processes cause by brain damage from impaired blood flow to the brain), unspecified protein calorie malnutrition (the body lacks enough protein and energy to function properly). Review of Resident 121's nursing progress, note dated 04/16/2024, showed they were at risk for falls related to urinary urgency, lack of strength, and poor safety awareness. Resident 121 was admitted to room [ROOM NUMBER], close in proximity to the nurse's station, and was on isolation precautions. Resident 121 was noted to be off isolation…

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 accurately monitor meal intake and resident weights, and failed to implement and evaluate the effectiveness of weight loss interventions to determine if additional interventions were needed for 2 of 2 sampled residents (Resident 59 and 121) reviewed for nutrition. These failures placed residents at risk for weight loss, inadequate nutrition, and diminished quality of life. Findings included . Review of the facility's policy, weights and heights, reviewed 08/23/2023, showed all residents are weighed within 24 hours of admission and weekly for four weeks and as needed thereafter or more as determined by the Resident at Risk (RAR) committee and/or physician order. Review of the facility policy titled, Resident at Risk (RAR) Policy, revised 04/25/2023, showed the facility conducted weekly resident at risk meetings to review residents who were identified or had the potential for developing nutritional issues. A list of actions or reviews were…

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 pharmaceutical services, including procedures that assure the accurate acquiring, receiving, and administering of all drugs, to meet the needs of each resident for 1 of 1 resident (Resident 59). Failure to ensure timely receipt and administration of ordered medications placed Resident 59 and other residents at risk for anxiety, discomfort, and withdrawal symptoms of headache, fatigue, dizziness, and constipation. Findings included . Resident 59 was admitted on [DATE] with diagnoses to include multiple myeloma (a cancer that forms in plasma cells then accumulates in the bone marrow), protein calorie malnutrition (the body lacks enough protein and energy to function properly), vertebral fractures, emphysema (a lung condition that causes shortness of breath and reduces the amount of oxygen in the blood), and anxiety. Review of Resident 59's physician order, dated 03/01/2024, directed nursing staff to administer Chantix 0.5 milligrams (mg), a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 3 of 5 sampled residents (Resident's 51, 29, and 10) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure consents were obtained, person-centered behavioral interventions were in place, appropriate indications were present for psychotropic medications and that residents received gradual dose reductions. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . As referenced in the Food and Drug Administration (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first…

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 there was safe and secure storage of drugs and biologicals when 1 of 4 medication carts (400 hall) was left unlocked and unattended, and medication found on the facility floor in 2 of 2 residents (Resident 17 and 32) rooms. These failures placed residents at risk of taking medications that were not prescribed to them, side effects, possible harm, and decreased quality of life. Findings included . <RESIDENT 17> Resident 17 was admitted to the facility on [DATE] with diagnoses to include anxiety, depression, and a hip fracture. In an observation on 04/23/2024 at 11:23 AM, Resident 17 had Systane (dry eye lubricant) eye drops and Imodium (anti-diarrheal medication) caplets at bedside and stated they brought the medications from home. Medication boxes for Systane eye drops and Imodium both had labels with guidance to keep out of the reach of children. In an observation on 04/24/2024 at 9:37 AM, Systane eye drops, and Imodium were…

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 prompt dental services were provided for 1 of 1 (29) residents reviewed for dental care. This failure placed Resident 29 and all other residents at risk for pain, unmet dental needs, and a diminished quality of life. Findings included . Resident 29 admitted to the facility on [DATE] with diagnoses that included vascular dementia (brain damage from impaired blood flow to the brain that causes changes in reasoning, planning, memory, and judgement), muscle weakness, atrial fibrillation (irregular heartbeat), and high blood pressure. In a review of Resident 29's care plan, dated 10/25/2022, showed a care plan focus for dental care. The care plan showed that Resident 29 had dental problems with upper partials and numerous missing lower teeth. Care plan interventions included to coordinate arrangements for dental care, transportation as needed and as ordered, observe and report as needed of any oral/dental problems needing attention. 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, observation, and record review, the facility failed to provide appetizing and palatable food to 9 of 12 residents (6, 8, 12, 14, 23, 25, 44, 59, and 60). This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life. Findings included . <RESIDENT INTERVIEWS> In an interview and observation on 04/22/2024 at 10:40 AM, Resident 59 said they were sent to the facility to gain weight so they could have neck surgery and start chemotherapy. The resident said This is not the best place to gain weight. I didn't even get breakfast this morning .lost in the shuffle, I guess. The food is inedible here. I got to 108 pounds, but it has gone down. In an interview on 04/22/2024 at 11:14 AM, Resident 14 (Resident Council President) stated the food was mediocre and was the biggest issue discussed repeatedly at resident council. Resident 14 described the eggs to be cold on delivery whether eating in the dining room and cited the meal does not come on a heated tray. Resident 14 stated they asked for cottage cheese and fruit the day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure resident medical records were accurate and consistent for 3 of 17 sample residents (Residents 11, 29 and 51) whose resident records were reviewed. The facility failed to ensure other resident information was not a part of Resident 11 and Resident 51's medical records and records (PASRR-preadmission screening and Resident Review and dental hygienist note) were accessible for Resident 29 in their medical records. These failures placed residents at risk for unidentified and/or unmet care needs, missed opportunities for care planning, and inaccessible health care instructions if/when needed. Findings included . <RESIDENT 11> Resident 11 admitted to the facility o 03/31/2022 with diagnoses to include Parkinson's disease (disorder of the central nervous system that affects movement), depression, and dementia (progressive or persistent loss of intellectual functioning). Review of Resident 11's current care plan, showed there was another 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.

Based on record review, and interview, the facility failed to ensure 2 of 5 Certified Nursing Assistants (NACs) (Staff X and Z) reviewed for training, had the required 12 hours per year of in-services and required annual dementia training. This failure placed residents at risk of less than competent care and services from staff. Findings included . Staff X's was hired on 08/10/2022. Review of their employee file showed they did not have the required 12 hours of in-service education or the required dementia training for the prior year. Staff Z was hired on 10/14/2021. Review of their employee filed showed they did not have the required 12 hours of in-service education for the prior year. In an interview on 04/23/2024 at 2:02 PM, Staff BB, Registered Nurse/Staff Development Coordinator, stated there were assigned annual general requirements for each staff which included abuse and dementia education. Staff BB stated the computer program tracked the education for staff, including how many total hours of education they had done. In an interview on 04/23/2024 at 3:40 PM, Staff B,…

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 residents' representative(s) was notified timely for 1 of 3 residents (Resident 1) reviewed for notification of change of condition. Failure to inform Resident 1's representative(s) when they had new symptoms of confusion, burning with urination, and increased blood sugars resulted in their being unable to advocate for the resident and be involved in decision-making for treatment. This failed practice placed all residents representatives from being fully informed in decision-making for treatment. Findings included . Review of facility policy, Changes in Resident's Condition or Status, issued 11/26/2018 and reviewed 08/09/2023, showed the facility would notify the resident, their primary care provider, and the resident representative of changes in the resident's condition or status. Resident 1 admitted to the facility on [DATE] with diagnoses to include orthopedic aftercare following bilateral (both sides of the body) below-the-knee…

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 residents received treatment and care in accordance with professional standards of practice for 3 of 5 sampled residents (Residents 1, 2, and 3) reviewed for quality of care. The facility failed to monitor and document residents condition after a fall, assess pressure injury's (PI - a pressure ulcer) weekly, and to provide pain management. These failures placed residents at risk for delayed identification of injuries, delayed wound healing, inadequate pain management, medical complications, and a diminished quality of life. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include a right hip fracture. Review of facility investigation, dated 11/04/2023, revealed Resident 1 had an unwitnessed fall in their room resulting in complaints of left hip pain. Review of Resident 1's progress notes, dated 11/04/2023 through 11/08/2023, showed the fall was documented on 11/04/2023. There was no further…

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 medical records were complete for 5 of 8 residents (Resident's 2, 3, 5, 6, and 7) reviewed for documentation. Failure to complete skilled charting, alert charting, timely complete admission assessment, and neurological checks after falls, placed residents at risk of staff not being able to identify changes in condition and residents not receiving the appropriate care and services for individual medical conditions. Findings included . <RESIDENT 2> Resident 2 admitted to the facility on [DATE] with diagnoses to include total hip replacement and urinary retention (failure to empty bladder). Review of progress notes throughout Resident 2's stay ([DATE] through [DATE]), showed there was no skilled charting on [DATE], [DATE], and [DATE]. Review of Resident 2's after-visit summary from their urologist, dated [DATE] showed the resident had been seen by the urologist, and was diagnosed with a urinary tract infection (UTI), and started on an antibiotic.…

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 residents' Power of Attorney was notified timely for 1 of 3 residents (Resident 1) reviewed for notification of change of condition. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include neuromuscular dysfunction of the bladder (bladder does not fill or empty correctly). Review of Resident 1's Quarterly Minimum Data Set (an assessment tool) assessment, dated 08/03/2023, showed the resident had moderate cognitive impairment. The resident required one-person supervision with bed mobility, transfers, walking, and locomotion with wheelchair. Resident 1 had a urinary catheter in place. Review of progress note, dated 09/16/2023, showed Resident 1's urinary catheter had come out and facility nurses were unable to reinsert the catheter. A bladder scan (an ultrasonic procedure that shows how much urine is in the bladder) was completed and showed the resident had urinary retention. The physician was notified, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to report allegations of potential abuse for 2 of 3 residents (Resident 2 and 6) reviewed for potential abuse and neglect. This failure to report to the required state agency resulted in lack of timely investigations and placed all residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect. Findings included . Review of the facility policy, Incident and reportable event management, revised 05/04/2023, showed the facility was to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property were reported immediately, but not later than two hours after the allegations were made, and not later than 24 hours if events that caused the allegation had not involved abuse and did not result in serious bodily injury. Additionally, the facility must have evidence that all alleged violations were thoroughly investigated…

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 review and revise care plans for 2 of 5 resident's (Resident 2, and 6) reviewed for care planning. These failures placed the resident at risk for lack of appropriate care, consistent interventions, unmet care needs, adverse health effects, frustration, and a diminished quality of life. Findings included . <RESIDENT 2> Resident 2 admitted to the facility on [DATE] with diagnoses to include left total hip replacement and urinary retention. Review of Urology instruction for 09/01/2023 follow-up appointment showed facility nurse to remove Resident 2's catheter at noon and be at urology appointment for bladder scan (an ultrasonic procedure that shows how much urine is in the bladder) at 3:30 PM. After removal of the catheter, the resident was to begin drinking eight ounces of liquid every hour, attempt to empty bladder every one to two hours even if no urge to void, do not push or strain, to sit down, take time and relax. Review of Resident 2's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly assess wounds on admission and weekly, maintain clear and accurate wound documentation, and develop an individualized care plan for pressure ulcer for 1 of 3 sampled residents (Resident 2) reviewed for pressure ulcers (PU's). This failure placed residents at risk for deterioration of their wounds and for diminished quality of life. Findings included . Review of the Minimum Data Set (MDS, an assessment tool) 3.0 Resident Assessment Instrument manual, v1.19.1, dated October 2019, showed a PU/Pressure injury (PI) defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. Review of the National Pressure Ulcer Advisory Panel staging showed a stage 2 PU is defined as a partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or…

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 they were free of significant medication errors for 3 of 5 residents (Resident's 2, 3, and 8), to include administration of correct dose of blood thinner medication (aspirin), tamsulosin (used in men to treat the symptoms of an enlarged prostate which include difficulty urinating, painful urination, and urinary frequency and urgency) for one resident, and oxycodone (narcotic pain medication). Additionally, the facility failed to administer medications on a resident's date of admission. These failures resulted placed residents at an increased risk of blood clots (aspirin), urinary complications (tamsulosin), and poor pain management. Findings included . <RESIDENT2> Resident 2 admitted to the facility on [DATE] with diagnoses to include urine retention, and left total hip replacement. Review of the hospital discharge summary and admission orders, dated 08/21/2023, showed Resident 2 was prescribed aspirin 81 milligrams (mg) twice daily and…

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

Based on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of concerns for 1 of 3 resident council's (March 2023), who verbalized complaints during a Resident Council (RC) meeting. The facility's failure to initiate, log, investigate verbalized concerns, inform residents of the facility's findings and the actions taken, if any, prevented the facility from identifying care trends and determining if actions taken to resolve grievances were effective. These failures led to residents repeatedly reporting the same care issues without resolution and placed them at risk for feeling frustrated, unimportant, with diminished self-worth and decreased quality of life. Findings included . Review of the Blue Card, titled, Concern & Comment Form, undated, stated the facility was committed to responding to the needs of our customers in a continuing effort to improve the quality of life for each of our residents. It is our desire to meet or exceed each 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 implement comprehensive person-centered care plans for 3 of 6 residents (Resident's 24, 57, and 38) reviewed for care plans. The facility failed to ensure a resident (Resident 24) had appropriate interventions for their dental needs. The facility failed to ensure a resident (Resident 57) had appropriate interventions for effective communication for a legally blind resident, and failed to ensure (Resident 38 and 57) had appropriate respiratory plan of care. This failure to ensure the comprehensive care plan was implemented placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . In a review of the facility policy and procedure titled, Comprehensive Care Plans and Revisions, dated 03/02/2022 and reviewed on 08/17/2022, stated the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. The policy also…

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, observation, and record review the facility failed to update and revise the care plan for 3 of 9 residents (Resident 28, 50, and 414) reviewed for care planning. The facility failed to update goals, interventions, resident preferences, and assess the effectiveness of current interventions related to nutrition and skin concerns. This failure placed residents at risk of unmet care needs and decline in their nutritional status. Findings included . <RESIDENT 28> Resident 28 was admitted to the facility on [DATE], with diagnoses to include delusional disorder (a belief or altered reality that is persistent), vascular dementia (decreased blood flow damages brain tissue), muscle weakness, and protein-calorie malnutrition. Review of Resident 28's Nutrition/Dietary progress note by Staff M, Registered Dietician (RD), dated 05/03/2023, showed that the resident had lost 13.5 pounds (lbs), or 8.6 percent (%) of body weight in one month, the weight taken on 05/02/2023 was 142.7 lbs. Staff M questioned 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 record review and interview the facility failed to follow physician's orders for 1 of 1 sampled resident (Resident 21) reviewed for orthostatic blood pressures (a person's blood pressure taken while lying down and then taken again while standing and or sitting upright). This failure placed the resident at risk for medical complications. Findings included . Review of Resident 21's Physician Orders, dated 07/05/2022, showed the resident's orthostatic blood pressures were to be taken daily every Monday. Review of Resident 21's Blood Pressure Summary Report, dated January through May of 2023, showed the resident's orthostatic blood pressures were not taken according to the Physician's Orders for the following dates: 1. January 2023 - 01/16/2023 and 01/30/2023. 2. February 2023 - 02/06/2023 and 02/27/2023. 3. March 2023 - 03/06/2023, 03/13/2023, 03/20/2023 and 03/27/2023. 4. April 2023 - 04/03/2023, 04/10/2023, 04/17/2023 and 04/24/2023. 5.May 2023 - 05/01/2023, 05/08/2023 and 05/15/2023. Review of Resident 21's Medication Administration Records (MAR) for January through May 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 observation, interview, and record review the facility failed to comprehensively assess and revise interventions as needed to prevent unidentified weight loss for 4 of 10 residents (Resident 54, 50, 24, and 414) reviewed for nutritional status and weight loss. These failures placed Residents 54, 50 and 24, at risk who had unidentified weight loss and placed residents at an increased risk for unmet nutritional needs, physical decline, and diminished quality of life. Findings included . <RESIDENT 54> Resident 54 admitted to the facility on [DATE] with diagnoses including recent history of a stroke with right sided weakness and difficulty with swallowing and speech. Review of Resident 54's admission Minimum Data Set (MDS) assessment, an assessment tool, dated 04/11/2023, showed the resident received nutrition through a feeding tube (a tube placed into the stomach for nutrition), and a mechanically altered diet. The assessment did not indicate the resident was on a physician's prescribed weight loss program…

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 offer and provide education on the risks and benefits of the influenza and pneumococcal vaccines for 2 of 5 sampled residents (Residents 47 and 54) reviewed for influenza and pneumococcal immunizations. These failures placed residents at risk for communicable diseases and of not being fully informed before making decisions about care and treatment. Findings included . Review of the facility policy titled, Influenza Vaccine & Pneumococcal Vaccine Policy for Residents, revised 01/25/2023, indicated each resident should be offered influenza and pneumococcal vaccines, provided education on benefits and potential side effects, and assessed for possible contradictions or if resident has already received vaccinations. The policy also showed, Education, assessment findings, administration, refusal or did not receive due to medical contraindications, and monitoring are documented in the resident's medical record. <RESIDENT 47> Review of Resident 47's medical…

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 residents were offered COVID-19 vaccine and/or provided education about COVID-19 (an infectious disease by a virus causing respiratory illness) vaccination, including benefits, and potential side effects, document if the vaccine was accepted and/or refused in the medical record, and document as to why the vaccine was refused for 2 of 5 residents (Resident 47 and 54) reviewed for COVID-19 immunizations. This failure denied the residents and/or their representative of the right to make informed decisions. Findings included . Review of the facility's policy titled, COVID-19 (SARS-CoV-2) Vaccination Program Policy for Residents, revised 01/06/2023, indicated The facility will educate residents or resident representatives regarding the benefits and potential side effects associated with the COVID-19 vaccine and offer the vaccine unless it is medically contraindicated, or the resident has already been immunized. <RESIDENT 47> Review of Resident 47'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 5 of 5 Nursing Assistants Certified (Staff C, D, E, F, and G) received the required dementia training per year. This failure of not ensuring staff received the required dementia care training placed residents at risk for unmet care needs potential abuse and/or neglect. Findings included . A review of Staff C, Nursing Assistant Certified (NAC), employee file on 05/18/2023, showed Staff C was hired on 12/06/2022. Staff C had no training and/or in-service records that indicated they had received yearly dementia training. A review of Staff D, NAC, employee file on 05/18/2023, showed Staff D was hired on 01/31/2023. Staff D had no training and/or in-service records that indicated they had received required dementia training on hire. A review of Staff E, NAC, employee file on 05/18/2023, showed Staff E was hired on 06/16/2008. Staff E had no training and/or in-service records that indicated they had received yearly dementia training. A review of Staff F, NAC, employee file on 05/18/2023, showed Staff F was hired 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 observation, interview, and record review, the facility failed to ensure a dignified existence was maintained for three of three sampled residents (Resident 31, 47, and 24) reviewed for resident rights. The facility failed to ensure the residents urinary catheter bag was kept covered to ensure privacy and dignity of the residents. This failure placed the resident at risk for a diminished self-worth and a diminished quality of life. Findings include . Review of the facility policy titled, Area of Focus: Resident Rights, revised 11/22/2022, states the facility and its associates have the responsibility for ensuring these rights are always upheld the resident while in their care. Center for Medicare and Medicaid Services (CMS) outlines at least 48 rights the residents have that span a wide range of topics .resident has the right to a dignified existence .and the facility must treat each resident with respect and dignity. <RESIDENT 31> Resident 31 admitted to the facility on [DATE] with diagnoses including…

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

Based on record review and interview, the facility failed to make a referral for the Pre-admission Screening and Resident Review (PASRR) II (screening assessment for possible serious mental health disorders or intellectual disabilities) for 1 of 5 sampled residents (Resident 21). This failure placed the resident at risk for unidentified mental health care needs, lack of mental health services and a diminished quality of life. Findings included . Review of Resident 21's admission Record document, dated 02/07/2019, showed Resident 21 had a diagnosis of bipolar disorder (a mental health disorder associated with of mood swings), with an onset date of 02/06/2019. This document also showed a diagnosis of Depression (a mental health disorder associated with moods of sadness), with an onset date of 10/01/2021. Review of Resident 21's annual Minimum Data Set (MDS) (screening elements which form a comprehensive assessment), dated 01/04/2023, showed diagnoses of Depression and Bipolar Disorder. Review of Resident 21's PASRR I, dated 06/14/2022, showed a serious mental health illness indicator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain effective communication, and vision methods to carry out the activities of daily living for 1 of 3 residents (Resident 57) reviewed for communication and sensory. This failed practice put the resident at risk for unmet care needs, decreased independence, and a decreased quality of life. Findings included . Resident 57 admitted to the facility on [DATE] with diagnosis that included end stage renal disease (when the kidneys permanently fail to work), legal blindness, and acute respiratory failure with hypoxia (failure of the respiratory system in one or both of its gas exchange functions). In a review of Resident 57's Minimum Data Set assessment, dated 05/01/2023, showed that resident had severely impaired vision. In review of Resident 57's Care Area Assessment (CAA), dated 05/07/2023, showed that a care plan would be developed for Resident 57's severe visual impairment. The CAA referenced the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 3 residents (Resident 57 and 38) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure when oxygen (O2) was ordered there was a dosage, route, or parameters for titration, and failed to ensure O2 tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, revised 11/28/2022, stated all oxygen devices should be change weekly, labeled with the residents, dated, and stored when not in use .staff should verify provider orders for oxygen therapy as oxygen was a medication or therapy and must be ordered by a provider. <RESIDENT 57> Resident 57 admitted to the facility on [DATE] with diagnosis that included…

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 ongoing communication and collaboration with the hemodialysis (was one way to treat advanced kidney failure) center for 1 of 1 resident (Resident 57) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre and post dialysis assessments and lack of consistent communication between the facility and the dialysis center about what occurred during HD, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes. Findings included . In a review of the facility's policy titled, Hemodialysis Offsite Policy, dated 04/24/2019 and revised 04/17/2023, stated the facility assured each resident received care and services for the provision of offsite hemodialysis (HD) consistent with professional standards of practice, which included ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. In a 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 1 of 5 residents (Resident 28) had a proper diagnosis for use of a psychotropic (antidepressants, antianxiety, antipsychotics, medications that affect mental function, behavior, and experience) medication. This failure placed the resident at risk for receiving unneeded or improper medications, side effects, and diminished quality of life. Findings included . Resident 28 was admitted to the facility on [DATE], with diagnoses to include delusional disorder (a type of psychotic disorder in which a person has trouble recognizing reality), depression, dementia, and protein-calorie malnutrition. Review of Resident 28's provider orders (physician, Advanced Registered Nurse Practitioner and Physician Assistant-Certified) showed the resident was prescribed sertraline (antidepressant medication) every day, which was initiated on 06/08/2022, related to vascular dementia. Review of Resident 28's care plan showed the resident used the antidepressant…

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 routine, and emergency dental services were provided to 1 of 2 residents (Resident 24) reviewed for dental services. This failure placed the resident at risk of unmet dental needs and a decreased quality of life. Findings included . Resident 24 was admitted to the facility on [DATE] with diagnosis that included unspecified protein calorie malnutrition (inadequate intake of food), urinary tract infection, atrial fibrillation (abnormal heart rhythm), and dysphasia, oropharyngeal phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing.) In a review of Resident 24's Minimum Data Set (MDS) (screening elements which form a comprehensive assessment), dated 04/19/2023, showed Resident 24 had no natural teeth. In a review of Resident 24's Care Area Assessment (CAA) worksheet dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods stored in a refrigerator were labeled and dated when opened, and discard food products on or before the use by date in 1 of 1 refrigerator (activity room) observed. These failures placed the residents at risk for potentially developing a food borne illness (caused by ingestion of contaminated food or beverages). Findings included . Review of the facility policy titled, Food from Outside Sources, revised 09/08/2022, stated food stored in the refrigerator should be labeled with the resident's name and room number .items should be discarded if expired . staff and resident food items should not be stored together in the same refrigerator. In an observation on 05/19/2023 at 11:15 AM, the Activities Department Refrigerator (ADR) had an unlabeled and undated drink item in a container, there was a plastic straw inserted into the drink, and frozen in freezer. There was a chocolate shake that had been opened with numbers 3/29 written…

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.