Caroline Kline Galland Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to thoroughly investigate a fall for 1 of 7 sampled residents (Resident 190) reviewed for accidents. Facility failure to complete thorough investigations placed residents at risk for further accidents, negative health outcomes, and poor quality of life.Findings included.<Policy>According to the facility policy titled, Fall Policy dated 04/2025, the facility would complete a thorough investigation after each incidence of a resident falling.According to the undated facility neurological assessment protocol, neurological assessments should be implemented immediately in the event of unwitnessed fall or if resident hits their head. Neurologic assessment protocol states that neurological assessments should be completed every 15 minutes for the first hour, every 30 minutes for two hours, every two hours for four hours, then every shift for two days.<Resident 190>According to the 07/11/2025 Significant Change Minimum Data Set (MDS - an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 2 of 6 residents (Resident 190 & 52) reviewed for PASRR. This failure placed residents at risk of not receiving timely and necessary services to meet their mental health needs.Findings included.<Policy>Review of the facility's 11/2025 PASRR policy showed the facility would refer any resident who exhibited a newly evident mental disorder or related condition to the state mental health authority for a Level II resident review.<Resident 190> According to the 07/11/2025 Significant Change Minimum Data Set (MDS – an assessment tool) Resident 190 admitted to the facility on [DATE] with diagnoses including Vascular Dementia (a degenerative brain disease), Traumatic Brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to assist residents with Activities of Daily Living (ADLs - personal hygiene, grooming, bathing,) for 2 of 5 residents (Residents 6 & 217) reviewed who were assessed to be dependent on staff for ADLs including oral care, nail care, and bathing. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.Findings included.<Facility Policy>The facility's Activity of Daily Living policy, revised 04/2025, showed the facility would provide the necessary services to maintain good nutrition, grooming, personal, and oral hygiene to the resident who was unable to carry out ADLs independently.<Resident 6> According to the 12/23/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 6 admitted to the facility on [DATE] and had diagnosis of cancer, heart failure, and urinary retention. The MDS showed Resident 6…

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 residents were monitored and received the treatment they were assessed to require for 2 of 3 (Residents 3 & 7) residents for edema (swelling) management and blood pressure monitoring. The failure to monitor and implement interventions for edema management and blood pressure management placed residents at risk for decline in medical status, quality of life related to unmet care needs and discomfort. Findings included .<Facility Policy>According to the facility's undated Resident handbook and Family guide, Notification of Changes section in the manual showed the facility would immediately inform the resident, consult with their provider and notify the resident representative whenever there was a significant change in the Resident's physical, mental or psychosocial status, that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications.<Resident 3> According to 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 appropriate treatment and services for catheter care for 1 of 4 residents (Resident 54) reviewed for Urinary Catheters (a tube inserted to drain the bladder). This failure placed residents at risk for unmet care needs, diminished quality of life, and poor health outcomes.Findings included.<Facility Policy>According to the undated facility policy titled, Indwelling Catheter Care and Maintenance, the facility would perform routine monitoring of indwelling catheters to ensure that residents receive appropriate catheter care and maintain dignity when indwelling catheters are in use.<Resident 54>According to the 11/28/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 54 admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis (a degenerative brain disease), Neurogenic Bladder (loss of bladder control), and Functional Quadriplegia (paralysis). The MDS showed Resident 54 had an indwelling catheter.Review…

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 medically related social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of residents for 1 of 5 residents (Resident 190) reviewed for nutrition; assist residents in obtaining resolution regarding refusals of treatment and care for 1 of 5 residents (Resident 190) reviewed for nutrition. This failure placed residents at risk of unmet social service needs, negative health outcomes, and a diminished quality of life. Findings included .<Policy>According to the facility policy titled, Resident Rights Regarding Treatment and Advanced Directives, revised 2025, the facility would document refusals in the resident's health record, the reason for the refusals, provider/ Interdisciplinary Team (IDT - Social Services, Nursing, Therapy if therapy services are being provided, Dietary, and Activities) notification of the refusal, and resident education of the risks associated with the refusals of care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 1 of 5 sampled residents (Resident 190) reviewed for nutrition, received necessary treatment and services consistent with professional standards of practice to treat broken or missing teeth and oral/dental pain. This failure placed all other residents at risk for lack of dental services, unmet care needs, negative health outcomes, and a diminished quality of life.Findings included.<Policy> According to the undated facility policy titled Dental Services the facility required staff to assess residents' dental status as part of routine nursing and MDS assessments and make appropriate referrals to facility providers or dental providers.<Resident 190>According to the 07/11/2025 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 190 admitted to the facility on [DATE]. The MDS showed Resident 190 had obvious or likely cavities or broken teeth, and mouth or facial pain. The MDS showed Resident 190 had a diagnosis 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 staff followed contact precautions (a type of isolation precaution used to prevent the spread of infections transmitted by direct or indirect contact) for 2 (2 East unit and 1 East unit) of 4 units reviewed for contact precautions; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear and gowns used to prevent exposure to infectious materials) for 1 of 3 residents (Resident 68) and 2 supplemental residents (4 & 142) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in long-term care settings); and ensure staff used appropriate Hand Hygiene (Staff P & BBB) during wound and catheter care. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.Findings included .<Facility Policy>Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to establish an infection prevention and control program that included implementation of the Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 2 (Resident 10 & 68) of 5 residents reviewed for ABO use. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABOs.Findings included.<Facility Policy>Review of the facility's Infection Surveillance, Antimicrobial Stewardship, and Reporting policy, revised 12/30/2025, showed the infection preventionist would survey community or hospital acquired infections and facility acquired infections on an ongoing basis through bedside observation, clinical chart review and reports, laboratory reports, resident and staff interviews, email communications, and by other means. This policy showed ABO medications would be monitored for appropriate use. The policy showed staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 (Residents 133, 17, & 142) of 6 residents reviewed for hospitalizations. Failure to ensure written notification was provided to the resident and/or the resident's representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . <Facility Policy> According to the facility's undated Transferor Discharge policy, for residents transferring/discharging emergently, notice of the transfer would be provided in writing to the resident or their representative as soon as practicable. The policy showed this notice would include contact information for the Long-Term Care Ombudsman. <Resident 133> Review of Resident 133's 05/29/2024 and 08/09/2024 Discharge Minimum Data Sets (MDS - an assessment tool) showed 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 a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the resident's mental health condition and refer the residents to the appropriate state authority for Level II evaluation and determination for 5 of 9 (Resident 159, 27, 48, 169, & 115) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and /or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 159> According to an 08/12/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 159 had multiple medically complex diagnoses including an anxiety disorder and depression which required the use of psychotropic medications during the assessment period. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 3 of 5 residents (Resident 159, 142, & 45) reviewed for unnecessary medications were free from unnecessary psychotropic medications and monitored for behaviors. Failure to discontinue as needed psychotropic medications after 14 days and to identify/monitor target behaviors for as needed antipsychotic medications placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects. Findings included . <Facility Policy> According to the Psychoactive Medication Program policy revised March 2024, showed as needed psychotropic drugs would be used only if the medication was necessary to treat a specific, diagnosed condition that was documented in the clinical record, and for a limited duration of 14 days. The policy showed the facility would document nonpharmacological interventions and target behavior monitoring for each resident on psychotropic medications. <Resident 159> According to an 11/02/2024 Quarterly…

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 implement an effective Infection Control Program for 4 of 5 units (Units 300 East, 300 North, 300 South, & 100 East) The failure to: ensure facility staff sanitized glucometers (a blood sugar monitoring device); ensure food and drinks were handled in accordance with infection control standards when being distributed on the unit; ensure staff used Personal Protective Equipment (PPE) when required for residents with infectious diseases; perform hand hygiene as required; use appropriate infection control standards during incontinence care and wound care (Residents 156 & 119); and ensure resident rooms were free from staff property; placed residents at risk for exposure to infectious materials, communicable diseases, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 09/06/2024 Infection Control Manual, an effective Infection Control Program required the cooperation of all staff, 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 ensure residents were provided care and services in a dignified manner for 7 (Residents 106, 12, 144, 123, 45, 123, & 156) of 36 sample residents reviewed. The failure to: provide dignified toileting assistance (Residents 106, 12, & 144), ensure staff sat when feeding residents (Resident 45), provide bodily privacy when transporting residents to and from the shower room (Resident 123), and ensure catheter bags (bags that collect urine from tubing placed in the body to assist with urinary drainage) were covered to obscure their contents (Resident 156) placed residents at risk for undignified care and a diminished sense of self-worth. Findings included . <Policy> According to the facility's undated General Rights policy, all residents had a right to a dignified existence, self-determination, and access to services inside the facility. The policy showed facility staff would treat each resident with respect and dignity and care for each in a manner that would promote maintenance or enhancement of their quality 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 develop and/or implement comprehensive Care Plans (CPs) for 7 (Residents 88, 83, 81, 119, 115, 159, & 429) of 36 sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, in appropriate care, and frustration. Findings included . <Facility Policy> According to the facility's reviewed January 2024 Care Plans - Comprehensive Person Centered policy showed the facility would develop a comprehensive, person-centered CP to address each resident's physical, psychosocial and functional needs . <Resident 88> According to the 09/13/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 88 was assessed with a severe memory impairment. The MDS showed Resident 88 depended on staff assistance to move in bed, was at risk for developing pressure ulcers and used a pressure reducing device on their bed. The MDS showed Resident 88 was rarely/never understood and rarely/never understood others in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated as needed to reflect changes in resident's care needs for 5 (Residents 45, 83, 156, 106, 169) of 36 sample residents whose CPs were reviewed and failed to provide care conferences as required for 2 (Residents 134 & 17) of 36 sample residents whose CPs were reviewed. The failure to update CPs with changes in residents' health status placed residents at risk for unmet care needs, unnecessary care, and frustration. Findings included . <Facility Policy> According to the facility's January 2024 Care plans - Comprehensive person centered policy, CPs would be revised as information about the residents and the residents' conditions change. <CP Revision> <Resident 45> According to a 10/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 45 had minimal difficulty with hearing while using a hearing appliance, had no wandering behaviors, and was assessed to be dependent on staff for transfers…

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 physician's orders were clarified for 2 of 36 sampled residents reviewed (Residents 88 & 144), and failed to ensure medications were administered timely for 1 of 5 sample residents (Resident 432) observed during medication pass. These failures placed residents at risk for ineffective treatments, inappropriate medications, and delayed treatment. Findings included . <Clarifying Orders> <Resident 88> According to the 09/13/2024 Quarterly Minimum Data Set, Resident 88 was assessed to have a severe memory impairment, and diagnoses including anxiety and depression. The MDS showed Resident 88 took an antidepressant medication. Review of the November 2024 Medication Administration Record (MAR) showed Resident 88 had a 07/31/2019 physician's order for an antidepressant medication, give 1 tablet once a day for depression/anxiety. In an interview on 11/21/2024 at 10:48 AM, Staff B (Director of Nursing) reviewed Resident 88's 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 provide assistance with Activities of Daily Living (ADL) related to toileting, cleanliness, and grooming for 2 (Residents 106 & 119) of 7 sample residents reviewed for ADLs. The failure to provide residents who were dependent on staff assistance the toileting, dressing, and shaving assistance they required placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life. Findings included . <Facility Policy> According to the facility's undated Activities of Daily Livings policy, the facility would provide ADLs in accordance with residents' comprehensive assessment, Care Plan (CP), and resident preferences to ensure residents' ADL abilities did not diminish unless a decline in function was unavoidable. <Toileting> <Resident 106> According to a 09/26/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 106 was dependent on staff for toileting hygiene. The MDS showed Resident 106…

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 activity programs met the needs of each resident for 2 of 2 sampled residents (Resident 106 & 142) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Policy> According to a facility policy titled, Activity Policy and Procedures, revised 08/2018, showed staff would provide meaningful activities to residents to address their physical, mental, and psychosocial well-being. The policy showed activities would be offered in a variety of formats, various times of day, and each day of the week taking into consideration each individual's abilities, needs, and preferences. The policy showed activity staff would document residents' attendance in activities in the residents health records under a progress note. The policy showed residents would receive assistance needed to participate in activities such as staff escort to/from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 3 of 36 sampled residents (Residents 429, 142, & 169) reviewed for care and services, received the necessary care and services they required in accordance with professional standards of practice. The facility failed to monitor resident's hypo/hyperglycemia (high and low blood sugar levels) symptoms and follow bowel management protocols that placed residents at risk for delays in treatment, potential decline in health, and other negative health outcomes. <Facility Policy> According to the facility's undated, Principals and Practices Glycemic Management in Diabetic Residents policy, the licensed nurse would identify signs and symptoms of hypo/hyperglycemia, respond promptly in providing appropriate interventions to restore the resident's blood sugar level, prevent reoccurrences of hypo/hyperglycemia, and prevent complications. The policy showed the Care Plan (CP) would establish measurable goals for the resolution for the problem,…

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 Restorative Nursing Program (RNP), rehabilitative treatment/services and to follow the physician orders for 3 of 5 residents (Residents 27, 134, & 144) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Resident 27> According to a 09/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 27 had limited ROM to both arms and legs. Resident 27 required total assistance from staff with personal hygiene, bed mobility, transfers, dressing, and toileting. The MDS showed Resident 27 had no rejection of care during the assessment period. Review of Resident 27's November 2024 physician orders directed staff to apply a palm protector to Resident 27's right hand contracture and keep the palm protector on at…

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 2 (Resident 45 & 169) of 5 sampled residents, reviewed for vaccinations, were up to date on the current recommendations from the Center for Disease and Control and Prevention (CDC) related to pneumococcal vaccinations. This failure placed residents at risk for contracting pneumonia, with their associated complications of infection. Findings included . <Facility Policy> According to the facility's revised 09/06/2024 Resident Vaccination Program policy, all newly admitted residents would be assessed for eligibility for the pneumonia vaccine. The policy showed residents would be educated about the benefits of the vaccine and the appropriate pneumonia vaccine would be offered. <Resident 45> According to a 10/3/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 was admitted to the facility on [DATE] and was up to date with their Pneumococcal vaccinations. Review of Resident 45's records showed two historical entries under 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 and interview, the facility failed to ensure expired medication and medical supplies were disposed timley for 4 of 4 medication rooms (East 2A, East 2B, North, & East 1) reviewed. These failures placed residents at risk for receiving medications with decreased or no potency, and use of medical supplies with compromised integrity. Findings included . <East 1 Medication Room> Observation on 08/02/2023 at 1:20 PM showed two boxes of safety needles expired on 05/31/2020, two boxes of lancets (equipment used to check blood sugar) expired on 12/07/2020, a box of disposable viral test kits expired 09/14/2022, and a bottle of local anesthetic expired 12/2022. These items were dispersed throughout the room. In an interview on 08/02/2023 at 1:35 PM, Staff H (Charge Nurse) stated the expired supplies should be removed from the medication room prior to the items expiring. <East 3 Medication Room> Observation on 08/02/2023 at 1:00 PM showed two urinary catheters (a tube to assist in bladder emptying) expired on 12/28/2022, extension tubing intended for urinary catheters…

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 resident safety from accidents and hazards for 3 of 4 (Residents 149, 27 & 104) residents reviewed for falls. The failure to determine the basic factors that caused resident falls and implement interventions related to the identified cause, placed residents at risk for further falls, significant injuries, and diminished quality of life. Findings included . <Resident 149> The 05/02/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 149 was admitted for a fall with pelvic fractures. Resident 149 was assessed to have memory impairment, difficulty making decisions, inattention, disorganized thinking, and worsening behaviors impacting their personal safety. Resident 149 was assessed with moderately impaired vision (not able to see newspaper headings but can identify objects). Review of the 01/04/2023 Fall Risk Care Plan (CP) showed Resident 149 was at increased risk of falls related to decreased functional mobility, weakness, and poor balance. The 01/04/2023 fall CP interventions…

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 indwelling urinary catheter (a tube to empty the bladder) care met infection control standards for 1 of 4 residents (Resident 12) reviewed for catheters. The failure to 1) review the risks and benefits of placing the catheter bag on the floor per Resident 12's preference, 2) update the care plan and 3) implement interventions to prevent contamination and Urinary Tract Infections (UTI), placed Resident 12 at risk for continued UTIs, sepsis (a blood infection) and a diminished quality of life. Findings included . <Facility Policy> The undated policy titled Indwelling Catheter Care and Maintenance, directed staff to perform routine maintenance and continued monitoring of residents with indwelling catheters and to ensure that residents received appropriate catheter care. The policy showed if a resident's preference went against infection control policies, it was important to prioritize the safety and well-being of the resident 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.