Heartwood Extended Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled resident (Residents 9) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (disease that effects multiple nerves in the body), diabetes (too much sugar in the blood) and dysphagia (difficulty swallowing). Resident 9 was able to make needs known. During an interview on 03/23/2026 at 11:29 PM, Resident 9 stated they were missing two pairs of jeans that were only worn once. Resident 9 stated they had not reported the missing clothing to any members of staff. Observation on 03/26/2026 at 10:36 AM showed Resident 9 reported to Staff H, Registered Nurse (RN), the missing jeans. Review of the EHR showed no documentation related to Resident 9's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure injuries of unknown sources were reported to the State Hotline for 1 of 2 sampled residents (Resident 5) when reviewed for accident hazards. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (loss of cognitive function), congestive heart failure (when the heart is unable to pump blood efficiently) and depression. Resident 5 was unable to make needs known. Review of the January 2026 accident and incident log showed an entry dated 01/19/2026 for a fall related to Resident 5 on 01/18/2026. The fall was logged as unwitnessed with Small bruises occurring in places generally vulnerable to trauma. The fall was said to be Reasonably related to the resident's condition. The action taken was medical treatment and was not reported to the State…

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 investigate the potential for abuse and/or neglect for 1 of 2 sample residents (Resident 9) reviewed for abuse and neglect. This failure placed Resident 9 at risk for psychosocial harm and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (a neurological condition occurring when multiple nerves are damaged), diabetes (too much sugar in the blood), and dysphagia (difficulty swallowing). Resident 9 was able to make needs known. During an interview on 03/23/2026 at 11:24 AM, Resident 9 stated they pressed their call light and after 15 minutes Collateral Contact went to the nurse's station to request assistance which took an additional 30 minutes. During an interview on 03/23/2026 at 11:28 AM, Collateral Contact (CC), stated they were unhappy with the care Resident 9 was receiving. CC stated they worked 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 develop comprehensive care plans for 2 of 20 sampled residents (Residents 10 and 1) reviewed for care plans. Failure to develop care plans that accurately reflected resident care needs related to dental issues placed residents at risk for not receiving needed care and services, negative outcomes, and a diminished quality of life. Findings included.Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include quadriplegia with incomplete damage to the neck (spinal cord damaged causing partial paralysis/partial or complete loss of muscle function and/or feeling to all four limbs and torso/trunk of the body), high blood pressure, and depression. Resident 10 was able to make needs known. During an interview on 03/24/2026 at 9:17 AM, Resident 10 stated they had a dental exam two or more months ago and were told they had broken upper teeth that needed to be pulled.…

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 and/or conduct quarterly care conferences in a timely manner to include the residents and/or their representative for 2 of 3 sampled residents (Residents 87 and 99) when reviewed for care planning. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included.Resident 87Review of the electronic health record (EHR) showed Resident 87 readmitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis (the process of filtering blood to remove waste and excess fluids due to kidney failure), high blood pressure, and encephalopathy (the brain does not work properly, often causing confusion, altered mental state, or personality changes). Resident 87 was able to make needs known. During an interview on 03/24/2026 at 11:52 AM, Resident 87 stated they did not remember going to a care conference. Review of Resident 87's EHR showed a care conference document dated 11/17/2025 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure providers orders were followed for 2 of 2 sampled residents (Residents 66 and 71) when reviewed for pain and edema. This failure placed residents at risk of increased pain and a decreased quality of life.Findings included.Resident 71 Review of the electronic health record (EHR) showed Resident 71 was admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (high blood sugar), anxiety and traumatic brain injury. Resident 71 was able to communicate their needs. Observation on 03/24/2026 at 11:40 AM showed Resident 71 laid in bed with their feet severely swollen. Resident 71 stated their legs were swollen and they may have a wound on the back of their leg. Review of the EHR showed Resident 71 had an order for TED hose (constrictive socks used to promote blood flow) to both lower legs to be on for 12 hours, dated 11/28/2025. During an interview on 03/26/2026 at 11:43 AM, Resident 71 stated nobody had talked 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 provide the necessary care and services to ensure that residents received their showers as scheduled and incontinent briefs for 2 of 3 sampled residents (Residents 9 and 1) reviewed for activities of daily living (ADLs). This failure placed the residents at risk for compromised dignity, unmet needs, and a diminished quality of life. Findings include. Resident 9Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (disease that effects multiple nerves in the body), diabetes (too much sugar in the blood) and dysphagia (difficulty swallowing). Resident 9 was able to make needs known. During an interview on 03/23/2026 at 11:46 AM, Resident 9 stated they were not receiving their showers consistently because there was only one shower aid. Review of the shower EHR showed Resident 9 received four showers in the past 30 days. During an interview on 03/25/20206 at 2:41 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with meal service for 1 of 3 sampled residents (Resident 8) reviewed for position and mobility. This failure placed the resident at risk for weight loss, malnutrition, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body due to tissue death in the brain), parkinsonism (disorder characterized by tremors, slowness and rigidity), asthma and epilepsy (condition of recurrent, unprovoked seizures caused by abnormal electrical activity in the brain). Resident 8 was able to communicate their needs. Review of the quarterly minimum data set (MDS, a required assessment) dated 01/01/2026 showed Resident 8 was dependent on staff for eating, oral care, hygiene, toileting, dressing and moving in and out of bed…

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 prompt services to maintain vision for 1 of 3 sampled residents (Resident 10) reviewed for communication sensory. This failure placed the resident at risk of unmet vision needs, continued visual impairment, decreased mood, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include quadriplegia with incomplete damage to the neck (spinal cord damaged causing partial paralysis/partial or complete loss of muscle function and/or feeling to all four limbs and torso/trunk of the body), high blood pressure, and depression. Resident 10 was able to make needs known. During an interview on 03/24/2026 at 9:01 AM, Resident 10 stated their vision had become blurry quite a while ago and the last time they saw an eye doctor was about six months ago and were told they needed glasses. Resident 10 stated staff were aware they needed glasses;…

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 restorative nursing programs were provided, thoroughly evaluated for effectiveness, carried out, and accurately documented for 1 of 4 sampled residents (Resident 10) reviewed for rehabilitation and restorative services, and/or position and mobility. This failure placed the resident at risk for worsening mobility, developing contractures (permanent tightening of muscle, tendons and skin, leading to deformity), and diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include quadriplegia with incomplete damage to the neck (spinal cord damaged causing partial paralysis/partial or complete loss of muscle function and/or feeling to all four limbs and torso/trunk of the body), high blood pressure, and depression. Resident 10 was able to make needs known. Observations on 03/24/2026 at 9:27 AM, 03/25/2026 at 9:01 AM, 03/26/2026 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 observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice for 2 of 4 sampled residents (Residents 106 and 12) when reviewed for respiratory care. Failure to provide oxygen (O2) per provider's order, notify provider when O2 saturation (Sats, measuring the percentage amount of O2 in the blood) were not within ordered parameters, clarify unclear O2 orders, and/or O2 use care planned placed residents at risk for negative outcomes, discomfort, unmet needs and a diminished quality of life. Findings included.Resident 106 Review of the electronic health record (EHR) showed Resident 106 admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (the process of filtering blood to remove waste and excess fluids due to kidney failure), anxiety disorder, and dorsalgia (a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other…

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 pain management that met professional standard for 1 of 8 sampled residents (Resident 106) when reviewed for unnecessary medications and/or pain management. Failure to thoroughly complete pain assessments/evaluations and to address any need for non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) with Resident 106, placed the resident at risk of having unmet pain needs, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 106 initially admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (the process of filtering blood to remove waste and excess fluids due to kidney failure), anxiety disorder, and dorsalgia (a group of condition that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column/back bone of the body). Resident 106 was…

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 medication and treatments were securely stored for 1 of 1 sampled resident (Resident 96) and 2 of 2 sampled treatment carts (Rose and Emerald Wings). These failures placed residents at risk for access to restricted medications and treatments, avoidable injury, and a diminished quality of life. Findings included.Medications at Bedside Observation and interview on 03/24/2026 at 9:49 AM showed Resident 96 sitting in their bed in the room, and next to them on the table was a saline laxative enema (water-based procedure that injects liquid directly into anus to induce bowel movements), two medicated inhalers, and a nasal spray. Resident 96 stated they were feeling constipated and would be using the enema that the facility had provided for them. During an interview on 03/27/2026 at 2:11 PM, Resident 96 stated they had not used the enema yet, but had it on standby. During an interview on 03/27/2026 at 2:34 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was for no medications at bedside, and 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 routine dental services for 2 of 2 sampled residents (Residents 1 and 10) reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life. Findings included .Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include quadriplegia with incomplete damage to the neck (spinal cord damaged causing partial paralysis/partial or complete loss of muscle function and/or feeling to all four limbs and torso/trunk of the body), high blood pressure, and depression. Resident 10 was able to make needs known. During an interview on 03/24/2026, Resident 10 stated they had a dental exam two or more months ago and were told they had broken upper teeth that needed to be pulled. Resident 10 stated it took longer to chew their food because of it. Review of the dental visit form dated 08/11/2025 showed Resident 10…

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 assess and manage the diagnosis of congestive heart failure (CHF, a weakened heart condition, in which the heart doesn't pump blood as effectively as it should, and causes fluid build-up in the feet, arms, lungs and other organs) for 1 of 3 sample residents (Resident 2) reviewed for the management of CHF. This failure placed the resident at risk for fluid overload, respiratory complications, exacerbation of (worsening of) heart failure, kidney and liver damage, hospitalization, and sudden death. Findings included . Resident 2 admitted on [DATE] with diagnoses including CHF and morbid obesity (severe obesity). The electronic health record showed that Resident 2 was alert and oriented, was their own decision-maker, and was able to make their needs known. Review of the hospital Discharge summary, dated [DATE], showed that Resident 2 admitted to the hospital, on 03/30/2025, with a chief complaint of shortness of breath. Resident 2…

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 risks/benefits and obtain consent for the use of a psychotropic (affecting the mind) medication for 1 of 5 sampled residents (Resident 72) when reviewed for unnecessary medications. This failure placed residents at risk of avoidable side effects, chemical restraint, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 72 admitted to the facility on [DATE] with diagnoses to include fracture of the spine, quadriplegia (inability to move arms and legs), and depression. Resident 72 was able to make needs known. Review of the current provider orders, Feburary 2025, showed Resident 72 received an antidepressant medication. Review of the EHR showed Resident 72 had not been provided risks/benefits for the use of the antidepressant and had not given consent to receive the antidepressant. During an interview on 02/12/2025 at 1:03 PM, Staff K, Staff Development /Licensed Practical Nurse…

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 initiate, investigate, and resolve a grievance for 1 of 4 sampled residents (Residents 67) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 67 admitted to the facility on [DATE] with diagnoses that included contracture (reduction in movement) of the right hand, muscle weakness, congestive heart failure (condition that happens when your heart is unable to pump blood well enough to give your body a normal supply) and chronic kidney disease (condition where the kidneys are damaged and unable to filter blood). Resident 67 was able to make needs known. During an interview on 02/07/2025 at 11:55 PM, Resident 67 stated they were unhappy staff came into their room that morning and threw away multiple condiments purchased by a family member. Review of a progress noted, 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 conduct an assessment for the use of a low bed for 1 of 1 sampled resident (Residents 39) reviewed for use of physical restraints. This failure placed the resident at risk for injury, unmet needs and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 39 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (complete loss of strength or paralysis on one side of the body) and hemiparesis (mild loss of strength in a leg, arm, or face). Resident 39 was assessed to be a fall risk and required the assistance of staff for mobility. Observation on 02/10/2025 at 11:09 AM and 02/11/2025 at 1:54 PM showed Resident 39 in their room lying on a bed that was lowered to the floor. Review of Resident 39's care plan showed an intervention place bed in low position initiated on 08/27/2022. During an interview on 01/28/2025 at 10:19 AM, Staff B, Director of Nursing Services,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to identify and investigate allegations of abuse/neglect for 1 of 7 sampled residents (Resident 56) when reviewed for abuse/neglect. This failure placed the resident at risk of continued abuse/neglect and a diminished quality of life. Findings included . Review of a facility policy titled, Abuse Investigation and Reporting, dated July 2017, showed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Review of the quarterly minimum data set assessment (MDS), an assessment tool, dated 08/08/2024, showed Resident 56 admitted on [DATE] with multiple diagnoses to include muscle weakness, anxiety and depression. The MDS showed Resident 56 was able to make needs…

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 written notification of the reason for hospital transfer to the resident or responsible party for 1 of 3 sampled residents (Resident 291) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility and diminished protection from been inappropriately discharged . Findings included . Review of the electronic health record (EHR) showed Resident 291 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (nerve disorder that affects multiple nerves) and bipolar disorder (condition that causes extreme mood swings). Resident 291 was able to make needs known. Review of Resident 291's EHR showed a transfer to the hospital on [DATE]. The EHR did not show documentation a notice of transfer was provided to Resident 291 or their representative. During an interview on 02/13/2025 at 12:12 PM, Staff B, Director of Nursing Services, stated Resident 291…

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 written bed hold notice at the time of transfer to the hospital for 1 of 3 sampled residents (Resident 291) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 291 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (nerve disorder that affects multiple nerves) and bipolar disorder (condition that causes extreme mood swings). Resident 291 was able to make needs known. Review of Resident 291's EHR showed a hospitalization on 02/08/2025. The EHR did not show documentation or progress notes that a bed hold was offered to the resident. During an interview on 02/13/2025 at 12:16 PM, Staff R, Business Office Manager, stated the Resident 291 or their resident representative was not offered a bed hold. During…

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 complete the comprehensive assessment for 3 of 21 sampled residents (Residents 79, 18, and 88) when reviewed for accuracy of comprehensive assessment. This failure placed residents at risk of not receiving needed care, a decline in ability, and a diminished quality of life. Findings included . Resident 79 Review of the electronic health record (EHR) showed Resident 79 admitted to the facility on [DATE] with diagnoses of chronic ulcer of the left thigh and diabetes. Resident 79 was able to make needs known. Review of the admission minimum data set assessment (MDS), an assessment tool, dated 12/31/2024, showed Resident 79 had two pressure ulcers which were not present on admission. During an interview on 02/12/2025 at 12:56 PM, Staff K, Staff Development /Licensed Practical Nurse (SD/LPN), stated Resident 79 admitted to the facility with two pressure ulcers and did not acquire any while in the facility. Staff K stated 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 conduct timely care planning meetings with residents or responsible party for 1 of 2 sampled residents (Residents 31) reviewed for care planning. These failures placed residents at risk for unmet needs, care not provided as directed, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 31 readmitted to the facility on [DATE] with diagnoses to include respiratory failure (condition in which your blood doesn't have enough oxygen), paraplegia (paralysis or loss of ability to move legs) and depression. Resident 31 was able to make needs known and was dependent on staff for activities of daily living. During an interview on 02/11/2025 at 11:21 AM, Resident 31 stated they did not recall having a recent care conference. Review of the EHR showed Resident 31 was last offered a care conference on 06/08/2024. During an interview on 02/12/2025 at 2:59 PM, Staff S, Social Service Director, stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure the discharge summary was completed and included recapitulation (overview) of the residents stay, a final summary of the resident's status, and the resident and/or their representative signature for 1 of 3 sampled residents (Resident 88) reviewed for discharge. This failure placed the resident at risk for unsafe discharge, complications and diminished quality of life. Findings included . Review of policy titled Discharge Summary and Plan, revised December 2016, showed 1. When the facility anticipates a resident's discharge [ .] a discharge summary and a post-discharge plan will be developed [ .]. Review of the electronic health record (EHR) showed Resident 88 was re-admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (disease in which the immune system eats away at the protecting covering of the nerves, resulting in damage in the communication between brain and the body), dementia (disease that affects memory,…

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 necessary interventions were in place to ensure correct positioning for 1 of 5 sampled residents (Resident 17) when reviewed for positioning and mobility. The facility also failed to consistently monitor and document bowel movements and implement the bowel program as needed for 2 of 4 sampled residents (Residents 4 and 82) reviewed for bowel protocol. These failures placed the residents at risk for worsening conditions, discomfort, and a decreased quality of life. Findings included . <Position/Mobility> Resident 17 Review of the quarterly minimum data set (MDS), a required assessment tool, dated 01/06/2025, showed Resident 17 admitted on [DATE] with multiple diagnoses to include heart and lung disease, diabetes, anxiety, depression, and muscle weakness. The electronic health record (EHR) showed Resident 17 had a stroke, had a contracture (tightening or lose of movement) of muscle to the left ankle/foot, was able to make their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure care and services to ensure residents increased or maintained range of motion (ROM) were provided for 1 of 5 sampled residents (Resident 67) reviewed for position, range of motion/mobility. This failure placed the residents at risk for worsening mobility, developing of contractures (permanent tightening of muscle, tendons and skin, leading to deformity), and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 67 admitted to the facility on [DATE] with diagnoses that included contracture of the right hand (reduced range of motion), muscle weakness, congestive heart failure (condition that happens when your heart is unable to pump blood well enough to give your body a normal supply) and chronic kidney disease (condition where the kidneys are damaged and unable to filter blood). Resident 67 was able to make needs known. Observation and interview on 02/12/2025 at 9:29 AM showed…

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 environments were free from accident hazards for 1 of 3 sampled shower rooms (200 Hall) and failed to ensure fall interventions were implemented for 1 of 1 sampled residents (Resident 67) reviewed for accident hazards. These failures placed residents at risk of having access to dangerous items, repeated falls, and a diminished quality of life. Findings included . Observations on 02/07/2025, 02/11/2025, and 02/12/2025 showed the shower room on the 200 Hall was unlocked. Observation showed inside the shower room was an electric razor, disposable razors, and nail clippers. During an interview on 02/12/2025 at 12:33 PM, Staff P, Registered Nurse, stated electric razors, disposable razors, and nail clippers were locked in the medication cart as residents were not to have access to these items. Staff P stated the 200 Hall shower room door was unlocked and these items were unsecured within the shower room. During an interview…

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 facility's Registered Dietician's (RD) recommendations were administered as ordered for 1 of 5 sampled residents (Resident 31) and ensure fluid restrictions were followed for 2 of 5 sampled residents (Residents 18 and 82) when reviewed for nutrition/hydration. This failure placed the residents at risk for unmet nutritional needs, dehydration, medical complications, and continued weight loss. Findings included . Review of the electronic health record (EHR) showed Resident 31 readmitted to the facility on [DATE] with diagnoses to include respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), paraplegia (paralysis or loss of ability to move legs) and depression. Resident 31 was able to make needs known and was dependent on staff for activities of daily living. Review of a quarterly nutrition note, dated 12/17/2024, from the RD showed Resident 31 had significant weight loss of 10%. RD…

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 have order and monitor oxygen services to meet professional standards for 1 of 2 sampled residents (Resident 18) reviewed for respiratory services. This failure placed the resident at risk for oxygen toxicity, injury, infection and diminished quality of life. Findings included . Review of policy titled, Oxygen Administration, revised October 2010, showed 1. Verify that there is a physician's order for this procedure [ .] 2. Review the resident's care plan [ .]. Review of electronic health record (EHR) showed Resident 18 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (condition where the kidney reaches advanced state of loss of function), acute respiratory failure (condition that results from inadequate gas exchange by the respiratory system), chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe) and cirrhosis (scarring) of the liver.…

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 staff conducted pain assessments for 1 of 3 sampled residents (Resident 9) who received an as necessary pain medication (oxycodone, a narcotic pain medication used to treat moderate to severe pain) when reviewed for pain management. This failure had the potential for the residents to not receive the necessary pain medication as ordered, a diminished quality of life and unmet needs. Findings included . Review of a document titled, Pain Assessment and Management, dated October 2022, showed the purpose of the procedures were to help the staff identify pain in the resident, and to develop interventions consistent with the residents that addressed the underlying causes of pain. The pain management program was based on facility-wide commitment to an appropriate assessment and treatment of pain, on professional standards of practice, and the comprehensive care plan. The facility staff were to assess the resident's pain and to use a consistent…

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 dialysis (a process to remove waste from blood) care consistent with professional standards for 1 of 1 sampled resident (Resident 18) when reviewed for dialysis care. This failure placed the resident at risk for receiving substandard dialysis care, injury, infection and diminished quality of life. Findings included . Review of the policy titled, Hemodialysis Access Care, revised September 2010, showed The general medical nurse should document in the resident's medical record every shift as follows: 1) Location of catheter 2) Conditions of dressing 3) If dialysis was done during the shift 4) Any part of report from dialysis nurse post-dialysis being given 5) Observations post-dialysis Review of electronic health record (EHR) showed Resident 18 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (condition where the kidney reaches advanced state of loss of function), acute respiratory failure (condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure an as needed or as the situation demands (PRN) psychotropic medication (drugs that affect the brain and central nervous system, that alter mood, thoughts, emotions and behavior) was limited to 14 days for 1 of 5 sampled residents (Resident 9) when reviewed for unnecessary medications. This failure had the potential to place the resident at risk for increased medical complications and decreased quality of life. Findings included . Review of a policy titled, Psychotropic Medication Use, dated July 2022, showed psychotropic medications were not to be prescribed or given on a PRN basis unless that medication was necessary to treat a diagnosed specific condition that was documented in the clinical record. Psychotropic orders were limited to 14 days and if psychotropic medications were prescribed and the attending provider believed that it was appropriate to extend the PRN order beyond 14 days a rationale was to be documented and the appropriateness…

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 routine dental services for 1 of 3 sampled residents (Resident 18) when reviewed for dental services. Failure to provide routine dental services placed the resident at risk for infection, pain, decrease ability to eat and diminished quality of life. Findings included . Review of electronic health record (EHR) showed Resident 18 was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure (condition that results from inadequate gas exchange by the respiratory system) and chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). Resident 18 was able to make needs known. Observation and interview and on 02/07/2025 at 11:03 AM, showed Resident 18 with multiple broken teeth. Resident 18 stated, My teeth are broken, and the staff are not doing anything about it. Review of the care plan, dated 11/06/2024, showed Resident 18's broken teeth were not…

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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: consistently applied Personal Protective Equipment (PPE) in accordance with the Enhanced Barrier Precautions/Transmission Based Precaution (EBP/TBP, implement precautions based on the means of transmission in order to prevent or control infection) signs posted outside of resident rooms for 1 of 3 sampled residents (Resident 47) and consistently ensure respiratory care equipment (an aerosol machine and oxygen tubing) were stored in a clean and sanitary manner for 1 of 2 sampled residents (Resident 18) when reviewed for infection control. These failures placed residents and staff at risk for contracting and/or spreading infections and a decreased quality of life. Findings included . Review of a document titled, Personal…

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 timely refund charges paid (less what was owed to the facility) for 1 of 3 residents (Resident 2) reviewed for misappropriation and personal funds. This failed practice placed the prior resident at risk of financial instability with their current housing placement and diminished quality of life. Findings included . <Resident 2> Review of Resident 2's electronic health record census showed they admitted to the facility on [DATE]. Resident 2 discharged to an Adult Family Home in the community on 11/22/2023. Review of Resident 2's Credit Statement, dated 11/01/2024, showed Resident 2 was due a credit in the amount of $4,363.44 on 11/05/2024, 11 months after they discharged (and still not issued). In an interview on 10/29/2024 at 12:09 PM, Staff E, Business Office Manager, stated Resident 2 discharged from the facility on 11/22/2023 with a zero balance but over-payments were made after Resident 2 discharged . Staff E was unable to locate documentation 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 observation, interview, and record review the facility failed to ensure 1 of 3 sampled residents (Residents 6) with urinary catheters (a flexible tube inserted into the bladder to drain urine) and bowel incontinence received care and services consistent with professional standards of care. The failure to obtain physician orders for the use of a catheter, develop/implement a care plan (CP) for catheter care/monitoring and a personalized bowel program, placed the residents at risk for infections, skin breakdown, constipation, and diminished quality of care. Findings included . <Facility Policy> Review of the facility's Bowel (Lower Gastrointestinal Tract) Disorders-Clinical Protocol, revised September 2017, showed staff would assess residents with previously identified bowel disorders which should include reviewing documentation from any recent hospitalizations and/or diagnostic studies. Risk factors related to bowel dysfunction would be identified and monitored. Review of the facility's Catheter 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 observations, interviews, and record reviews the facility failed to provide a safe, sanitary, and homelike environment in 1 of 2 units (Rose unit-100 Hall and 300 Hall) and 1 of 3 shower rooms (300 Hall) for 3 sampled Residents (Resident 9, 36, & 52) plus 5 supplemental Residents (Residents 7, 13, 57, 60 & 77) reviewed for environment. The failure to ensure walls, wallpaper, privacy cubical curtains, doors/door handles, window coverings, resident rooms, shower equipment, linen cart covers, and wheelchairs were sanitary, clean, odor-free, and in good repair placed residents at risk for infections, accidents, injuries, medical complications, and diminished quality of life. Findings included . WHEELCHAIRS <Resident 52> Observations on 04/08/2024 at 11:10 AM, 04/09/2024 at 8:00 AM, and 04/10/2024 at 11:30 AM, and 04/11/2024 at 1:16 PM of Resident 52's wheelchair appeared to be unclean with dirt, dander and/or debris that resembled dried spilled food. <Resident 60> Observations on 04/08/2024 at 11:12 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 accurately assess 7 of 20 sampled residents (Residents 27, 88, 6, 9, 51, 69, and 72) whose minimum data sets (MDS, a required assessment tool) were reviewed. The failure to accurately assess the residents care needs directly affected the ability to develop a comprehensive care plan that met the residents care needs and placed them at risk for further unmet needs, inaccurate medical records, medical complications,and diminished quality of care/quality of life. Findings included . <Resident 27> During an interview on 04/08/2024 at 12:05 PM, Resident 27 stated they had fallen out of bed one time. Review of Resident 27's electronic health record (EHR) showed the resident readmitted to the facility on [DATE] and was able to make needs known. Review of the facility's incident reporting log dated November 2023 showed that Resident 27 had incidents of falls logged for falls on 11/17/2023 and 11/21/2023. Review of Resident 27's quarterly MDS…

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 develop, implement, and/or update person-centered comprehensive care plans (CP) and ensure the appropriate CP information for direct care staff carried over to the Kardex (bed-side CP direct care staff depend on to provide person-centered care) for 6 of 20 residents (Residents 55, 70, 13, 52, 6, and 69) reviewed for comprehensive CPs. These failures placed the residents at risk for poor clinical outcomes, lack of services, unmet care needs, medical complications, diminished quality of care/quality of life. Findings included . <Resident 55> Review of the 03/18/2024 admission Minimum Data Set (MDS-assessment tool) showed Resident 55 they admitted to the facility on [DATE] and had diagnosis of depression. Review of the physicians' order (PO), dated 03/13/2024 showed Resident 55 was to receive an anti-depressant medication to treat their depression, starting on 03/14/2024. Review of Resident 55's comprehensive CP showed no care plan 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 services provided met professional standards of practice for anti-hypertensive medication administration, orthostatic vital signs, physician orders, insulin administration, injection site rotation for injections, weight monitoring, edema monitoring, and care of patients with heart failure for 9 of 20 sampled residents (Residents 70, 73, 47, 16, 51, 52, 6, 36, and 69) reviewed. These failures placed residents at risk of unmet needs, medical complications, injuries, and diminished quality of care/quality of life. Findings included . ANTI-HYPERTENSIVE MEDICATION PARAMETERS (Residents 16 & 69): POLICY Review of the facility's Standing Physician Orders, dated 09/01/2022, provided by the Medical Director to be used for the care of residents when needed, and unless otherwise specified. The document showed any of the orders could be implemented following an appropriate nursing assessment of the patient and initiation of a PO for physician…

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

Based on observations, interviews, and record review the facility failed to provide food that accommodated identified resident preferences for 4 of 20 Residents (Residents 3, 62, 301, and 91) reviewed for food preferences. This failure placed residents at risk for weight loss, malnutrition, and diminished quality of life. Findings included . During an interview on 04/08/2024 at 12:35 PM, Resident 22 stated they disliked tomatoes, but the facility still served them tomato soup. During an interview on 04/09/2024 at 10:18 AM, Resident 6 said, They asked me what I like and don't like, but then serve me what i don't like, so I have them take it back. During an interview on 04/09/2024 at 9:41 AM, Resident 72 stated sometimes preferences for food choices were not followed, they had a pineapple allergy and were served pineapple. Resident 72 said they didn't eat because they were concerned the pineapple may have touched other food. <BREAKFAST TRAY LINE> <Resident 3> Review of Resident 3's breakfast tray card showed one banana identified as a breakfast preference. Observation of the breakfast…

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

Based on observations, interviews, and record review the facility failed to ensure preplanned menus were followed and the appropriate portion sizes were served according to the tray card for 3 of 20 Residents (Resident 75, 76, and 92) reviewed for dietary services. These failures placed residents at risk for decreased/increased caloric intake, nutritional deficits, and a diminished quality of life. Findings included . Review of the preplanned breakfast menu for 04/11/2024 showed toast, scrambled eggs, ham, 2% milk, juice, and fruit. Observation of the breakfast tray line on 04/11/2024 at 7:25 AM showed Staff H, Cook, plated a donut, scrambled eggs, and a slice of ham for the general diet and low-fat milk was added to the tray. When asked about the preplanned menu, Staff H stated they ran out of bread and 2% milk so they decided to serve donuts and low-fat milk as the alternative. <Resident 75> Review of Resident 75's breakfast tray card showed double portions. Observation of the breakfast tray line on 04/11/2024 at 7:28 AM showed Staff H served Resident 75 one donut, one scoop of…

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

Based on observations and interviews, the facility failed to ensure food was prepared and served according to in accordance with professional standards. These failures placed residents at risk of foodborne illness and a diminished quality of life. Findings included . <FIRST KITCHEN OBSERVATION> An observation on 04/08/2024 at 10:19 AM showed three packages of partially thawed ground beef, an uncovered and unlabeled container of cheese sauce, and an open can of a Named Brand Energy drink on the prep table. During an interview on 04/08/2024 at 10:25 AM, Staff G, Dietary Manager (DM), stated the ground beef thawing on the counter, uncovered and unlabeled food and personal drinks on the counter did not meet expectations. <TEMPERATURES> An observation on 04/11/2024 at 7:50 AM, showed Staff H, Cook, added a large pitcher of hot water from the coffee maker to the oatmeal on the steam table. Observation showed no temperature was taken. An observation on 04/11/2024 at 8:11 AM showed Staff H take a tray of ham from the oven and put it on the steam table. Observation showed no temperature was…

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 include documentation of the Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement to the resident and/or representative for 4 of 4 residents (Residents 81, 87, 73 and 66), reviewed for Arbitration Agreement. This failure placed the residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life. Findings included . Review of a facility's admission Agreement for Skilled Nursing Facilities, admission Agreement (AA)packet, dated May 2017, showed in section 9.1: Attachments / Arbitration Agreement: The Center offers the Resident Group [resident or resident representative] the option of signing an Arbitration Agreement. The Resident Group acknowledges receiving a copy of the Arbitration Agreement, being informed orally of the content 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 include documentation of the Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement to the resident and/or representative for 4 of 4 residents (Resident 81, 87, 73 and 66), reviewed for Arbitration Agreement. This failure placed the residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life. Findings included . Review of a facility document titled, admission Agreement for Skilled Nursing Facilities, dated May 2017 showed section 9.1: Attachments / Arbitration Agreement. The Center offers the Resident Group [resident or resident representative] the option of signing an Arbitration Agreement. The Resident Group acknowledges receiving a copy of the Arbitration Agreement, being informed orally of the content of the Arbitration Agreement…

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 maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the collection and analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 2 of 3 months (February and March 2024) reviewed for Infection Control. The facility also failed to implement isolation precautions for 1 of 2 wings (Rose wing) reviewed for transmission-based precautions. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, and a decreased quality of life. Findings included . <Tracking and Trending> Review of the facility policy titled Infection Control, revised October 2018, showed the surveillance for infections would identify both individual cases and trends to guide appropriate interventions and prevent future infections based on current standards. It showed that 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 implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 4 of 7 residents (Residents 69, 304, 56 and 305) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Resident 69 Review of the electronic health record (EHR) showed Resident 69 admitted to the facility on [DATE] with diagnose of infected amputation stump. Review of the laboratory report dated 06/24/2023 showed the resident had a urinary tract infection (UTI) and identified e-choli (a bacteria) extended spectrum beta lactamase (ESBL) which was resistant to multiple antibiotics (MDRO) and also identified proteus mirabilis (a bacteria) which was not resistant to antibiotics. The…

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

Based on interview and record review, the facility failed to ensure residents had access to their money during evenings and weekends for 1 of 37 sampled residents (Resident 36) reviewed for personal funds. This failure placed residents at risk for decreased autonomy (independence), dishonored residents rights, and a diminished quality of life. Findings included . During an interview on 04/09/2024 at 12:56 PM, Resident 36 stated they did not have a lock box and had to keep funds in their room because they did not have access to personal funds after business hours. Review of Resident 36's financial Trial Balance statement, dated 04/08/2024, showed Resident 36 had a monthly deposit allowance of $45.36 and an available balance total of $407.18. During an interview on 04/10/2024 at 1:53 PM, Staff D, Business Office Manager, stated residents did not have access to personal funds after hours. During an interview on 04/12/2024 at 1:09 PM Staff A, Administrator, stated residents did not have access to personal funds after hours (due to a recent petty cash audit) like they should, which did…

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

Based on observations and interviews the facility failed to protect the resident's right to personal privacy for 2 of 4 Residents (Resident 52 and 69) reviewed for dignity. The failure to provide privacy and maintain dignity during the provision of personal cares and wound treatment for Resident 52 and for Resident 69 placed the residents at risk for embarrassment, frustration, and undignified quality of life. Findings included . <Resident 52> During an observation on 04/09/2024 at 9:34 AM, Resident 52 was seated in their wheelchair facing the doorway. The door was not closed and the privacy curtain was not pulled to provide privacy during care. Staff T, Certified Nursing Assistant (CNA), was observed re-arranging Resident 52's shirt and exposed Resident 52's left breast which was observed from the hallway. In an interview on 04/09/2024 at 9:41 AM, Staff T stated they tried to shut the door, but the door did not have a doorknob and would not stay closed. Staff T stated they pulled the curtain but must not have pulled the curtain far enough to provide privacy. <Resident 69> During a…

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

Based on observation, interviews, and record review the facility failed to timely identify (or should have identified) a significant change is status for 1 of 2 residents (Resident 6) reviewed for change of condition. The failure to conduct a Significant Change in Status Assessment (SCSA) within 14 days of the determination of a resident's significant change in status placed the resident at risk for unmet care needs, diminished quality of care/quality of life. Findings included . <Resident 6> During an observation and interview on 04/09/2024 at 10:13 AM, Resident 6 was observed lying in their bed, the shades closed, and the room very dark. Resident 6 stated they were aware they had gained a considerable amount of weight which they contributed to their food choices, their loss of mobility and independence, their body altering leg amputation, pain, and lack of motivations/loss of interest in doing anything. Resident 6 stated before they came to this facility, they could walk, and they were continent of bladder. Resident 6 stated they disliked living in a nursing facility, felt like…

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 conduct timely/routine care planning conferences with the resident and/or responsible party for 3 of 4 residents (Residents 63, 72 and 78) reviewed for care conferences. This failure placed the residents at risk for unmet needs, not being involved and/or informed of their care plan (CP), and a diminished quality of life. Findings included . <Resident 63> Review of the 03/20/2024 Quarterly Minimum Data Set (MDS-assessment tool) showed Resident 63 readmitted to the facility on [DATE], diagnoses included a brain injury caused by lack of oxygen, and dysphasia (a condition that affects the ability to speak and/or understand spoken language). Resident 63 was usually able to make their needs known. In an interview on 04/08/2024 at 2:23 PM, Resident 63's Responsible Party stated they did not recall when an actual care conference was conducted or what their CP was. Review of Resident 63's electronic health record (EHR) on 04/09/2024 showed the last time a 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 observations, interviews, and record review the facility failed to provide the care and assistance with activities of daily living (ADLs) they required to maintain good grooming, oral hygiene, and toileting for 2 of 6 Residents (Residents 52 and 69) plus 2 supplemental residents (Resident 60 and 7) reviewed for ADLs. These failures placed the residents at risk for unmet care needs, poor oral health, skin impairment, medical complications, and diminished quality of life/quality of care. Findings included . <Resident 52> Review of the 03/12/2024 Quarterly Minimum Data Set (MDS-assessment tool) showed Resident 52 was dependent on staff for eating, oral hygiene, toileting, personal hygiene, and transfers. Resident 52 was assessed to be always incontinent of bowel and bladder. Resident 52 received feeding through a stomach tube and had no dental problems. Review of Resident 52's [NAME] on 04/08/2024 showed Resident 52 required extensive toileting assistance by staff, staff were directed to turn 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 observations, interview, and record review the facility failed to ensure residents were provided resident-centered activity programs that incorporated their interests, hobbies, and cultural preferences for 1 of 2 Residents (Resident 52) plus 3 supplemental Residents (Residents 60, 57, and 7) reviewed for activities. The failure to provide independent and/or community activities that met each resident's physical, mental, and psychosocial needs placed residents at risk for social isolation, boredom, decreased sense of security/identity/meaning, and a diminished quality of life. Findings included . <Resident 52> Review of the 03/12/2024 Quarterly Minimum Data Set (MDS-assessment tool) showed Resident 52 was assessed to have adequate hearing, unclear speech, usually made themselves understood, and usually understood others. Resident 52 had moderate vision impairment without corrective lenses and diagnoses included brain injury from lack of oxygen, dementia, and anxiety. Resident 52 has no behaviors 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 provide an environment free of accidents/hazards for 3 of 9 residents (Residents 13, 66, and 27) and 2 of 2 smoking areas (on the property and on the street sidewalk-adjacent to the facility property) reviewed for accidents. The failure to re-assess Residents 13 and 66 after unsafe smoking incidents and provide adequate supervision and/or assistance for smoking safety compliance, equally enforce the facility smoking policy for all residents, visitors, and staff; ensure smoking receptacles were available for safe and sanitary collection of cigarette refuse; and ensure a re-assessment and care plan (CP) update occurred for Resident 27 after a fall. These failures placed the residents at risk for further accidents, smoking related injuries, unsanitary environment, and diminished quality of life. Findings included . SMOKING <POLICY> Review of the facility's admission Agreement Packet, Notice of Smoke-Free Center Policy, revised November…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews, and record reviews the facility failed to ensure 2 of 3 residents (Residents 69 and 70) with urinary catheters (a flexible tube inserted into the bladder to drain urine) received care and services consistent with professional standards of care. The failure to ensure routine catheter care was provided, and the catheters were properly secured and positioned placed the residents at risk for infections, skin breakdown, discomfort, and diminished quality of care. Findings included . <Resident 69> Review of the 03/01/2024 Annual Comprehensive Minimum Data Set (MDS-assessment tool) showed Resident 69 diagnoses included paraplegia, an amputation of the left lower leg, urine retention (condition where the bladder is unable to empty all the urine), and a multi-drug resistant organism (MDRO). Resident 69 required the use of a foley catheter and was dependent on staff for toileting care. Review of the elimination care plan (CP), revised 03/20/2024, showed: an intervention (revised…

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

Based on observations, interviews, and record review the facility failed to ensure staff provided pain medication as ordered for 1 of 4 Residents (Resident 73) reviewed for pain. The failure administer a routinely scheduled anti-inflammatory analgesic (a medication to reduce swelling and pain) and accurately document the provision of acetaminophen (a mild analgesic that has potential for medical complications when taken in excess) in the clinical record placed the resident at risk for delay in care and services to treat their chronic pain condition, potential for acetaminophen toxicity, medical complications, and diminished quality of care/quality of life. Findings included . POLICY Review of the facility's Pain-Clinical Protocol policy, dated March 2020, showed the provider and staff would identify residents who had pain, conduct a pain assessment, and provide treatment to relieve pain. The pain management protocol showed staff would evaluate and report the residents use of scheduled medication and PRN (as needed) medication usage. If there were more than occasional analgesic…

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 provide adequate hemodialysis (HD, a process in which blood is filtered of waste, toxins and fluid) services for 1 of 1 Residents (Resident 66) reviewed for dialysis. The facility failed to provide consistent monitoring of the dialysis documentation of communication, to the dialysis unit, to inform them of pertinent clinical information. This failure placed the resident at risk for unmet care needs, medical complications, and diminished quality of care. Findings included . POLICY Review of the facility's Nursing Home Dialysis Transfer Agreement policy, dated 05/16/2013, showed the facility and the HD Center would provide each other with the necessary health information to ensure the residents received the care and services they required related to their kidney disease. The facility would ensure all appropriate medical, social, and administrative information regarding the resident would be communicated to the HD Center at the time of transfer. <Resident 66> Review of the 04/04/2024 Quarterly Minimum Data Set (MDS-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 provide Influenza and Pneumococcal vaccines for 2 of 5 residents (Resident 55 and 70) reviewed for vaccinations. This failure placed the residents at a higher risk for contracting influenza and pneumococcal infections, related complications, and a decreased quality of life. Findings included . Resident 55 Review of Resident 55's electronic health record (EHR) showed the resident admitted on [DATE]. A signed consent form was located in the medical record that listed influenza, and pneumococcal vaccines, there was no indication if the resident consented or declined the vaccines. Review of the administration record showed the vaccines had not been administered. Resident 70 Review of Resident 70's EHR showed the resident admitted on [DATE], a signed consent form which indicated the resident consented to the influenza vaccine was located in the medical record dated 08/04/2023. Also, a signed consent form for the pneumococcal vaccine was located, it did…

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 follow-up on the completion of COVID-19 immunizations for 2 of 5 residents (Residents 55 and 70) reviewed for vaccinations. This failure placed the residents at an increased risk for complications related to COVID-19 infection that could result in severe illness or death. Findings included . Review of Resident 55's electronic health record (EHR) showed the resident admitted on [DATE] with diagnoses of heart disease, presence of a pacemaker and asthma. There was no record of the resident receiving the Covid-19 vaccine prior to admission. A signed consent form dated 03/14/2024 was located in the medical record that listed the Covid-19 vaccine, there was no indication if the resident consented or declined the vaccine. Further review showed no record of the residents Covid-19 vaccination status and that the vaccine had not been administered since admission. Review of Resident 70's EHR showed the resident admitted on [DATE] with diagnoses of…

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

Based on interview and record review the facility failed to develop and implement an effective, personalized discharge plan for 6 of 6 sampled residents (Residents 1, 10, 11, 13, 14, & 15) reviewed for discharge planning. The facility failed to: ensure the discharge needs of each resident were identified,; the Interdisciplinary Team (IDT) involved the resident/responsible party to develop a personalized discharge care plan based on each resident's needs, goals, & preferences,; provide timely referrals to the LCA for residents who desired to discharge to the community,; and ensure the Home Health Agency (HHA) was provided all required documents to start services and issued a preliminary start date. These failures placed residents at risk for unmet care needs after discharge, potential for re-hospitalization, and diminished quality of life. Findings included . <POLICY> Review of the facility's policy, Discharge Process and Planning, revised December 2016, showed the IDT team would evaluate each resident for their discharge needs and develop an individualized post-discharge plan 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.

Based on interview and record review, the facility failed to ensure residents experienced a smooth transition during their discharge, received medications and post-discharge care and services timely for 6 of 6 sampled residents (Residents 1, 10, 11, 13, 14, & 15) reviewed for discharge planning. The facilities failure to: prepare a complete discharge summary that included a recapituation of the resdient's stay with all required components, a complete final summary of the resident's status, a reconciliation of all pre-discharge and post-discharge medications, and ensure a discharge plan of care was implemented, documented, and provided to the Resident and/or Responsible Party placed the residents at risk for unmet care needs, potential for re-hospitalization, and diminshed quality of life. Findings included . Review of the facility's policy, Preparing a Resident for Transfer or Discharge, revised December 2016, showed nursing services would: obtain POs for discharge including the recommended discharge care, services, and equipment the resident required; prepare the discharge summary…

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 or arrange for care and services consistent with accepted standards of quality for 3 of 6 sampled residents (Residents 2, 18, & 20) reviewed for change of condition and tube feeding. The facility's failure to develop and implement a care plan to meet resident specific care needs; identify, document, and timely notify the appropriate parties of a change of condition; timely implement Physician Orders (POs); and ensure documentation was accurate and complete placed the residents at risk of diminished quality of care, unmet care needs, and potential for significant medical complications. Findings included . Review of the facility's Acute Condition Changes-Clinical Protocol policy, revised March 2018, showed to assess and recognize a change in condition, the nurse would conduct and document a baseline assessment of the resident's vital signs, pain, neurological status, most recent labs, active diagnoses, and all current medications. Direct care staff would be trained in recognizing subtle but significant…

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's medical records were complete, accurately documented, readily accessible, and systematically organized according to professional standards of practice for 5 of 5 residents (Residents 20, 1, 2, 11, & 14) reviewed for medical records. These failures placed the residents at risk for significant medication errors, unmet care needs, delayed response to changes of condition, and diminished quality of care/quality of life. Findings included . <Resident 20> Review of the hospital Discharge summary dated [DATE] showed Resident 20 was allergic to ceftriaxone (Rocephin). Review of the facility admission orders dated 10/24/2023 showed Resident 20's allergy was cephalexin (Keflex). Review of Resident 20's facility Nursing admission Evaluation dated 10/24/2023 showed Resident 20 was allergic to cephalexin, and the relevant history and diagnoses sections of the assessment were blank and not completed. In an interview on 11/29/2023 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.

Based on interview and record review, the facility failed to immediately inform the resident, physicians, and resident representative of a significant change of condition for 1 of 1 sampled residents (Resident 20) reviewed for change of condition. This failure placed residents at risk of potential life-threatening clinical complications, psychosocial harm, and diminished quality of care/quality of life. Findings included . According to the American Heart Association/American College of Cardiology Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary, dated March 21, 2017 (Volume 135, Issue 12), a comprehensive treatment plan to achieve intact skin and a functional foot included coordinated efforts with vascular medical specialists. To minimize further tissue loss, prompt recognition of foot infection through daily inspections was necessary especially for patients who had diabetes and peripheral neuropathy. Foot infections were to be suspected in patients with pain or tenderness to the area, redness or swelling around the wound, any…

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 care and services were provided according to resident's needs, physician orders (POs), and professional standards of practice for 2 of 5 sampled residents (Residents 2 & 18) reviewed for tube feeding. The facility's failure to: follow POs for tube feeding administration to ensure the resident received the ordered amount of formula, ensure POs were in place to monitor and document the frequency and volume of water flushes for medication administrations, ensure the total volume of formula was accurately documented to monitor daily intake of calorie needs, and ensure formula and water tubing/containers were properly labeled placed the residents at risk of potential illness, weight loss, altered nutritional status, and diminished quality of care/quality of life. Findings included . <Resident 2> In an interview on 11/29/2023 at 3:30 pm, Resident 2 stated their tube feeding was not started as ordered on 11/09/2023 and they reported it to the nurse on 11/10/2023. The nurse started their tube feeding and it ran…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or resident representative, written information that specified the facility's bed-hold policy, including the Washington State specific bed-hold periods, rights to return to the facility, and bed-hold facility rates before and at the time of transfer to the hospital for 6 of 6 residents (Residents 1, 4, 9, 10, 11, and 12) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to return and resume residence at the facility after hospitalization. Findings included . Review of the facility's policy,Bed-Holds and Returns, revised March 2017, showed prior to transfers or therapeutic leaves, the facility would provide written notification of the facility bed-hold and return policy to each resident/resident representative prior to transfers or therapeutic leaves. The notification would include the resident rights and limitations regarding bed-holds 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 develop and implement a comprehensive care plan that addressed the risk for pressure injury for 1 of 3 residents (Resident 1) reviewed for pressure injury. This failure placed the resident at risk for unmet needs, reoccurrence of a pressure injury, development of new pressure injuries, complications, and a diminished quality of life. Findings included . Review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, revised December 2016 indicated that the interdisciplinary team, in conjunction with the resident and the resident's representative was expected to develop and implement a comprehensive, person-centered care plan for each resident. The policy and procedures further showed care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of Resident 1's admission Minimum Data Set (MDS, a required assessment tool) dated 06/13/2023 showed…

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.