Evansville Manor Nursing And Rehab, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications (R1). R1 takes a medication used for anxiety PRN (as needed). The facility failed to recognize that all PRN psychotropic medications or medications used off-label as psychotropic medications should be limited to 14 days unless deemed appropriate by the provider. Evidenced by:The facility policy, Psychotropic Medication, dated 8/1/15 with a last revision date of 5/1/25, states, in part: . Procedure: . 11. PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. R1 was admitted to the facility on [DATE] with diagnoses that include, in part: bipolar disorder (mental…

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 protect the resident's right to be free from verbal abuse by a CNA (certified nursing assistant) for 1 of 3 Residents (R1) reviewed for abuse. R1 and CNA C (certified nursing assistant) had a verbal altercation. The facility did not implement appropriate actions to protect R1. CNA C continued to provide direct care to residents. The facility did not educate all staff on abuse during the abuse investigation. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. The guidelines include…

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 did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 residents (R1) reviewed for abuse. Facility became aware of an abuse allegation on 9/26/25 at 10:15 PM and did not report to the State Agency until 9/27/25 at 12:12 PM. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough…

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 did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 1 or 3 residents reviewed (R1). On 9/27/25, the facility became aware of an abuse allegation regarding R1. The facility failed to provide evidence to prevent further abuse to R1 and other residents. The facility allowed the staff member identified in the abuse allegation to continue working with residents. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the…

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

Based on observation, interview, and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (R5) reviewed for medications.R5 has medications that should not be crushed prior to administration. R5 received those medications crushed. R5 received an enteric coated medication when the medication should have been in a chewable form. This is evidenced by: The facility's policy Medication Error, dated 5/14/21, includes: All medication errors and drug reactions will be reported promptly to the licensed nurse, the attending physician, and will be documented according to established procedures. Medication error is defined as the preparation or administration of medications or biological that is not in accordance with the prescriber's orders, manufacturer specifications regarding the preparation and administration of the medication or biological and/or accepted professional standards for medication…

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 that residents (R) receive treatment and care in accordance with professional standards of practice or the comprehensive person-centered care plan for 1 of 1 residents (R3) reviewed. R3 voiced concern that her bottom was getting sore from sitting on the Hoyer sling. The Registered Nurse (RN) did not complete an assessment and delayed in notifying the provider of R3's potential skin breakdown. R3 has a diagnosis of Congestive Heart Failure (CHF) that was not being adequately monitored. The facility did not follow physician's orders for bi-weekly weights and did not notify the provider when there were weight fluctuations. Findings include: Example 1: Facility policy entitled, Pressure Injury Prevention and Wound Care Management, dated 8/26/18 with last revision date of 3/4/24, states, in part: Purpose: The purpose of the policy is to provide healthcare staff with the standards of care, and processes to be followed for all residents .…

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 did not ensure residents received food that is palatable and at a safe and appetizing temperature for 1 of 1 test tray on the 100 hallway affecting 9 out of 10 residents and 1 of 4 residents (R16) interviewed on food. R16 voiced concerns regarding cold food. Surveyor received a test tray, and the food was cool and not palatable. Evidenced by: The facility policy, entitled Food Temperature Record, dated 6/28/22, states, in part: .Policy: To ensure that foods and beverages are held and served at temperatures which comply with State and Federal Regulations. F804: Each resident receives, and the facility provides food that is palatable and at the proper temperature . Procedure: . 2. TCF (Time/Temperature Control for Safety Food) foods such as meat, poultry, fish and eggs should be cooked to the minimum internal temperature specified below: Pork, Beef, or Veal (Steaks or Chops)- 145* F for 15 seconds (Roasts)- 145* F for 4 minutes Poultry- 165* F for 15…

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

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 9 residents (R8 and R9) reviewed for abuse. A friend of MR O (Medical Records) observed DA P (Dietary Aide) post a photo of R8 and R9 on her personal Snapchat account with text indicating Hanging with my homies. The friend of MR O forwarded the photo to MR O, who is employed at the facility. MR O did not immediately report this allegation of abuse to the facility. This is evidenced by: The Facility's Vulnerable Adult Abuse and Neglect Prevention Policy and Procedure, revised 3/25/25, documents in part: .It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse .Additionally, residents and staff will be protected from…

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

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 9 residents (R8 and R9) reviewed for abuse. A friend of MR O (Medical Records) observed DA P (Dietary Aide) post a photo of R8 and R9 on her personal Snapchat account with text indicating Hanging with my homies. The friend of MR O forwarded the photo to MR O, who is employed at the facility. The facility did not interview other residents to determine the scope of the concern or educate staff regarding timely reporting. This is evidenced by: The Facility's Vulnerable Adult Abuse and Neglect Prevention Policy and Procedure, revised 3/25/25, documents in part: .It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse 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 did not ensure adequate monitoring for medications for 1 of 4 Residents (R3) reviewed for unnecessary medications. R3 was receiving Metoprolol (blood pressure medication) without evidence of R3's blood pressure being monitored per physician orders. Evidenced by: The facility policy, entitled Administering Medications, dated 1/22/24, states, in part: . Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: . 4. Medications shall be administered per provider's (Medical Doctor, Nurse Practitioner. Physician Assistant) written/verbal orders upon verification of the right medication, dose, route, time . R3 was admitted to the facility on [DATE] and discharged on 4/30/25. R3 has diagnoses that include hypertension (high blood pressure, a condition in which the force of the blood against the artery walls is too high) and paroxysmal atrial fibrillation (a type of irregular…

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 did not ensure food was stored or labeled in accordance with professional standards. This has the potential to affect the census of 59 residents. Multiple food and beverage items for resident consumption stored in the facility's kitchen refrigerator and dry storage room were not labeled with open or expiration dates and/or were beyond the labeled discard date. Dish washing was completed without testing the dishwasher temperature and concentration of the sanitizer. Sanitizer buckets were utilized without testing for temperature and concentration of sanitizer. Findings include: Facility policy entitled Sanitation and Cleaning Schedule, dated revised on 8/15/23, states, in part: Procedure .5. Sink Sanitizer Log must be completed per policy for both three and four compartment manual ware washing sink and buckets or spray bottles filled with quat sanitizer and reviewed daily.Storage (Dry) .5. All food items must be dated upon receiving and dated and sealed when opened.Storage (Refrigerated) . 3. All refrigerated and prepared…

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 Example 5 R7's shower day is Friday. R7 did not receive a shower three times from August 1, 2024, through September 26, 2024. R7 did not have showers on 8/9/24, 8/30/24, and 9/13/24. R7's shower documentation for the dates of missed showers, documents: 8, 8 NA which indicates 8- Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity, Not Applicable. Of note, these dates were not noted to be resident refusals. Example 6 R27's shower day is Thursday. R27 did not receive a shower in August at all and had not received a shower in September as of September 26, 2024. R27 did not have showers on 8/1/24, 8/8/24, 8/15/24, 8/22/24, 8/29/24, 9/5/24, 9/12/24, and 9/19/24. R27's shower documentation for the dates of missed showers, documents: 8, 8 NA which indicates 8- Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity, Not Applicable. Of note, these dates were not noted to be resident refusals. Example…

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 did not ensure drugs and biological's are labeled in accordance with currently accepted professional standards for 2 of 2 Medication carts reviewed for medication storage. The 300 Hall medication cart had an undated open insulin pen for R26, R512, and R33. The 200 Hall medication cart had an undated open insulin pen for R40. RN R (Registered Nurse) repackaged Aspirin 81 milligrams for her residents at the beginning of her shift and stored them in a medication cup in the top drawer of the medication cart. As evidenced by: The facility policy entitled, Medication Storage, dated 2/12/24 states in part, Purpose: To ensure that medications and biologicals [sic] are stored in a safe, secure storage and safe handling. Procedure: General Guidelines . 3. No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy. 4. Expired medications are to be removed from areas medication carts prior to or at the time of expiration . Multi-Dose vials: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature, for 4 of 4 hallways and one of one dining room This has the potential to affect the total census of 59 residents (4 of 4 hallways, 1 of 1 dining room, and 1 of 1 test tray). Residents voiced concerns with receiving hot foods cold. Test tray was observed to have hot foods served cold and beverages served warm. R2 indicated that hot food is not served hot. R38 and R31 indicated hot food is served cold and cold foods are served warm often. R38 and R31 indicated this has been discussed previously at monthly Resident Council meetings. R17 & R9 voiced concerns with receiving cold food. Findings include: Facility policy entitled Food Temperature Record, dated 6/28/22, states, in part: Policy: To ensure that foods and beverages are held and served at temperatures which comply with State and Federal Regulations. Example 1 On 9/24/24 at 8:19 AM, Surveyor…

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 did not ensure each resident has a safe, clean, comfortable, and homelike environment for 1 (R32) of 28 residents reviewed. Surveyor observed R32's room to smell like urine, a brown substance on floor, garbage can full of garbage, and white debris under R32's bed and on floor on 9/23/24 and 9/24/24. Evidence by The facility policy, Cleaning Resident Room, revision date 5/8/24, states, in part; .To ensure appropriate cleaning procedures using an EPA (Environmental Protection Agency)- approved cleaning agent for disinfection of room surfaces and equipment .10. Thoroughly mop entire floor with approved cleaning solution (under furniture, behind doors, along baseboards. Mop your way out the door and place wet floor sign in doorway. 11. Discard all disposable items . On 9/23/24 at 10:20 AM, Surveyor observed resident bedroom to smell like urine, a brown substance on floor, garbage can full of garbage, and white debris under resident bed and on floor. On 9/24/24 at 3:17 PM, Surveyor observed R32's room to still have brown…

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 did not ensure that each resident was free from misappropriation for 1 of 8 abuse investigations reviewed (R24). On 9/22/24, R24 filled out a grievance indicating he gave a Norro foot massager to RN L (Registered Nurse) to borrow and did not see it again. R24 further documents, he asked RN L for it back on 9/21/24, and was ignored. R24 threatened to call the police on RN L before RN L provided R24 with his belonging. This is evidenced by: The facility's policy and procedure, Abuse and Neglect Prevention, revised, 10/4/23, documents in part, the following: Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. All residents are susceptible to maltreatment and exploitation due to their need for nursing…

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

Based on the interview and record review, the facility did not ensure alleged violations involving misappropriation were reported to the State Agency immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, for 1 of 8 (R24) allegations reviewed. On 9/22/24 R24 filled out a grievance/allegation indicating he gave a Norro foot massager to RN L (Registered Nurse) to borrow and did not see it again. R24's grievance (an allegation of misappropriation) was forwarded to BOM M (Business Officer Manager), who is the Manger on Duty. BOM M did not read the allegation in its entirety nor did she report this allegation of abuse to DON B (Director of Nursing) or NHA A (Nursing Home Administrator). BOM M left the grievance (allegation of abuse) for SW C (Social Worker) to receive the following day.…

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

Based on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation for 1 of 8 abuse allegations (R24). On 9/22/24 R24 filled out a grievance indicating he gave a Norro foot massager to RN L (Registered Nurse) to borrow and did not see it again. DON B (Director of Nursing) and NHA A (Nursing Home Administrator) have not investigated this allegation of misappropriation. This is evidenced by: The facility's policy and procedure, Abuse and Neglect Prevention, revised, 10/4/23, documents in part, the following: Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. The guidelines include compliance with the seven (7) federal components of prevention and investigation. All residents are susceptible 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 did not develop and implement a comprehensive person-centered care plan for 1 of 29 sampled residents (R32) to meet a resident's medical, nursing, and psychosocial needs that are identified. R32's Comprehensive Care Plan does not reflect person-centered interventions to best support R32. Evidenced by: The facility policy, Care Plan- Baseline and Comprehensive, dated 6/20/23, states, in part; .Purpose: To ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative .Policy: The Interdisciplinary Team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessments from different members of the interdisciplinary team, lifestyle, and current resident goals R32 was admitted to the facility on [DATE] with a diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident reviewed for change of condition (R56). R56 has congestive heart failure and did not have his weight monitored and reported to the physician in accordance with orders and standards of practice. Findings include The AHA (American Heart Association) states that daily weights is one of the most important symptoms to track for those with heart failure. The AHA notes, Many people are first alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week. This weight gain may be due to retaining fluids since the heart is not functioning properly. It's a good idea to track your weight and check in with your health care professional if you notice sudden changes…

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 did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 1 resident (R39) reviewed for hydration. R39 had an order for a fluid restriction that was not monitored by staff, as well as a significant weight gain that was not reported to R39's medical provider. Evidenced by: The facility's policy titled Hydration revised on 2/4/24 states in part .3. Fluid breakdown for residents on fluid restrictions will be placed on the MAR (Medication Administration Record), on the POC (Point of Care) task list, and in the resident care plan .14. Intake and Output monitoring will be assessed by licensed nursing staff at least weekly, and physicians will be contacted regarding continuous monitoring as needed . The facility's policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 3 Residents reviewed for pain (R45). The facility failed to provide R45 with his ordered PRN pain medication when reporting 8 out of 10 pain, in consecutive shift assessments. The facility also failed to reassess the resident's pain after non-pharmacologic interventions had been administered. This is evidenced by: The facility policy entitled, Pain Management and Assessment, dated 4/27/22 states, in part: . Procedure: 1. Nursing staff will identify individuals who have pain or who are at risk for having pain .7. Non-pharmacological interventions (i.e. repositioning resident, turning lights off, warm cloth, etc.) will be attempted prior to the use of PRN (as needed) analgesics whenever appropriate. Use of interventions and effectiveness will be documented. 8. Evaluation of the effectiveness of analgesic pain…

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 did not ensure that it was free of medication error rates of 5% or greater. There were 8 errors out of 27 opportunities that affected 1 of 1 sampled residents (R43) and 2 of 9 supplemental residents (R513 & R15) included in the medication pass task, which resulted in an error rate of 29.63%. The facility's medication error rate was 29.63% with medication errors observed for R513, R43, and R15. This is evidenced by: The facility policy, Administering Medications, dated 8/1/2015, states in part, as follows: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Medications shall be administered per provider's (MD, NP, PA) written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. Medications…

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 did not ensure residents are free of significant medication errors for 1 of 1 total sampled residents (R513). Surveyor observed R513's medication pass on 9/23/24. RN R (Registered Nurse) stated, R513's Entresto (combination medication to treat heart failure) is not available. R513's order for Entresto for high blood pressure is dated 8/30/24. R513 has not received Entresto since it was ordered. This is evidenced by: The facility policy, Administering Medications, dated 8/1/2015, states in part, as follows: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Medications shall be administered per provider's (MD, NP, PA) written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. Medications should be administered within one (1) hour of the prescribed times.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that an allegation of abuse, neglect, exploitation or mistreatment was reported immediately, for 1 of 5 sampled residents (R1). Findings include The facility's abuse policy states the following: *All residents are susceptible to male treatment and exploitation due to their need for nursing home care. *Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; Involving protected loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; Or an injury resulting from criminal sexual abuse . *Accident means a sudden, unforeseen, and unexpected occurrence or event which: (a) is not likely to occur and which could not have been prevented by exercise of due care; and (b) if occurring while a vulnerable adult is receiving services from a facility, happens when the facility and the employee or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an incident and did not take action to prevent further potential abuse for 1 of 5 sampled residents (R1). Incident occurred with a CNA where R1 fell out of bed and sustained an injury. This incident was not investigated and the results of the investigation were not reported. Findings include The facility's abuse policy states the following: *Upon receiving a complaint of alleged maltreatment the administrator must be notified immediately and they, the director of nursing, or assigned designee, will coordinate an investigation, which will include completion of witness statements. All parties involved including two of the following-staff, residents or visitors, who were potentially involved, or observed the alleged incident are to be interviewed by the DON, director of social services or their designees. R1 was admitted to the facility with diagnoses that include. Hemiplegia and hemiparesis following cerebral infarction, aphasia,…

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 did not ensure 2 Certified Nursing Assistants (CNAs; CNA N and CNA O) of 5 CNA's employed by the facility received 12 hours per year of in-service training. This practice had the potential to affect multiple residents in the facility. CNA N was hired on 9/13/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA O was hired on 12/22/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. Evidenced by: The Facility Assessment with a date completed/updated of 1/23/24, indicates, in part: .Yearly education requirements are managed by Relias. Annual education includes training in dementia, depression, PTSD (Post-Traumatic Stress Disorder), schizophrenia, adjustment disorder and anxiety. This training will include basic information in de-escalation techniques, appropriate verbal and non-verbal communication and safety awareness including but not limited to the listed diagnosis .Education/Inservices .Resident's rights and facility…

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 Example 5 R25 was admitted to the facility on [DATE], has diagnoses that include hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body due to brain or spinal cord damage), R25 has a BIMS (Brief Interview for Mental Status) of 00 indicating a severe cognitive impairment. R25's Care Plan, revised on 3/16/23, with a target date of 6/22/23, states: Weigh at the same time of day and record: Monthly. Report significant changes to MD (Doctor). On 1/4/23, at 5:18 PM, a progress note was entered into R25's eMAR by Diet. P (Dietician) that states in part: R25 has experienced a significant weight loss of 9.5 lbs./5.8% in less than 90 days. Current weight is 153.5 lbs.Will continue current plan and monitor for further weight loss. On 2/27/23, at 12:27 PM, a progress note was entered into R25's eMAR by Diet. P that states in part: .Will continue to monitor weights . On 2/27/23, an order for R25 was given for the facility to provide weekly weights r/t (related to) tube feeding one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Residents (R) receive care, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 5 of 5 Residents reviewed for Pressure Injuries out of a total sample of 22 Residents (R361, R43, R23, R28, & R25). R361 was admitted to the facility with a pressure injury to her bottom, that was not assessed or measured until several days after her admission. R43 developed a pressure injury (PI) to left heel on 6/13/23 there was no Registered Nurse (RN) assessment, Braden tool was not re-done, and Provider (Physician or Nurse Practitioner) was not updated. The facility did not follow R23's physician orders for wound care treatment. The facility did not follow R28's physician orders for wound care treatment. Surveyor observed the settings for R25's air mattress outside the range of care planned settings. This is evidenced by: Facility policy entitled 'Pressure Injury…

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 did not provide a safe, clean, comfortable, and homelike environment for 1 of 19 residents (R35). R35's bed linens were not replaced, nor was her bed made after having been incontinent. Findings include: On 6/26/23 at 10:33 AM, Surveyor observed R35 sitting in her wheelchair in her room. R35 stated to Surveyor that she had just been assisted out of bed just before 10:30 AM. R35 stated that staff are slow to get beds changed. R35 stated that she understands and that she was recently a CNA (Certified Nursing Assistant) at a nearby facility before she had a stroke. Surveyor noted R35's bed was not made. At 3:20 PM, Surveyor again observed R35 sitting in her room in her wheelchair. Her bed was not made; covers untucked and rolled all the way to the foot of the bed with a bed pad visible on top of the sheets. R35 stated to Surveyor that she had not been back in bed since 10:00 AM. R35 stated that she had been incontinent twice between 6:30 AM and when she was first assisted out of bed and into the bathroom at 10:00 AM and had told this 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.

Based on interview and record review the facility did not ensure that preadmission screening for individuals with a mental disorder were followed through with for 1 of 5 residents (R26) reviewed for unnecessary medications. R26 did not have a Preadmission Screening and Resident Review (PASRR) II completed. This is evidenced by: R26 admitted to the facility in 2019 with the following diagnoses: major depressive disorder- recurrent severe without psychotic features, chronic PTSD (post-traumatic stress disorder), and personality disorder. At the time of admission, the facility completed a PASRR I with a 30-day exemption (meaning they thought he would be discharged back into the community within 30 days). The facility's Policy and Procedure entitled admission Criteria dated 2/25/22, documents in part: .8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. 8. Potential residents with mental disorders 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 did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 19 sampled residents (R22 and R25) that were reviewed for ADLs. R22 voiced of not receiving a shower for 22 days. R25 nails were observed to be dirty and extending past fingertips. This is evidenced by: The facility policy, entitled Activities of Daily Living (ADLs), dated 3/15/21, states in part: . 2. The facility will provide care and services for the following activities of daily living: Hygiene- bathing, dressing, grooming, and oral care . Elimination- toileting . 4. Resident's abilities to perform ADLs will be monitored for evidence of any decline and appropriate interventions put in place as applicable . 7. If a resident refuses care, this shall be reported to the nurse and the resident reapproached. Documentation of refusal shall be completed 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 interview and record review the facility did not ensure residents are free of any significant medication errors for 2 out of 18 residents (R22 & R32). R22 did not receive his ordered Carbidopa-Levodopa in the correct time parameters of the medication order 42 times out of 360 opportunities. R32 did not receive her ordered Lantus in the correct time parameters as ordered 9 times out of 59 opportunities. R32 did not receive her ordered Novolog Insulin in the correct time parameters as ordered 24 times out of 177 opportunities. This is evidenced by: The facility policy, entitled Administering Medications, dated 8/15/22, states, in part: . Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: . 3. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are…

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 did not ensure that before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 2 of 5 residents (R26 and R34) reviewed for immunizations. R26 did not have a consent or declination in his medical record for the influenza vaccine for 2022. R34 consented to receive the pneumococcal vaccine and did not get it. This is evidenced by: The facilities Policy and Procedure entitled Seasonal Influenza Vaccine dated 6/28/23…

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

Based on interview and record review, the facility did not ensure that before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. This affected 1 of 5 residents reviewed for immunizations (R52). R52 was not offered the COVID-19 vaccine(s). This is evidenced by: The facilities Policy and Procedure entitled COVID-19 Vaccine dated 5/3/23 documents in part: .2. COVID-19 vaccine will be offered, and education provided to all residents of the facility unless medically contraindicated. a. The resident's medical record will include documentation that indicates, at a minimum, the following: i. That the resident 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.