Florence Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not thoroughly investigate an allegation of abuse/neglect for 1 resident (R) (R5) of 23 sampled residents. R5 reported that Registered Nurse (RN)-T refused the change R5's dressing or cover a pressure injury on R5's buttocks after R5 was incontinent of stool multiple times. The facility did not thoroughly investigate the allegation of abuse/neglect. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law .An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur .The Administrator will follow-up with government agencies to report the results of the investigation when…

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 staff interview and record review, the facility did not ensure a care plan was revised for 1 resident (R) (R10) of 1 sampled resident.R10's care plan was not revised to include behavioral interventions following resident-to-resident altercations on 3/29/26.Findings include:The facility's Comprehensive Care Plan policy, revised 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .This policy does not set the standard of care. The care and services provided to each resident are dependent on the individual resident and circumstances present at the time .3.The comprehensive care plan will describe, at a minimum, the following .resident-specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated.On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide the necessary care and treatment to prevent pressure injuries and/or promote healing for 2 residents (R) (R6 and R5) of 3 sampled residents. R6 had an order for a specialty air mattress set to R6's weight and to monitor the setting every shift. R6's air mattress was not set to the desired firmness to prevent pressure injuries. R5 had a pressure injury on the buttocks. Staff refused to dress R5's pressure injury to keep it free of feces and potential infection during multiple episodes of diarrhea. Findings include: The facility's Comprehensive Care Plan policy, revised 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .8. Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R10) of 1 sampled resident.R10 was at risk for falls and had multiple falls in the facility. R10's care plan contained interventions for increased supervision and to ensure R10 had shoes on in the dining room. The interventions were not consistently implemented. Findings include:The facility's Fall Prevention and Management Guidelines policy, revised 7/18/24, indicates: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury .The nurse will initiate interventions to help prevent falls on the resident's baseline care plan.The facility's Comprehensive Care Plan policy, revised 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive…

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 staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 1 sampled resident received appropriate care and services after removal of a Foley catheter to prevent urinary retention and avoid infection.R9's Foley catheter was removed on 4/1/26. Staff did not monitor R9's urinary output as ordered by the physician.Findings include:The facility's Indwelling Catheter Use and Removal policy, revised 7/26/22, indicates: To ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice.From 4/6/26 to 4/8/26, Surveyor reviewed R9's medical record. R9 had diagnoses including obstructive uropathy and diabetes. R9's Minimum Data Set (MDS) assessment, dated 3/16/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9's cognition was intact.R9's medical record contained a physician order, dated 4/1/26, to discontinue R9's Foley catheter, monitor input and output, and reinsert the Foley catheter if R9 is unable to void or has low…

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, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R4) of 2 sampled residents.Staff did not clean R4's continuous positive airway pressure (CPAP) machine per manufacturer's instructions or facility policy. In addition, R4's medical record did not contain an order for use of a CPAP machine.Findings include:The facility's CPAP Therapy policy, revised 6/4/22, indicates: Continuous positive airway pressure (CPAP) is used to treat obstructive sleep apnea. The goals of this therapy include: improve ventilation, improve quality of sleep, decrease hospitalizations, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve lung compliance .Verify physician orders .Follow these steps for cleaning your CPAP patient circuit .wash your hands .Remove headgear from the mask or nasal pillows shell, disconnect mask or Shiley swivel and tubing with a soft cloth, gently wash mask or pillows with a solution of warm water and a mild clear…

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, staff and resident interview, and record review, the facility did not ensure toilets were in a clean and home-like condition for 4 residents (R) (R17, R6, R18, and R10) of 18 sampled residents. The toilets in R17, R6, R18, and R10's shared bathrooms contained rusty metal strips. R17, R6, and R18 stated they did not like the rusty metal strips and had reported them to staff.Findings include:The facility's Safe and Homelike Environment Policy, dated 6/16/22, indicated: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.During a concurrent observation and interview on 3/3/26 at 10:40 AM, the toilet in R17's shared bathroom contained a rusty metal strip at the opening of the toilet. R17 stated the rusty metal strip bothered R17 and R17 had told a Certified Nursing Assistant (CNA) and a housekeeper about it.During a concurrent observation and interview on 3/3/26 at 10:54 AM, the toilet in R6's shared bathroom contained a rusty metal strip. R6 had just exited the bathroom and stated R6 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 staff interview and record review, the facility did not ensure medical records were complete for 1 resident (R) (R8) of 18 sampled residents.The facility did not ensure communication with medical providers was documented during a change in condition for R8.Findings include:The facility's Change in Condition of the Resident Policy, revised 9/20/22, indicates: Documentation needs to include, but is not limited to the following: 1. Description of change in condition noted and assessment or observation of findings. 2. Emergency care provided, if appropriate. 3. Notification of provider - include date, time, what was conveyed, any orders received (each time notified). 4. Notification of responsible party - include date, time, what was conveyed, any comments (each time notified). 5. Names and titles of employees involved with resident's care at that time.An admission Record indicated R8 was admitted to the facility on [DATE]. According to the admission Record, R8 had a medical history that included diagnoses…

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 staff and resident interview and record review, the facility did not ensure the resident environment remained free from abuse for 3 residents (R) (R3, R4, and R2) of 5 sampled residents. On 9/11/25, a resident-to-resident altercation occurred between R3 and R4 and involved verbal and physical aggression. The facility did not put interventions in place to address R3's aggressive behavior or prevent future instances of abuse, including a resident-to-resident altercation between R3 and R2 on 9/13/25.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports…

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 staff and resident interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 2 residents (R) (R3 and R4) of 5 sampled residents. On 9/11/25, an altercation occurred between R3 and R4 that involved verbal and physical aggression. The facility did not report the allegation of abuse to the SA. Findings include:The facility's Abuse, Neglect and Exploitation policy, with a revised date of 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective 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 staff and resident interview and record review, the facility did not thoroughly investigate a resident-to-resident altercation for 2 residents (R) (R3 and R4) of 5 sampled residents. On 9/11/25, a resident-to-resident altercation occurred between R3 and R4 that involved verbal and physical aggression. The facility did not thoroughly investigate the altercation. Findings include:The facility's Abuse, Neglect and Exploitation policy, with a revised date of 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure its policies are implemented as written .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation,…

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 staff interview and record review, the facility did not develop or implement an individualized comprehensive resident-centered care plan for 1 resident (R) (R2) of 5 sampled residents. R2 was identified as having trauma on quarterly assessments. R2's diagnoses list did not contain a trauma-related diagnosis and R2's care plan did not contain resident-specific trauma interventions. Findings include: The facility's Comprehensive Care Plan policy, revised 9/23/2022, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery…

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 staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R1) of 5 sampled residents.R1's hospital discharge summary contained an order for sliding scale insulin and a recommendation to monitor R1's blood sugars closely. R1's Medication Administration Record (MAR) did not reflect the order or recommendation.Findings include:The facility's Blood Glucose Monitoring policy, revised 8/5/22, indicates: It is the policy of this facility to perform blood glucose monitoring to diabetic residents per physician orders .Procedure: 1. Verify the physician's order .The facility's Medication Orders Non-Controlled Medication Orders policy, revised 1/2023, states: .Documentation of the Medication Order: .b. Written transfer orders (sent with a resident from a hospital or other healthcare facility): Implement a transfer order without further validation if it is signed and dated by the resident's current attending…

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, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy when 1 of 2 medication carts was left unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the 50 residents residing in the facility. On 6/25/25, staff left a medication cart unlocked and unattended on multiple occasions during medication administration. Findings include: The facility's Storage of Medication policy, dated 1/2023, indicates: .In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as Medication Aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access . On 6/25/25 at 8:25 AM, Surveyor observed Licensed Practical Nurse (LPN)-I leave a medication cart unlocked and unattended on the 200 wing. The medication cart drawers faced the hallway 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 staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse was not reported to local law enforcement for 1 resident (R) (R2) of 6 sampled residents. R2 reported to staff that Certified Nursing Assistant (CNA)-C got in R2's face and would not wash R2 when R2 requested it. R2 reported to staff that R2 felt that was abuse. The facility did not report the allegation of abuse to local law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicate: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .VII Reporting/Response: A. The facility will have written procedures 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 staff interview and record review, the facility did not ensure preventative action was taken following an allegation of misappropriation for 1 resident (R1) of 6 sampled residents. R1's family reported that two $50 bills were missing from R1's wallet. The facility was not able to determine what happened to R1's money and did not provide staff education on misappropriation to prevent recurrence. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicates: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .III. Prevention: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation .VII. Reporting: A. The facility will have written procedures 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.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 50 of 53 residents residing in the facility. Three residents received nutrition via tube feeding. Staff did not store food in a manner to ensure food safety and did not date food appropriately. Staff did not follow safe microwave safe heating procedures. Staff did not adhere to temperature requirements for testing sanitizing solution. Findings include: On 11/11/24 at 9:20 AM, Dietary Manager (DM)-G indicated the facility followed the Food and Drug Administration (FDA) Food Code as their standard of practice. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food…

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, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 53 residents residing in the facility. The facility did not maintain thorough surveillance/tracking documentation for a COVID-19 outbreak in September 2024 and did not report the outbreak to the local health department in a timely manner. In addition, the facility did not maintain thorough surveillance/tracking for a Respiratory Syncytial Virus (RSV) outbreak between 3/19/24 and 3/21/24 and did not report the outbreak to the local health department in a timely manner. The facility did not ensure consistent symptom tracking and documentation was completed for 5 residents (R) (R2, R18, R28, R31, and R163) of 6 residents who tested positive for COVID-19 in September 2024. Infection Preventionist (IP)-F also worked as a floor nurse. IP-F 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 staff interview and record review, the facility did not implement their antibiotic stewardship program by ensuring the accurate use of an antibiotic for 1 resident (R) (R261) of 5 sampled residents. R261 was transferred to the hospital on 1/5/24 and prescribed an antibiotic for a urinary tract infection (UTI) that did not meet the facility's criteria for infection. Fourteen doses of the unnecessary antibiotic were administered. Findings include: The facility's Antibiotic Stewardship Program Policy, reviewed 11/18/22, indicates: The purpose of the program is to optimize the treatment of infections while reducing adverse events associated with antibiotic use .i. Monitor response to antibiotics and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed…

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 staff interview and record review, the facility did not ensure the Infection Preventionist (IP) dedicated a minimum number of part-time hours to adequately manage the facility's infection prevention and control program. This had the ability to affect all 53 residents residing in the facility. Licensed Practical Nurse (LPN)-F was designated as the facility's IP. LPN-F also worked as a full-time floor nurse which resulted in LPN-F's inability to adequately maintain the facility's infection prevention and control program. Findings include: The facility's Infection Preventionist policy, dated 9/22/22, indicates: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program .1. The facility will designate a qualified individual as Infection Preventionist (IP) whose role is to coordinate and be actively accountable for the facility's infection prevention and control program including the antibiotic stewardship program .6. The IP must be employed at least part-time. Designated IP hours per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 3 residents (R) (R8, R11, and R29) of 5 sampled residents were offered or received a COVID-19 vaccine. R8, R11, and R29's medical records did not indicate R8, R11, and R29 received, were offered, or declined the most recent COVID-19 vaccine. Findings include: The facility's COVID-19 Vaccination policy, dated 9/13/24, indicates: It is the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering residents and staff the COVID-19 vaccine .Up-to-date is defined as receiving a 2024-2025 updated COVID-19 vaccine (as per CDC) .11. The facility will educate and offer the COVID-19 vaccine to residents and staff and maintain documentation of such .14. Consent will be signed prior to administration of the COVID-19 vaccine. This information will be retained in the resident's medical record .16. Residents or resident representatives retain the right to accept,…

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 staff interview and record review, the facility did not ensure injuries of unknown origin were reported to Nursing Home Administrator (NHA)-A or the State Agency (SA) for 1 resident (R) (R15) of 6 sampled residents. R15 was transferred to the hospital with a head injury following a fall from A Hoyer lift on 8/6/24. R15 was also hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. The facility did not report an injury of unknown origin to NHA-A or the SA after hospital staff notified the facility that R15 had a vaginal mucosa tear with dried blood. In addition, the facility did not report bruises on R15's legs and compression fractures to R15's mid and lower back that were documented on R15's hospital discharge summary to the SA. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .1. The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect, and exploitation of residents .2. 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 staff interview and record review, the facility did not ensure injuries of unknown origin were thoroughly investigated for 1 resident (R) (R15) of 6 sampled residents. R15 was transferred to the hospital on 8/6/24 with a head injury following a fall from a Hoyer lift. R15 was also hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. The facility did not investigate an injury of unknown origin after hospital staff notified the facility that R15 had a vaginal mucosa tear with dried blood. In addition, the facility did not investigate bruises on R15's legs and compression fractures to R15's mid and lower back that were documented on R15's hospital discharge summary. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: 1. The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect, and exploitation of residents .b) Establish policies and procedures to investigate any such allegations .B.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R15) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of one of R15's transfers. R15 was transferred to the hospital on 8/6/24 and 9/4/24. Neither R15 or R15's Power of Attorney (POA) were provided with a written transfer notice for either transfer. In addition, the Ombudsman was not notified of R15's 8/6/24 transfer. Findings include: The facility's Transfers and Discharges document, revised 7/12/22, indicates: .Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility .Transfer and discharge include movement of a resident to a bed outside of the certified facility whether that bed is in 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 staff and resident interview and record review, the facility did not ensure 1 resident (R) (R15) of 2 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R15 was transferred to the hospital on 8/6/24 and 9/4/24. Neither R15 or R15's Power of Attorney (POA) were provided with a written notice of the bed hold policy. In addition, the bed hold policy form was not filled out by the facility. Findings include: The facility's Transfer and Discharge policy, revised 7/15/22, indicates: .7. Emergency Transfers/Discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident .i) Provide a notice of the bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours after the transfer. From 11/11/24 to 11/13/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 1 resident (R) (R31) of 17 sampled residents. The facility did not honor R31's meal preferences during the lunch meal on 11/12/24. Findings include: The facility's Meal Distribution document, revised February 2023, indicates: 1. All meals will be assembled in accordance with the individualized diet order, plan of care and preferences .4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients . The facility's Dining and Food Preferences document, revised October 2022, indicates: .7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies, intolerances, and preferences. 8. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. 9. The alternate meal and/or beverage will be provided in a timely manner. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure meals were prepared by a method that conserved nutritive value for 2 residents (R) (R10 and R38) of 2 residents who received pureed diets. Kitchen staff did not follow a recipe when preparing pureed food items to ensure and conserve the nutritive value of the food. Kitchen staff did not provide R38 all of the items listed on R38's meal ticket. Findings include: The facility's contracted food service's document, dated February 2018, indicates: The federal requirements for the provision of therapeutic diets stipulates that food must be in a form to meet individual needs and that a mechanically-altered diet is part of the physician prescribed diet order .As outlined in the position description for the Cook, the ability to properly prepare texture-modified foods is a part of the required skillset for the position. The facility's contracted food service's Menus Policy Statement, dated October 2022, indicates: Menus will be planned…

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 staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 2 residents (R) (R29 and R48) of 5 sampled residents. Staff did not offer R29 or R48 the PCV20 (Prevnar 20®) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. This occurred for 1 of 3 residents (R) R1, reviewed for change in condition. R1 presented with symptoms of low blood pressure and weakness on 5/30/24 at 9:43 a.m. R1 had symptoms of vomiting and diarrhea from approximately 3:30-4:00 p.m. to 7:00 p.m. when R1 was transferred to the emergency room. R1's physician was not consulted between when episodes of vomiting and diarrhea occurred. Findings include: The facility policy, entitled Change of Condition of the Resident revision date 9/20/2022, states: Policy: Facility should . consult with the physician .when there is a .significant change in the resident's physical .status in either life-threatening condition or clinical complications. Policy Explanation and compliance Guidelines: When a resident presents with a possible change in condition .Notify the residents physician. Immediate…

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, the facility did not ensure that a comprehensive person centered care plan was developed for 1 of 5 sampled residents (R) R1. R1 was admitted to the facility on [DATE] with diagnoses that included in part, malignant neoplasm of esophagus and was undergoing chemotherapy treatment. The facility did not develop a care plan to address R1's increased risk for infection, risk for dehydration or abnormal lab values with increased need for monitoring related to his diagnosis and chemotherapy treatments. This is evidenced by: Surveyor requested and received the facility policy titled Comprehensive Care Plan dated as most recently revised on 9/23/2022. The policy in part reads: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the 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 interview and record review, the facility did not comprehensively assess resident medical status with a change in resident's clinical condition. This occurred for 1 of 3 residents (R1) reviewed for change in condition. R1 presented with symptoms of low blood pressure and weakness on [DATE] at 9:43 a.m. R1 had new onset of vomiting and diarrhea noted on [DATE] on the p.m. shift without a comprehensive nursing assessment of his clinical condition from 9:43 a.m. until his time of transfer to the hospital at approximately 7:00 p.m. Findings include: The facility policy, entitled Change of Condition of the Resident revision date [DATE], states: Policy Explanation and compliance Guidelines: When a resident presents with a possible change in condition .noted changes in mental physical functioning: Assess/evaluate the resident. This assessment/evaluation could include; but is not limited to: ~Vital signs, oxygen saturation, blood glucose level ~Personality, behavioral and/or cognitive changes ~Alteration 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, staff and resident interview, and record review, the facility did not develop an individualized comprehensive care plan for 2 Residents (R) (R247 and R9) of 13 sampled residents. R247's care plan did not include pain interventions for pain management. R9's care plan did not include arm sleeves to protect R9's skin. Finding include: The facility's Comprehensive Care Plan Policy indicates: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 1. On 9/25/23 at 11:44 AM, Surveyor interviewed R247 who stated R247's chest pain from surgery was at a level 7-8 on a pain scale of 1 to 10 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not revise a plan of care in accordance with current care needs for 1 Resident (R) (R32) of 13 sampled residents. R32 had a fall with a fracture. R32's plan of care was not updated with a new intervention following the fall. R32 was changed to a Hoyer transfer after R32's fall with fracture. R32 was observed in a wheelchair sitting on a sling on multiple occasions. R32's plan of care was not updated. R32 was prescribed a PRAFO boot by the wound clinic to protect R32's left heel pressure injury. The intervention was not implemented or added to R32's plan of care. R32 was admitted the facility on dialysis. R32's dialysis ended on 7/13/23. R32's plan of care was not updated to reflect R32 was no longer on dialysis. Findings include: The facility's Comprehensive Care Plan policy, with a revised date of 9/23/22, indicated: The comprehensive care plan will describe, at a minimum, the following: A. The services that are to be furnished to attain…

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 staff and resident interview, and record review, the facility did not provide the necessary care and services to monitor for fluid retention by ensuring post hospitalization weights were completed as ordered for 1 Resident (R) (R25) of 1 resident reviewed for hospitalization. R25 was weighed daily prior to hospitalization for a change in condition related to an exacerbation of congestive heart failure. R25 had 17.8 kilograms (kgs) or 38.58 pounds (lbs) of fluid removed while hospitalized . R25 returned to the facility with a standard order for weight monitoring. Findings include: R25 was admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure (CHF), morbid obesity (severe), and obstructive sleep apnea. R25's most recent Minimum Data Set (MDS) assessment, dated 9/4/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R25 had intact cognition. Between 9/25/23 and 9/28/23, Surveyor reviewed R25's medical record 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.