Sheridan Health and Rehabilitation Center

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R7) of 2 Residents.*Staff were not wearing gowns during care observations for R7 who is on EBP (enhanced barrier precautions) and appropriate hand hygiene was not observed during pressure injury treatment. Findings include:The facility's policy titled, Enhanced Barrier Precautions and last revised 9/9/25 under guidelines documents It is the guideline of this facility to implement enhanced barrier precaution for the prevention of transmission of multidrug-resistant organisms. Under explanation and compliance guidelines for 3. Implementation of Enhanced Barrier Precautions documents.b. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include a. Dressing; b. Bathing; c. Transferring; d. Proving hygiene; e.…

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 a registered nurse (RN) worked at the facility for at least eight (8) consecutive hours a day, seven days a week, on 1 of 30 days reviewed. This deficient practice had the potential to affect all 56 residents residing at the facility on 12/14/2025. The facility did not have a RN working in the facility for at least 8 consecutive hours on 12/14/2025. Findings include:Surveyor reviewed the facility staff scheduled and nurse posting for the last 30 days (December 2025). Surveyor noted on 12/14/2025 (Sunday) there was not a registered nurse (RN scheduled for 8 consecutive hours. On 1/7/2026, at 8:10 AM, Surveyor interviewed scheduler-K who stated scheduler- K completes the staffing schedules and if there is a call-in during scheduler-K's working hours, then scheduler-K would find a replacement. If a call in occurs after hours, weekends, or holidays then the person on call would be responsible for finding coverage. 12/14/2025 was a Sunday, so whoever was on call that day would be responsible for looking at the schedules 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 it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare and Medicaid Services (CMS).Staffing information for Quarter 4 (July 1 - September 30, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 61 residents residing in the facility.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2025, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care…

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

Based on interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. *Infection surveillance for July 2025, did not include date of onset, criteria met, culture, results or treatment (if any) for every listed resident.*Infection surveillance for September 2025, did not include signs/symptoms, criteria met, date of onset, culture taken, resulted organism or date infection resolved for every resident listed.Findings:The facility's undated policy titled, Infection Prevention and Control Program documents: The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious disease, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious disease. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable…

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 that drugs and biologicals used in the facility were stored in accordance with currently accepted professional standards for 1 of 2 medication refrigerators located in the medication room.*The North unit refrigerator, located in the medication room, did not have a temperature log to ensure proper temperature range.*R3's insulin vial was not stored in the medication refrigerator.Findings:The Facility policy, titled Medication Storage, with a last reviewed date of 11/12/2024, indicated the following: . 6. Refrigerated Products: a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and in each medication room. b. Temperatures are maintained 36-46 degrees F (Fahrenheit). Charts are kept on each refrigerator and temperature levels recorded daily by the charge nurse or other designee. On 01/08/2026, at 8:40 AM, Surveyor toured the medication room on the North Unit with Director of Nursing (DON)-B. Surveyor noted there was no temperature log for the 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.

Based on interview and record review, the facility did not inform residents when changes in coverage was made from Medicare Part A to items and services offered by the facility for which the resident may be charged and the amount of charges for those services by providing the residents with a Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for 2 (R23 and R48) of 3 residents reviewed for requiring the NOMNC and SNF ABN to be provided.*R23 was not provided a SNF ABN prior to ending Medicare Part A coverage for services and the NOMNC was emailed to R23's Guardian with no verification of receipt.*R48 was not provided a SNF ABN prior to ending Medicare Part A coverage for services.Findings include:1.) R23 received Medicare Part A coverage for services from 9/6/2025 through 9/13/2025. On 9/11/2025 at 10:58 AM, in the progress notes, Social Service Coordinator (SSC)-I documented R23's Guardian was issued a NOMNC via email. R23's Guardian was provided with the number to call and instructions on how to file an…

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 1 (R9) of 6 resident's reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R9 and/or their representative received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility.R9 was transported and admitted to the hospital on [DATE]. There was no evidence of a transfer notice or bed hold policy being provided to R9 and or R9's representative. Findings include:The facility policy titled Bed Hold Notice last reviewed/ revised on 5/1/2025 documents: Guideline: It is the guideline of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R12) of 35 residents reviewed had a comprehensive care plan developed and implemented so that residents can attain their highest practicable physical, mental and psychosocial well-being.* R12 has a diagnosis of vision loss. R12's care plan for impaired visual function did not include person-centered interventions to address R12's needs.Findings:R12 was admitted to the facility on [DATE] with diagnoses including vision loss.R12's Minimum Data Set (MDS) assessment, dated 8/18/2025, documents R12 has a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment; has moderate vision impairment, cannot see newspaper headlines but can identify objects and does not wear glasses.On 01/05/2026, at 11:25 AM, Surveyor interviews R12 who complains of being blind and needs mail read to her, which staff is not doing.Surveyor reviewed the facility provided document, titled Care Plan Report for R12 and noted a focus area for impaired…

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 at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries for 1 (R1) of 4 residents reviewed for pressure injuries.R1's heels were observed to be directly on the mattress and not offloaded according to R1's plan of care.Findings include:The facility policy titled Pressure Injury Prevention and Management last reviewed/revised on 12/3/2024 documents: Policy: This facility is committed to the prevention of avoidable pressure injuries . 4. Interventions for Prevention and to Promote Healing: a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. c. Evidenced- based interventions for prevention will be implemented for all residents who 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 (R30) resident reviewed for accidents.*R30 was observed self-transferring from R30's bed to wheelchair.Findings:R30 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body).R30 admission Minimum Data Set (MDS), dated [DATE], indicates R30 has ok long and short term memory, has impairment on one side of upper and lower extremities, requires substantial/maximal assistance with lying to sitting, substantial/maximal assistance with sit to stand, substantial/maximal assistance from bed to chair transfer and has had 1 fall since admission to the Facility.Surveyor reviewed the Facility's provided document titled SBAR Communication Form and Progress Note dated 3/1/2025. Surveyor noted R30 sustained a unwitnessed fall while…

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 provide the necessary respiratory care and services for 1 (R33) of 1 resident receiving oxygen therapy.*R33's oxygen was observed during the survey to be set at 4.5L (liter)/minute without humidification. R33's physician orders is for oxygen to be administered at 3L/minute.Findings include:The Facility's policy, titled Oxygen Administration, with a last reviewed date of 10/8/2024, indicates the following, . 1. Oxygen is administered under orders of the attending physician, except in the case of an emergency. a. Nasal Cannula- Oxygen is administered through plastic cannulas in the nostrils. Effective for low oxygen concentrations less than 40%. Requires humidification at flow rates greater than 4 liters/minute.R33 was admitted to the facility on [DATE] with diagnosis of pulmonary fibrosis.On 01/05/2026, at 9:57 AM, Surveyor observed R33 in bed with a nasal cannula in place for oxygen administration. Surveyor observed R33's oxygen concentrator…

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 the medication rate was below 5 percent in 1 (R5) of 5 residents observed receiving medications. The facility medication error rate was 12 percent.*R5 had medications that were not administered in the correct method per the facility policy and procedure and current standards of practice.ASMP Medication Safety Alert, Preventing errors when preparing and administering medications via enteral feeding tubes, November 17, 2022, Volume 27, Issue 23, . Wrong administration technique. Common inappropriate administration techniques include: 1) mixing multiple medications together to give at once.Findings include:The facility policy and procedure titled Medication Administration via Enteral Tube dated 1/1/2026 documents: . 6. Each medication will be administered separately, not combined or added to an enteral feeding formula. 7. A physician's order and Pharmacist review is required if medications are 'cocktailed' (combined) and will speak to both risk and benefit of combining medications for administration. 12.…

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 Pneumococcal immunizations were offered, or refused, as eligible to residents. This was observed for 1(R30) of 5 residents whose immunization records were reviewed.* R30 did not have documentation of the Influenza vaccine being offered and did not have risk versus benefits were offered after a refusal. Findings:The facility's undated policy titled, Infection Prevention and Control Program, documents: . 7. Influenza and Pneumococcal Immunization: . c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations. R30 was admitted to the facility on [DATE] with diagnoses that includes Aphasia (a language disorder from brain damage), hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness 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 interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 1 (R30) of 5 residents reviewed for immunizations.*R30's medical record does not contain any documentation as to whether R19 was offered, received, or declined the COVID-19 immunization.Findings include:The facility's policy undated policy and titled, Infection Prevention and Control Program documents: . 8. COVID-19 Immunization: . f. Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine. R30 was admitted to the facility on [DATE] with diagnoses that include Aphasia (a language disorder from brain damage), hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body).R30's admission Minimum Data Set (MDS), dated [DATE], documents that R30 has ok long- and short-term memory, is able to recall current season, location of own room, staff names/faces, 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 record review, staff interviews, and policy review, the facility failed to protect residents from resident-to-resident abuse for five (Residents (R)1, R6, R19, R12 and R11) of 20 sampled residents. This failure had the potential to create an environment where other residents had the potential to be abused. Findings include: Review of the facility's policy titled Abuse Neglect and Exploitation revised 12/22/24 revealed . The facility will implement policies and procedures to prevent and prohibit all types of abuse . 1. Review of R2's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnosis which included dementia. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/25 and located in the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated the resident was severely cognitively impaired. Review of R1's Face Sheet…

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, record review, and policy review, the facility failed to ensure reportable allegations of abuse were reported to the State Agency (SA) in a timely manner and failed to notify the police of the abuse allegation for three residents (Resident (R)5, R8 and R11) of five residents reviewed for abuse in the sample of 20. Findings include: 1. Review of R11's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 in the electronic medical record (EMR) under the MDS tab revealed R11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure, type 2 diabetes mellitus, and pulmonary fibrosis. R11 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R11 was cognitively intact. Review of the facility's investigation into the incident revealed that on 01/04/25, Licensed Practical Nurse (LPN)1 heard agency Certified Nurse Aide…

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, staff interviews, and policy review, the facility failed to complete a thorough investigation of abuse allegations for three residents (Residents (R)1, R6, and R8) out of 20 sampled residents. The facility demonstrated their lack of knowledge in completing a thorough investigation, which had the potential to increase a resident's risk of abuse throughout the facility. Findings include: Review of the facility's policy titled Abuse Neglect and Exploitation revised 12/22/24 revealed, . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframe's .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports abuse, neglect or exploitation occur .Providing complete and thorough documentation of the investigation. 1. Review of R2's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed…

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, interview, and review of facility policy, the facility failed to revise the care plan for one resident [(R)4] of 20 after a change in the resident's medication self-administration status. This failure had the potential for the resident's need to be not known by nursing staff. Findings include: Review of facility's policy titled Comprehensive Care Plans revised 05/01/25 revealed: It is the guideline of this facility to develop and implement a comprehensive person-centered care plan for each resident .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . Review of the policy titled Resident Self-Administration of Medication revised 04/17/25 revealed: It is the guideline of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered…

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, record review, and facility policy review, the facility failed to inform a family member of care conferences and/or provide sufficient notice in advance of care conferences for one of three residents (Resident (R) 3) reviewed for care planning out of a total sample of 13. This had the potential to affect the family member's right to have input into the development of the resident's care plan. Findings include: Review of the facility's policy titled, Care Planning-Resident Participation (Care Conference), dated 09/18/24, revealed, . The facility will honor the resident's choice in individuals to be included in the care planning process .The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative .If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record . Review of R3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to provide nail care to one of three residents (Resident (R) 12) reviewed for assistance with activities of daily living (ADLs). R12 had fingernails that extended approximately one-half inch beyond the tips of his fingers and required staff assistance in trimming them. This failure caused R12 to have unmet personal hygiene needs. Findings include: Review of the facility's undated policy titled, Nail Care revealed, . Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis . Routine nail care, to include trimming and filing, will be provided on a regular schedule . Nail care will be provided between scheduled occasions as the need arises . The resident's plan of care will identify . The frequency of nail care to be provided . The type of nail care to be provided . The person(s) responsible for providing nail care . Review of R12's Profile tab of the electronic medical record…

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, record review, and review of facility policy, the facility failed to ensure pressure ulcer treatments were ordered and treatments provided for two of four residents (Resident (R) 12 and R2) reviewed for pressure ulcers out of a total sample of 13. This failure put R12 and R2 at risk for deterioration of their pressure ulcers. Findings include: Review of the facility's undated policy titled Pressure Injury Prevention and Management revealed, . This facility is committed to . provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . 1. Review of a hospital facsimile, dated 09/06/24, located under the Documents tab of the electronic medical record (EMR), and addressed to the Assistant Director of Nursing (ADON), revealed, . Wound care notes for [R12] . Plan: Wound care . Left and right buttocks wounds: Cleansed liberally with wound cleanser and gauze, pat dry. Apply 3M No Sting skin barrier to surrounding skin…

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, record review, facility policy review, and review of current standards of practice, the facility failed to ensure one of one resident (Resident (R) 3) reviewed for enteral feedings out of a total sample of 13 received appropriate care and services to prevent complications. This failure had the potential to cause increased risk of infection for R3. Findings include: Review of the facility's policy titled, Care and Treatment of Feeding Tubes, dated 08/21/24, revealed, . It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . Review of the Journal of Parenteral and Enteral Nutrition, located at https://www.nutritioncare.org/uploadedFiles/01_Site_Directory/Guidelines_and_Clinical_Resources/EN_Pathway/Boullata_et_al-2016-Journal_of_Parenteral_and_Enteral_Nutrition.pdf, revealed, . Practice Recommendations . standardize the labels for all EN [enteral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were available for administration for two of three residents (Resident (R) 5 and R2) reviewed for medication availability out of a total sample of 13. R5 did not have pain medication available to treat pain and R2 did not receive cefepime, an antibiotic, for 22 hours after admission to the facility. This had the potential to cause uncontrolled pain for R5 and increased risk of infection complications for R2. Findings include: 1. Review of R5's Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with diagnoses that included spondylosis without myelopathy and polyosteoarthritis. Review of R5's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/24 and located under the MDS tab of the EMR, revealed R5 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Review of R5's Progress Notes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to serve food that was served at an appetizing temperature for one of three residents (Resident (R) 5) reviewed for food palatability out of a total sample of 13. This failure had the potential for R5 to have unmet nutritional needs. Findings include: Review of the facility's policy titled, Food Preparation Guidelines, dated 10/24/22, revealed, . It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status . Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature . Strategies to ensure resident satisfaction include . Serving hot foods/drinks hot . Review of R5's Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with diagnoses that included spondylosis without myelopathy and polyosteoarthritis. Review of R5's quarterly Minimum Data Set (MDS), with an Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to perform pressure ulcer treatments in a manner to prevent potential cross contamination for one of four residents (Resident (R) 12) reviewed for pressure ulcers out of a total sample of 13. Licensed Practical Nurse (LPN) 1 took the treatment cart into the resident's room while performing the treatment and placed unused supplies back into the cart after the treatment was performed. This placed any residents requiring treatments at risk for cross-contamination. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 05/16/23, revealed, . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . All staff shall assume that all…

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 a plan of care was developed based on the findings of the comprehensive assessment for 1 (R11) of 1 resident reviewed for hearing loss. The facility did not develop a plan of care that addresses R11's hearing loss or interventions of wearing or the refusal of wearing hearing aids. Findings include: The facility policy entitled Care Plan Revisions Upon Status Change no date indicated documents: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan . Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary . 2. Procedure for reviewing and revising the care plan: . b. The minimum data set (MDS) Coordinator and the Interdisciplinary team will discuss the resident condition and collaborate on intervention options. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R52) of 3 residents were free from unnecessary psychotropic medications ordered on an as needed (PRN) basis. On 8/1/2024 R52 was prescribed Ativan (anti-anxiety medication) 0.5 mg every eight hours PRN without an end date. Findings include: The facility policy entitled Unnecessary Drugs- Without adequate indication for Use no date indicated documents: It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. Policy Explanation and Compliance Guidelines: . 2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into…

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 maintained a medication error rate below 5 percent during observations of medication administration affecting 2 (R9 and R24) of 3 residents observed. Three medication errors were observed out of twenty-eight opportunities, for a total error rate of 10.71 %. * R9 was administered levothyroxine after breakfast and not on an empty stomach per medication guidelines and R9 was Administered Timolol Maleate eye drops after their manufacturers instructions of discarding them 4 weeks after opening. * R24 was administered 150 milligrams (MG) of Venlafaxine immediate release when she was ordered to have 150 MG of extended release Venlafaxine. Findings include: 1.) R9 was admitted to the facility on [DATE] with diagnoses that included: Hypothyroidism and Glaucoma. On 8/21/24 at 9:22 AM, the Surveyor observed Licensed Practical Nurse (LPN) -C administer medication to R9. R9 was observed coming back to her room after eating breakfast. LPN-C…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed (R24) was free of significant medication errors. * R24 was administered 150 milligrams (MG) of Venlafaxine immediate release when she was ordered to have 150 MG of extended release Venlafaxine. Findings include: R24 was admitted to the facility on [DATE] with diagnoses that included depression. On 8/22/24 at 8:35 AM, the Surveyor observed Licensed Practical Nurse (LPN) -D administer medication to R24. LPN-C poured Venlafaxine 37.5 MG from R24's medication card. LPN-D then indicated she did not have the additional 150 MG of Venlafaxine and would get it from the back up medication supply. LPN-D then came back to the medication cart and indicated she was instructed to give 4 more immediate release tablets from R24's medication card to equal an extra 150 MG of Venlafaxine. LPN-D then administered R24 a total of five 37.5 MG tablets of Venlafaxine to R24. Immediately after the observation, R24's current physicians orders…

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 interviews and facility job description review, the facility failed to ensure a qualified full-time staff with the required certification and skill sets was employed to serve as Food Service Manger (FSM) for 52 of 53 census residents. Findings include: Review of the facility's undated job description titled Food Service Manager revealed: Overview: The primary purpose of your job position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. Qualifications: Graduate of an accredited course in dietetic training approved by the American Dietetic Association Minimum of two (2) years' experience in a supervisory capacity in a hospital, nursing care facility, or other related medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure two of two residents and their resident representatives (Resident (R)1 and R14) reviewed for facility initiated emergent hospital transfer, from a total sample of 32 residents, were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility policy titled, Transfer and Discharge including AMA [Against Medical Advice]), dated 10/26/22 showed: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. Policy Explanation and Compliance Guidelines: . 4.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure physician orders were followed for three of five residents (Resident (R) 2, R30, R32) reviewed for weights, out of a sample of 32 residents. This failure could create a scenario where significant weight loss or gain is not recognized as no baseline weight was established. Findings include: Review of the facility's policy titled Weight Monitoring, dated 05/2024, showed: Policy: Based on the resident's comprehensive assessment, the facility will ensure that all 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. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility did not ensure 4 (R48, R33, R36, R8) of 16 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. * Staff did not understand the 4/12/23 physician's order for R48 which documented may have 1 drink a day. One ounce liquor per drink. Maximum of three ounces within 2 hours in a 24 hour period. Hold liquor if [R48] appears to be intoxicated or impaired. As needed. Staff were not consistently following the order resulting in R48 receiving 3 times the amount ordered. * During wound care for R33, staff did not use soap for incontinence care prior to dressing change. * R36 was missing neurological checks for unwitnessed falls that occurred on 1/10/2023 and 3/10/2023. * R8 did not have RN assessments before being lifted off the ground and neurological checks completed for unwitnessed falls on: 1/12/2023, 2/13/2023, 2/23/2023, and 12/26/2023. Findings include: 1. R48 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide a bed hold notice upon transfer to the hospital as required for 1 (R1) of 4 residents reviewed for hospitalization. *R1 was hospitalized on [DATE]. The facility did not provide a bed hold notice for R1's hospitalization on 4/3/23. Findings include: R1 was admitted to the hospital on [DATE] On 7/13/23 at 9:35 AM, Surveyor asked SSC (Social Services Coordinator)-H if the facility had any evidence that a bed hold notice been provided to R1 and R1's representative on 4/3/23. SSC-H said she would look into this. On 7/13/23, at 3:05 PM, Surveyor conducted an interview with Nursing Home Administrator (NHA)-A. NHA-A notified Surveyor there was no documentation in R1's record indicating R1 and R1's responsible party was provided with a bed hold notice. No further information was provided by the facility at this time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries receives appropriate care, treatment, and preventative interventions to promote healing for 2 (R26 and R62) of 6 residents reviewed for pressure injuries. 1. R26 had a right gluteal pressure injury and is at high risk for pressure injuries. On 6/15/23 R26's sacral would reopened. Treatments were for the right gluteal fold, sacrum and a protective dressing was put in place for the right buttocks on Tuesdays, Thursdays and Saturdays. On 7/10/23 Surveyor observed R26 with 3 bandages dated 7/6/23 which should have been changed Saturday 7/8/23. Documentation showed missed wound treatments on 7/8/23. On 7/10/23, the facility changed the order to Mondays, Wednesdays and Fridays. On 7/13/23 Surveyor again observed R26 with 3 bandages dated 7/11/23 (Tuesday) which should have been changed 7/12/23 (Wednesday). 2. R33 was observed with his air mattress on the incorrect settings. Findings include: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not provide adequate nutritional support to 1 of 2 residents reviewed for Nutrition. * R62 was admitted to the facility on [DATE]. The facility did not accurately conduct a baseline weight upon admission for R62 in accordance with their policy and procedure. The facility did not provide nutritional supplement for R62 per dietician recommendations. Findings include: R62 was admitted to the facility on [DATE] with diagnoses of malnutrition and cognitive communication deficit. Surveyor reviewed the facility's policy titled Weight Assessment and Intervention with a revision date of September 2008. The facility's policy reads: The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss. Policy Interpretation and Implementation: Weight Assessment 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks, thereafter. If no weight concerns are noted at this point,…

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 consistent communication for 1 (R20) of 1 Residents reviewed who receive dialysis services. R20 did not have communication forms between the Facility and Dialysis provider until April 1, 2023. On 7/10/23 R20 was observed waiting for pick up for dialysis. R20 had no communication paperwork to bring with her to the dialysis appointment. Additionally, the dialysis center is noted to not send communication paperwork back to the facility. There is inconsistent communication between the facility and the dialysis center. Findings include: The facility policy, entitled Hemodialysis, implemented on 2/15/2023, states: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Purpose:…

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 1 (R33) of 5 residents observed during wound treatment had the necessary hand hygiene performed. On 7/12/23 at 8:14 a.m. Surveyor observed pressure injury treatment performed on R33. RN K had missed opportunity for hand hygiene during the observation. Findings include: R33 was admitted to the facility on [DATE] with diagnoses of quadriplegia, schizophrenia, cerebral infarction and pulmonary hypertension. R33 has a healing Stage 4 pressure injury. On 7/12/23 at 8:14 a.m. Surveyor observed R33 receive treatment to the sacrum pressure injury. RN K proceeded to perform the wound treatment. During the wound treatment, RN K performed donning and doffing gloves along with hand hygiene prior to cleaning the wound, after cleaning the wound and prior to applying the prescribed santyl to the wound bed. After RN K completed the wound treatment, she kept the gloves on and proceed to place a clean brief on R33, placed a clean pillow under R33 calf, clean up 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.