Waters Edge Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure staff did not engage in misappropriation of 1 (R9) of 1 resident's reviewed for misappropriation of property.*R9's cell phone was reported to be missing on 9/15/2025. Through investigation it was determined there was a misappropriation of property when housekeeper-PP took R9's personal cell phone on 8/21/2025 while R9 was hospitalized without R9's consent.Findings include:R9 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R9 has diagnoses that include Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Tracheostomy, and Encephalopathy. R9's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R9 has moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. R9 was confused and forgetful at times and had a guardian to assist in making healthcare decisions. On 9/15/2025, at 3:23 PM, the facility submitted an initial facility self-report to the State Agency…

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 incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R11) of 1 Resident reviewed with PASARR level 2 recommendations. *R11's PASARR dated 7/28/25 determination states R11 requires intensive, continuous treatment program called specialized services to address R11's intellectual/developmental disability or mental illness.Findings Include:The facility's Specialized Rehabilitative Services revised 11/11/24 documents:.The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan. These services will assist them in attaining, maintaining, or restoring their highest practicable level of physical mental functional and psycho-social well-being. It will also ensure that residents with Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility did not ensure 2 of 20 sampled residents' plan of care contained accurate information to implement interventions. * R90 was observed with an air mattress on their bed and a blue mat on their floor. R90 plan of car for a pressure injury did not include an air mattress. R90 plan of care for falls did not indicate when, and where, to use a blue mat. *R11 Guardian directed them to have pleasure feedings. This intervention was not documented on R11 comprehensive plan of cares. The facility's policy and procedure titled Care Plan Revisions Upon Status Change dated 5/12/2025. The purpose of this policy is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Findings include: 1.) R90 was admitted to the facility on [DATE] for wound care. On 9/22/2025, at 10:37 AM, Surveyor interviewed R90 in their bed. R90 was laying on their right side in bed. There was a mat on the left side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and assistance with repositioning for 1 of 2 (R60) residents reviewed for ADL's (Activity of Daily Living).R60 was not provided assistance to reposition as she requested until Surveyor intervened and asked staff to assist the resident.Findings include:R60 was admitted to the facility on [DATE] and has diagnoses that include chronic kidney disease stage 3, chronic obstructive pulmonary disease, morbid obesity, asthma, dysphagia, anxiety disorder, major depressive disorder, hypertension, gout, gastroesophageal reflux disease and hereditary and idiopathic neuropathy.R60's BIMS (Brief Interview for Mental Status Score) dated 7/28/25 documents a score of 15, indicating no cognitive impairment.R60's admission MDS (Minimum Data Set) dated 8/3/25 documents: Functional…

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 its procedures for indicating a residents' code status was followed for 1 (R11) of 20 residents sampled.R11 did not have a current physician order for R11's code status.Findings Include:The facility's policy and procedure Communication of Code Status revised 4/1/25 documents: .Explanation and Compliance Guidelines:2. When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. 3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record.4. The designated sections of the medical record are: physician orders obtained per election form and uploaded signed election form.R11 was admitted to the facility on [DATE] and has a legal guardian. On 9/22/2025, at 12:55 PM Surveyor completed a record review and notes that on 7/7/25, R11's guardian signed for R11…

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 3 (R101, R131 and R50) of 3 resident received necessary care and treatment. On 8/25/25, R101 had signs and symptoms of a urinary tract infection (UTI) and an order for a urinalysis with culture and sensitivity was obtained. The urine sample was not processed. On 9/4/25, R101 had an order for a wound culture and the specimen was obtained and not stored properly. Another specimen was not obtained until 9/9/25 delaying treatment to an infected wound R131 was admitted to the facility on [DATE] with surgical wounds to the left leg. A comprehensive wound assessment was not completed until 8/13/2025. R131 did not have monitoring or treatments to the left leg surgical wounds until 8/12/2025. On 9/24/25 R50 was observed to have pericare performed and 2 incontinent briefs were placed on R50. Findings include: 1) R101 was admitted to the facility on [DATE] with diagnoses of paraplegia and chronic obstructive pulmonary disease (COPD). The quarterly minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that resident with pressure injury received necessary treatment and services consistent with professional standards of practice for 3 (R7, R50, and R131) of 8 residents reviewed for pressure injuries. R7 developed a blister to the thumb that declined to a stage 3 pressure injury from R7's palm guard. There were no interventions in place prior to R7 developing the stage 3 pressure injury and the interventions put in place after development were not clear as to what needed to be in place for R7. R50's pressure injury was not staged correctly on admission; a treatment was not put in place for 3 days after admission. On 7/2/25, R50's pressure injury doubled in size. R50's treatment and care plan were not revised after R7's pressure injury worsened. R131 was admitted to the facility on [DATE] with a stage 2 pressure injury to the sacrum. R131 did not have a comprehensive assessment to R131's stage 2 pressure injury until 8/12/2025 and treatment was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure 1 (R49) of 1 resident receiving oxygen had the prescribed oxygen setting. On 9/22/25 and 9/23/25, Surveyor observed R49 with a nasal cannula and oxygen flowing at 4 liters per minute. The physician orders document oxygen 2 liters per minute. Findings include: R49 was admitted to the facility on [DATE] with diagnoses of anxiety, chronic obstructive pulmonary disease (COPD) and hypertension. The oxygen therapy care plan with initiation date of 1/31/25 and revision date of 7/1/25 documents R49 receives oxygen via nasal cannula at 2 liters per minute. The physician orders dated 7/16/25 documents R49 received oxygen via nasal cannula at 2 liters per minute. On 9/22/25 at 9:54 a.m. Surveyor observed R49 in bed with a nasal cannula in her nose with the oxygen concentration indicating 4 liters of oxygen flowing. On 9/23/25 at 7:40 a.m. Surveyor observed R49 in bed with a nasal cannula in her nose with the oxygen concentration indicating 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 and record review, the facility did not ensure 1 (R3) of 1 resident reviewed for Dialysis received Dialysis care in accordance with professional standards of practice.*R3 did not have a MD (Medical Doctor) order for dialysis and for monitoring R57's Arterio-Venous (AV) Fistula for bruit (the regular, whooshing sound made by blood flowing through a dialysis fistula or graft) or thrill (the vibration felt over an arteriovenous fistula or graft) from 5/21/25 through 9/24/25.Findings include:The facility policy with a last reviewed date of 12/02/24 and titled, Hemodialysis documents, in part: 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. The facility will ensure that the physician's orders for dialysis include: The type 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 that irregularities noted by the pharmacist during the Medication Regimen Review (MRR) were sent to the attending physician to include at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified for 2 of 5 (R11 and R60) residents reviewed for unnecessary medications. R11's pharmacy MRR recommendations for July and September 2025 were not acted upon by the facility or physician. R60's pharmacy MRR recommendations for August 2025 were not acted upon by the facility or physician. Findings include: 1.) R60 admitted to the facility on [DATE] and has diagnoses that include chronic kidney disease stage 3, chronic obstructive pulmonary disease, morbid obesity, asthma, dysphagia, anxiety disorder, major depressive disorder, hypertension, gout, gastroesophageal reflux disease and hereditary and idiopathic neuropathy. The facility policy titled “Addressing Medication Regimen Review Irregularities (Pharmacist…

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 there was a medication error rate below 5 percent. There were 2 medication errors in 25 opportunities which resulted in a medication error rate of 8%. Two medication errors were identified for R71.R71 Pantoprazole Sodium 20 mg was not available to be administered and after receiving Advair inhaler, LPN-MM did not have R71 rinse & spit. Findings include:The facility's policy titled, Oral Inhalations and dated 01/23 under procedures documents 15. For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup.On 9/23/25, at 9:37 a.m. Surveyor observed Licensed Practical Nurse (LPN)-MM prepare R71's medication which consisted of Metoprolol Tartrate 12.5 mg (milligrams), Gabapentin 100 mg, Eliquis 5 mg, Furosemide 40 mg, Isosorbide Monitrate 30 mg, Aspirin 81 mg, Vitamin D3 25 mcg (micrograms), Hydrocodone-Acetaminophen 5-325 mg and Fluticasone Propionate & Salmeterol 250mcg/50 mcg (Advair) inhaler.On 9/23/25, at 9:42 a.m., LPN-MM informed Surveyor R71…

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 therapy services were provided in a timely manner for 2 (R11 and R50) of 2 residents reviewed for therapy services. *R11 has a MD order to start therapy services initiated on 9/11/25. R11 did not have a therapy evaluation until 9/22/25. *R50 was admitted to the facility on [DATE]. On 6/20/25, R50's MD documented that R50 should have a Physical (PT) and Occupational therapy (OT) evaluation and treatment. R50 was not evaluated and treated by PT and OT until 7/11/25. Findings include: The facility policy with a reviewed/revised date of 11/12/24 and titled, “Therapy Evaluation”, documents, in part: The licensed Therapist will perform an initial resident evaluation upon physician referral and re-evaluation where indicated . The rehabilitation department will be notified when a physician order is written for therapy evaluation and treatment. The licensed therapist will perform a chart review and initiate the evaluation. The initial evaluation will…

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 5 residents were offered/administered the pneumonia vaccine and/or influenza vaccine. R12 was admitted to the facility on [DATE] and was not offered or administered the influenza vaccine.Findings include:The facility's policy titled Influenza Vaccination, dated 5/29/24 documents the following:It is the guideline of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our resident's, staff members, and volunteer workers annual immunization against influenza.The facility's policy titled Pneumococcal Vaccine, dated 12/3/24, last reviewed 1/30/25, documents the following:It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current Center for Disease Control (CDC) guidelines and recommendations:Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any…

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

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 3 (R9, R11, R12) of 5 residents reviewed for immunizations.R9's Electronic Medical Record (EMR) does not contain any documentation as to whether R9 was offered, received, or declined the COVID-19 immunization.R11's EMR does not contain any documentation as to whether R11 was offered, received, or declined the COVID-19 immunization.R12's EMR does not contain any documentation as to whether R12 was offered, received, or declined the COVID-19 immunization.Findings include:The facility's policy titled COVID-19 Vaccination, dated 10/31/24, last reviewed 1/30/25, documents the following:It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 by educating and offering our residents and staff the COVID-19 vaccine.1.) R9 was admitted to the facility on [DATE]. R9 is [AGE] years old and has a Guardian. R9's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to have sufficient nursing staff with the competencies and skills sets to ensure one (Resident (R)7) out of a total sample of 15 residents, had the correct ordered amount of insulin administered. This had the potential for the resident to have a decreased blood glucose level and potential complications. Findings include:Review of R7's undated admission Record located in the electronic medical record (EMR) under the Resident tab revealed she was admitted to the facility on [DATE] with a diagnosis of type II diabetes mellitus. Review of the facility's Incident Report provided by the facility dated 07/26/25 revealed that R7 was inadvertently given 15 units of lispro insulin, instead of four units as prescribed. Licensed Practical Nurse (LPN)1 took R7's blood sugar at 9:35 PM. Her blood sugar was 185. Lantus was held. Responsible party and medical provider were contacted because of significant medication error. Monitoring orders were…

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 staff interview, the facility failed to ensure a significant medication error did not occur when the physician's orders were not followed during administration of insulin for one (Resident (R)7) of three sampled residents related to insulin administration out of a total sample of 15 residents. This had the potential for the resident to have an adverse reaction to the incorrect amount of insulin administered. Findings include:Review of R7's undated admission Record located in the electronic medical record (EMR) under the Resident tab revealed she was admitted to the facility on [DATE] with a diagnosis of type II diabetes mellitus. Review of R7's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 06/09/25 and located under the MDS tab of the EMR revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated the resident was severely cognitively impaired.Review of R7's physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to adhere to infection control practices and policies during wound care related to staff failing to wear a gown for a resident on Enhanced Barrier Precautions (EBP) for one of two residents (Resident (R) 3) observed for wound care in the sample of six residents. The deficient practice increased the risk for cross contamination and infections.Findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 02/05/25, provided by the facility indicated, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gowns and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions. for residents with any of the following: wounds.even if the resident is not known to be infected or colonized with MDRO. PPE [Personal Protective Equipment] for…

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 failed to ensure a sufficient supply of clean linen was readily available for resident care for three of four linen closets on two of two floors observed. This had the potential for the residents to have unmet personal care needs. Findings include: During a group interview on 05/14/25 at 10:00 AM, with 12 alert and oriented residents, including the President of Resident Council revealed R14, R15, R16, R20, R21, and R23 all agreed that the facility was low on linens like towels and washcloths, and they sometimes had to wait for clean linens to take a shower or receive care. R16 added some residents would stockpile towels and washcloths in their rooms in order not to run out. 1. Review of R14's annual Minimum Data Set (MDS), with an Assessment Reference Date of 02/20/25 and located under the MDS tab of the EMR, revealed she was admitted to the facility on [DATE] and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R2) of 2 Facility Self Report investigations was reported to the State Agency as required. On 7/21/24 R2's family member expressed concerns related to incontinence care on 7/19/24. On 8/5/24 R2's family member expressed additional concerns related to all cares for the same date of 7/19/24. The facility did not submit the facility investigation within 5 days of the initial report to the state agency. The 5 day investigation was submitted on 8/21/24 instead of within 5 working days after the allegation. Findings include: R2 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R2's diagnoses include dysphagia, dementia, stroke, and muscle contracture. R2's Significant Change MDS (Minimum Data Set) completed on 9/4/24 documents that R2 is dependent with toileting, bathing, transfers, and eating. R2 is always incontinent of bowel and bladder. R2's BIMS (Brief Interview for Mental Status) was not completed due 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.

The facility did not ensure a charge nurse was assigned for each shift. This had the potential to affect all 95 residents that reside in the building. Findings include: On 7/29/24, at 11:30 AM, the facilities staffing schedules for January though March 2024 and July 2024 were reviewed and did not indicated which nurse was to be assigned as the charge nurse for each shift. The Schedule also did not indicate if each nurse was a Registered Nurse or Licensed Practical Nurse. On 07/29/24, at 1:47 PM, Scheduler-E was interviewed and indicated she did not know she had to indicate on the schedule who was the charge nurse and she just knows who it is on each shift. On 7/29/24, at 2:15 PM, Director of Nurses (DON)-B was interviewed and indicated each of the 4 wings has their own charge nurse. DON-B indicated they just know who it is if 2 nurses are on the same floor. On 7/30/24, at 9:00 AM, the schedule for 7/30/24 was reviewed and had each of the nurses titles as well as designating one nurse per shift to be assigned as charge nurse. The above findings were shared with Nursing Home…

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 food was prepared to conserve nutritive value and flavor. This has the potential to effect 13 (R37, R67, R29, R86, R18, R59, R73, R88, R71, R36, R24, R547, and R548) of 13 residents on a pureed diet. The [NAME] did not follow a recipe for preparing texture and modified consistency diet for pureed food. Findings include: On 07/29/24, at 11:10 AM, Cook-C was observed preparing pureed Salisbury steak. [NAME] -C put 12 patties and approximately 3 cups broth in metal container. [NAME] -C then used the food processor to puree the food. After Cook-C pureed the Salisbury steak he put the pureed food under the running water and added an unmeasured amount of water to the container. Cook-C then added instant potatoes to the Salisbury steak saying it was too thin. Cook-C then added a can of carrots with an unmeasured amount of liquid from the can into a metal container and pureed it with the food processor and indicated it was completed. Cook-C was interviewed immediately after the observation and indicated he…

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

Based on observation and interview, the facility did not ensure residents had bed linens in good condition that properly fit the bed for 1 (R23) of 19 residents reviewed in the sample. *R23 did not have a bottom sheet on the bed that covered the whole bed with 2 observations. Findings include: On 7/29/2024, at 10:16 AM, Surveyor observed R23 lying on the bed with R23's head lying directly on the mattress. The fitted sheet that covers the mattress was not fitted to the top of the mattress. The mattress was a bolstered air mattress. R23's head was resting directly on the mattress with no sheet under the head and the pillow was off to the side. The bottom portion of the fitted sheet was tucked around the bottom of the mattress allowing R23's lower body to be on the fitted sheet. On 8/01/2024, at 11:25 AM, Surveyor observed Certified Nursing Assistant (CNA)-L and CNA-M enter R23's room to reposition R23 and provide care assistance. Surveyor observed R23's fitted sheet to be fitted to the top of the mattress and not fitted to the bottom of the mattress so R23's lower body was directly 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 complete a significant change in status assessment MDS (Minimum Data Set) for 1 (R59) of 2 residents reviewed for significant change. R59 elected to receive hospice services on 06/28/2024. The facility did not complete a Significant Change MDS when R59 was enrolled into hospice care. Findings include: R59 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, Dementia, cognitive communication deficit and unspecified psychosis. R59's annual MDS, dated [DATE] documents R59 is rarely/never understood. On 06/28/2024, R59's medical record indicates R59 elected to receive Hospice services that began on 06/28/2024. On 07/30/2024, at 10:42 AM, Surveyor noted R59 had a significant change MDS in progress and was not completed/submitted. On 07/30/2024, at 10:45 AM, Surveyor interviewed MDS Coordinator-U. MDS Coordinator-U informed Surveyor that most significant changes are from hospice and significant changes are talked about 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 observations, interviews, and record review, the facility did not ensure 1 (R84) of 1 Resident reviewed for having received proper treatment and assistive device to maintain R84's hearing abilities. Findings Include: R84 was admitted to the facility on [DATE] with a primary diagnosis of Dementia. R84's admission Minimum Data Set (MDS), dated [DATE], documents R84 has adequate hearing and does not use hearing aids. R84 has an active guardian in place. On 07/29/24, at 11:03 AM, Surveyor interviewed R84. Surveyor had a very difficult time speaking with R84 due to R84's hearing difficulties. Surveyor noted R84 did not have hearing aids. Surveyor reviewed R84's Electronic Health Record and noted an order for R84 to have an Audiology consult regarding hearing aids dated 01/17/2024. Surveyor noted the order was not documented as completed. Surveyor noted R84's MDS did not assess/document R84 as being hard of hearing. Surveyor noted an order, dated 03/11/2024, which documents R84 to be set up with audiology…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure residents received the necessary treatment and services consistent with professional standards of practice for 1 (R61) of 9 residents reviewed with pressure injuries. R61 was noted to have developed two blisters on R61's left hand after staff removed R61's hand splint. R61's comprehensive care plan did not include interventions for the use of hand splints and R61's treatment administration record (TAR) was not revised after R61 developed blisters to left hand to include documentation of when the hand splint and/or palm guard should be applied. Findings include: The facility policy entitled Pressure Injury Prevention and Management implemented 2/14/2023 documents: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Policy…

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 ensure 1(R36) out of 1 residents reviewed with limited range of motion received appropriate treatment and equipment to increase range of motion and/or to prevent further decrease in range of motion. *R36 was observed not wearing a splint used to improve range of motion per R36's plan of care. Findings include: The facility policy titled Prevention of decline in Range of Motion and dated 01/22/24, documents: Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care. R36 was admitted to the facility on [DATE] with a diagnosis that includes Huntington's disease, Muscle Wasting and Atrophy, and Muscle Weakness. R36's Care Plan, dated 06/11/2024 and with a…

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

Based on observation, record review and interview, the facility did not ensure a resident was supervised with meals to prevent choking. This was observed with 1 (R37) of 1 residents requiring supervision with eating meals. R37 requires supervision with eating to prevent choking. R37 was observed eating on their own without supervision. Findings include: 1.) R37 has a diagnosis of schizophrenia, and has a Guardian appointed for decision making. The physician orders signed 7/6/24, prescribe a regular diet with puree consistency. R37 had Speech Therapy services for dysphagia. The Speech Therapist recommendation on 6/14/24 document, puree consistency; close supervision; upright position for intake; constant supervision for intake; small bites/sips; slow rate. The Progress Note on 6/14/2024 document, New orders to change texture of diet to pureed diet r/t (related to) poor swallowing and choking. Also to remain sitting upright when eating, not to be left alone when eating, small bites with liquid wash every 4-5 bites. R37's plan of care for eating documents: · I have an ADL (activity of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review the facility did not ensure that residents with an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for 1 (R63) of 5 residents reviewed for catheter care. Surveyor observed staff perform catheter cares for R63 that were not consistent with standards of practice for indwelling catheter care. Findings include: The Facility's policy, titled: Catheter Care, with a last revision date of 10/16/2023, documents in part: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Male: 14. Gently grasp penis, drawn foreskin back if applicable. 15. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). 16. With a new moistened cloth, stating at the urinary meatus moving down, cleanse the shaft of the penis. 17.…

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 who were fed by enteral means received the appropriate services to prevent complications of enteral feeding for 2 (R23 and R36) of 4 residents reviewed for enteral feeding. *R23 had enteral feeding orders for seven times a day that were transcribed as five times a day in the medical record resulting in weight loss. R23 had multiple formulas on one order with each formula having a different number of administration times affecting the amount of free water that would be administered with no documentation as to which formula was provided and no communication with the Registered Dietician (RD) as to what formula and free water was provided to R23. *R36 had orders for enteral feeding and free water flushes. The orders did not correlate with the RD's documentation of what R36 was being provided. Findings include: The facility policy and procedure entitled Care and Treatment of Feeding Tubes dated 5/1/2024 documents: Policy…

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 grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly and did not to demonstrate their response and rationale for such requests. The grievance log generated from Resident Council Meetings does not identify the name of the resident filing the grievance, grievance details, how the grievances were investigated, or the outcome of each grievance investigation. This has the potential to affect all 98 residents residing at the facility. Findings include: The facility's Resident Council Meetings policy and procedure implemented 12/23/22 documents: This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. This policy provides guidance to promoting structure, order, and productivity in these group meetings. Definitions: Resident or family group is defined as a group of residents or residents' family members that meets regularly to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide notice of resident rights and services prior to or upon admission for 40 (R2, R18, R19, R20, R21, R12, R22, R23, R24, R25, R11, R26, R27, R28, R29, R30, R16, R31, R32, R33, R34, R35, R10, R36, R37, R38, R39, R40, R41, R5, R42, R43, R44, R45, R46, R47, R48, R49, R50, R1) of 40 residents reviewed. *R2 was admitted to the facility on [DATE] and was handed a facility admission agreement packet to sign on [DATE]. R2 does not currently have a signed admission agreement on file for the facility. *R18, R19, R20, R21, R12, R22, R23, R24, R25, R11, R26, R27, R28, R29, R30, R16, R31, R32,R33, R34, R35, R10, R36, R37, R38, R39, R40, R41, R5, R42, R43, R44, R45, R46, R47, R48, R49, and R50 did not have signed admission agreements when they were admitted to the facility. *R1 was admitted to the facility [DATE]. His activated Power of Attorney for Healthcare (POA-HC) was not provided with the facility's admission agreement until [DATE], the day before his…

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 report 3 of 4 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. This has the potential to affect R6, R12, R13, R14, R15, R10, & R11. R6's sexual abuse allegation was not reported to Nursing Home Administrator-A & State agency immediately but not later than 2 hours after the allegation is made. The allegation of possible drug diversion was not reported to the Nursing Home Administrator and State agency within 24 hours for R12, R13, R14, R15, & R11. R11's allegation of misappropriation was not reported to the State agency within 24 hours. Findings include: The Abuse, Neglect, and Exploitation policy implemented 9/18/2023 documents under the Policy section: It is the policy of this 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…

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

Based on observation and staff interview, this facility did not ensure that confidential medical records were safeguarded against loss, destruction, or unauthorized use. This has the potential to affect up to 30 current residents at this facility. The confidential medical records are not stored in a secure manner to prevent unauthorized access. Findings include: On 5/20/24 at 2:06 PM, Surveyor toured the medical records archive room with Medical Records-OO. The room is in the basement of the facility. Surveyor observed ten cardboard boxes containing approximately 30 current and previous resident medical records sitting on the floor. Surveyor observed the ten cardboard boxes containing medical records to be sitting below a water fire sprinkler. Surveyor noted that the cardboard boxes containing records were open and did not contain lids. Surveyor asked Medical Records-OO how the facility would protect these medical records from water damage if the fire sprinkler were to turn on. Surveyor asked Medical Records-OO how many medical records in the cardboard boxes were from current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that R7 & R16, a married couple, have the right to share a room together after both consented. R7 & R16 informed Surveyor they wanted to live in the same room but this was not being allowed by the facility. Findings include: The facility's policy titled Resident Right to Share a Room implemented on 10/1/23 documents under the Policy section: It is the policy of this facility to support and facilitate a resident's right to share a room with their roommate of choice when practicable and to the extent possible. Under Policy Explanation and Compliance Guidelines section it documents: 1. The facility will permit a resident to share a room with his or her spouse, when married residents live in the same facility and both spouses consent to the arrangement. R7 was admitted to the facility on [DATE] with diagnoses which includes anxiety disorder, chronic pain syndrome, depressive disorder, diabetes mellitus, hypertension and dementia. R7's Quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not notify the state mental health authority promptly after a significant change in 1 (R6) of 1 Residents mental illness. R6 was diagnosed with bipolar disorder on 2/22/24 and started receiving Depakote Delayed Release Sprinkles 250 mg (milligrams) twice a day on 2/23/24. The Facility did not submit a level 1 PASARR (Preadmission Screening and Resident Review) until 5/13/24 and the level 1 did not include the bipolar disease diagnosis or Depakote. Findings include: The Resident Assessment- Coordination with PASARR Program policy implemented on 1/18/23 documents under the Policy section: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Under the Policy Explanation and Compliance Guidelines it documents: 9.…

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 ADL (Activities of Daily Living) services for 1 (R4) of 4 residents who were dependent on staff to provide ADL care. R4 was observed with long nails pressing into the palms of her hands due to bilateral hand contractures. R4's care plan indicated her nails should be kept short to prevent injury. Findings include: 1.) R4 was admitted to the facility on [DATE] with diagnoses that included Anoxic Brain Damage and Coma. R4 is unable to make her needs known. On 5/13/24 at 9:00 AM, R4 was observed in bed with long fingernails pressing into both of her palms and no protection to her skin. On 5/13/24 at 12:30 PM, R4 was observed in bed with long fingernails pressing into both of her palms and no protection to her skin. On 5/13/24 at 2:00 PM, R4 was observed in bed with long fingernails pressing into both of her palms and no protection to her skin. On 5/14/24 at 8:00 AM, R4 was observed in bed with long fingernails and a rolled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices was provided for 2 (R3 & R9) of 9 Residents. R3 was admitted to the facility on [DATE] with a right diabetic foot ulcer and a left below knee amputation surgical incision. Treatments for these areas were not started until 1/19/24, 3 days later. R3's blood pressure, heart rate, and fluids were not monitored according to physician orders. R9's sacrum surgical wound with a wound vac was not comprehensively assessed until 5 days after admission on [DATE] when the wound doctor assessed R9's sacrum surgical wound. Findings include: 1.) R3 was originally admitted to the facility on [DATE] with diagnoses which include hypertension, atrial flutter, cirrhosis of liver, left below knee amputation, diabetes mellitus, peripheral vascular disease, congestive heart failure, and depression. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not have identified safety devices/supervision in place for preventing falls/accidents or incidents requiring increased supervision for 2 (R4 and R6) of 2 residents reviewed for safety/supervision. * R4 was observed to be left unattended in bed, with the floor mats not in place to both sides of her bed per her plan of care. * R6 exhibited agitated and sexually inappropriate behavior and was not supervised closely enough to prevent future inappropriate behaviors. Findings include: 1.) R4 was admitted to the facility on [DATE] with diagnoses that included Anoxic Brain Damage and Coma. R4 is unable to make her needs known. On 5/13/24, R4's Current care plan for Risk for Falls dated 6/23/23 was reviewed and documented: Intervention- Fall mats to bilateral sides of floor with a start date of 3/2/24. On 5/14/24 R4's current CNA care sheet was reviewed and documented: Fall mats (sic) to bilateral sides of the floor, R4'fall risk assessment dated [DATE]…

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 2 (R10 & R3) of 2 residents reviewed for nutrition maintained acceptable parameters of nutritional status. *R10's weights were not obtained per facility guidelines. No weights were obtained in November 2023 or April 2024. *R3 should have been weighed on 1/16/24, 1/17/24, 1/18/24 and one time during the week of 1/21/24 to 1/27/24. Upon return to the facility on 2/13/24, R3 should have been weighed on 2/13/24, 2/14/24, 2/15/24 and during the week of 2/18/24 to 2/24/24. No weights were obtained on those dates. Findings Include: Surveyor reviewed the Weight Monitoring policy and procedure dated 4/10/24 documents: 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…

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, interview, the facility did not ensure 1 (R4) of 2 residents reviewed had their oxygen administered according to physician's orders. * R4 was observed to have her oxygen administered at 6 liters per minute and her orders were to have her oxygen at 1-5 liters per minute according to her oxygen saturation levels. Findings include: 1. R4 was admitted to the facility on [DATE] with diagnoses that included Anoxic Brain Damage and Coma. R4 is unable to make her needs known. On 5/13/24 at 9:00 AM R4 was observed in bed with oxygen running to her tracheostomy at 6 liters per minute. On 5/13/24 at 12:30 PM R4 was observed in bed with oxygen running to her tracheostomy at 6 liters per minute. On 5/13/24 at 2:00 PM R4 was observed in bed with oxygen running to her tracheostomy at 6 liters per minute. On 5/14/24 at 8:00 AM R4 was observed in bed with oxygen running to her tracheostomy at 6 liters per minute. On 5/14/24 at 11:00 AM R4 was observed in bed with oxygen running to her…

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, interview, and facility policy review, the facility failed to ensure the physician was notified with a need to alter treatment of a pressure ulcer for one of two residents (Resident (R9) reviewed for pressure injuries. The facility's failure to notify the physician with a need to alter treatment had the potential to impede healing of a pressure ulcer. Findings include: Review of the policy provided by the facility titled, Notification of Change, dated 10/22/22, revealed The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances that require a need to alter treatment .may include new treatment, discontinuation of current treatment due to: Adverse consequences Review of the Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R9 was admitted…

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, interviews, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 8) reviewed for abuse were free from physical abuse. The failure to ensure a resident was free from resident-to-resident abuse could have resulted in the potential for harm when R7 struck R8 in the back of the head and left chest. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed 09/18/23, revealed Policy: It is the policy of this 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 . Definitions: . Abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure the discharge planning process was following which included notifying the resident's Physician or Nurse Practitioner (NP) and APS (Adult Protective Services) when residents left Against Medical Advice (AMA) per the facility's policy for three of three residents (Residents (R) 6, R1, and R10) reviewed for discharge out of 16 sampled residents. Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA), dated 10/26/22, revealed . Discharge Against Medical Advice (AMA). a. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA. b. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. 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 record review, interview, and policy review, the facility failed to ensure the ordered non-pressure wound treatment was provided to one of three residents (Resident (R) 2) reviewed for non-pressure wounds of 16 sample residents. Findings include: Review of the facility's policy titled, Wound Injury Prevention and Management, dated 02/14/23, revealed .Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a skin injury present .Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics . interventions will be documented in the care plan and communicated to all relevant staff Review of R2's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility on [DATE] with diagnoses which included insulin dependent diabetes…

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, interview, and facility policy review, the facility failed to ensure the ordered pressure ulcer treatment was provided to one of two residents (Resident (R9) reviewed for pressure injuries of 16 sampled residents. Findings include: Review of the facility's policy titled, Pressure Ulcer Injury Prevention and Management, dated 02/14/23, revealed This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Policy explanation and compliance guidelines: .The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize; reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .Evidence based treatments…

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 ensure call lights were within reach for 2 Residents (R) (R1 and R4) of 17 residents reviewed. R1 and R4 were observed on multiple occasions without a call light within reach. Findings include: The facility's undated Call Light: Accessibility and Timely Response policy included the following: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call light will directly relay to a staff member or centralized location to ensure appropriate response .3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. 4. Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly (examples include touch pads, larger…

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 specialized services were incorporated into the plan of care for 1 Resident (R) (R1) of 1 sampled resident. The facility identified R1's intellectual disability through a diagnosis of cerebral palsy and submitted a Pre-admission Screening and Resident Review (PASRR) Level II. After specialized services were obtained, R1's plan of care was not assessed and specialized services were not incorporated into R1's transition of care. Finding include: The facility's undated Resident Assessment-Coordination with PASARR Program includes the following: This facility coordinates assessment with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder (MD), intellectual disability (ID), or a related condition receive care and services in the most integrated setting appropriate to their needs .b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines…

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 care and treatment was provided in accordance with professional standards of practice for 1 Resident (R) (R1) of 6 sampled residents. R1 was admitted to the facility with skin damage and was not provided treatment according to physician orders. Findings include: From 10/2/23 through 10/4/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including history of cerebral palsy, chronic respiratory failure with use of a tracheostomy and osteomyelitis of vertebra (infection in hardware of the spine). R1's medical record contained documentation on admission that R1 had trauma to the back of the neck from the tracheostomy (trach) ties. An assessment by Wound Physician (WP)-K, dated 1/4/23, contained the following information: Posterior neck trauma wound bed early partial granulation with moderate serous (not infected) drainage with a depth of 0.1 centimeters (cm) and periwound clean, dry and…

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

Based on observation and interview the facility did not ensure 4 (R15, R66, R50 and R46) of 4 residents that receive insulin had open vials dated and 1 (R32) of 1 residents that receive eye drop medication had the open container dated. During the medication storage task, Surveyor observed R15, R66, R50 and R46 insulin vials, from the medication cart on the 1 north unit, were opened and not dated as to when they were opened. During the medication pass, Surveyor observed R32's eye drop medication was opened and not dated as to when it was opened. Findings include: On 5/23/23, at 8:37 a.m., Surveyor observed Registered Nurse (RN) E administer medications to R32. RN E administered dorzolamide 2% eye drop to R32. The eye drop medication was opened but not dated as to when it was opened. On 5/24/23, at 10:40 a.m., Surveyor observed medication carts, medication storage and medication refrigerators. ADON (assistant director of nursing) D accompanied Surveyor during this observation. Surveyor observed R15's lispro insulin opened and not dated, R66's novolog insulin opened not dated, R46'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.

Based on observation, interview, and policy review, the facility did not store or prepare food in accordance with professional standards for food safety. This deficient practice had the potential to effect 78 of 98 residents who receive food from the facility kitchen. Facility kitchen observations include: - Food in unsealed bags in which the food item was exposed to the air - Food in containers that were unlabeled and without an open on or use by label on the container. - Equipment not appropriately cleaned between food items when pureed. - Food in unit refrigerators without an open on or use by date label, and not labeled with individual's name. Findings include: The facility policy, entitled Food Receiving and Storage', revised October 2017, states: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designates staff, will maintain clean food storage areas. 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 11. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R12) of 3 residents reviewed for grievances had their grievances fully investigated or followed up on by the facility to ensure resolution of the concern. R12 submitted grievances to the facility that were not followed up on to ensure R12 was satisfied with the outcome. Findings include: R12 was admitted to the facility on [DATE] and had diagnoses that included quadriplegia, mononeuropathy, contracture of the left elbow, muscle weakness, cognitive communication deficit, and need for assistance with personal care. R12's quarterly Minimum Data Set (MDS) dated [DATE] indicated R12 had intact cognition with a brief interview for mental status (BIMS) score of 15; is totally dependent on staff for all care including bed mobility, transferring, dressing, eating, toilet use, hygiene, and bathing; impairment to the upper and lower extremities and was immobile. R12 required a Hoyer lift for transfers and used a motorized wheelchair to get…

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 who were unable to carry out personal hygiene received incontinence care and oral hygiene for 2 (R88 and R12) of 5 residents who are dependent on staff for activities of daily living. *R88 was repositioned in bed and an odor of stool was noted. The staff assisting with repositioning did not perform incontinence care at the time of repositioning R88. *R12 was not provided oral hygiene twice daily with physician ordered toothpaste. Findings include: 1) R88 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage, chronic respiratory failure with tracheostomy, and dysphagia resulting in a gastrostomy tube for all nutrition. R88's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R88 was in a vegetative state and the facility assessed R88 as being totally dependent on staff for all activities of daily living (ADLs). R88 had a court appointed Guardian. R88's ADL Care Plan,…

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 1 (R34) of 20 residents reviewed for quality of care received treatments and care based on the comprehensive assessment of a resident and in accordance to professional standards of practice. R34 was observed having a peripherally inserted central catheter (PICC) for medication administration. The PICC was observed to be dirty with dried blood underneath and rolled up on the edges but reinforced with tape. The facility did not have adequate monitoring of the site including: no as needed changes to the dressing, no flush orders and no care plan to address changing the dressing or monitoring the site. MD (Medical Doctor) wrote an order to discontinue the PICC and then canceled the order but it was not updated in R34's Electronic Medical Record (EMR). This had the potential to cause an infection. Findings include: Surveyor reviewed Intravenous Therapy (IV) policy with an implementation date of 2/1/23. Documented was: Policy: The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 (R75) of 3 residents reviewed for weight loss and nutrition had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. R75 was admitted to the facility with a G-Tube (Gastrostomy Tube) and Protein Calorie Malnutrition. R75 was not weighed or assessed by the RD (Registered Dietitian) in December 2022. R75 was not weighed in January 2023. In January 2023, R75 was assessed by the RD who based the assessment off a November 2022 weight. In February 2023 R75 is documented to have had a significant weight loss that was identified by the Registered Dietician who ordered a reweigh to confirm weight loss and then would increase to tube feedings if it was confirmed a true weight loss. The reweigh was not done and subsequently the tube feeding increase was not done. In March the significant weight loss was confirmed and RD-P recommended the increase in tube feeding again that was not…

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

Based on observation, interview and record review the facility did not ensure 1 (R27) of 1 resident with a G (gastrostomy) tube received the necessary services to ensure appropriate administration of medication. On 5/23/23 during morning medication pass, R27 received medication through a G tube and Licensed Practical Nurse (LPN) C did not flush the G tube prior to administration of the medication and after administration of the medication. LPN C also did not verify the G tube placement prior to administering of the medication. Findings include: The facility policy regarding medication administration for enteral tubes, dated 1/23, indicate: Guidelines . 11. Enteral tubes are flushed with at least 15 ml (milliliters) of water before administering any medications and after all medications have been administered. Procedures . 8. Verify tube placement per facility protocol. 9. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100 ml. 13. Flush the tube with at least 15 ml of water prior to medication administration. 15. Flush…

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 they were free of medication errors for 1 (R27) of 6 residents reviewed during medication pass. Two medication errors were observed out of twenty five opportunities with a medication error rate of 8%. On 5/23/23 Surveyor observed Licensed Practical Nurse (LPN) C administer R27's morning medication. R27 did not receive two medications, scheduled humalog 6 units and lacosamide 10 ml (milliliters). Findings include: On 3/23/23, at 7:47 a.m., Surveyor observed LPN C prepare and administer R27's morning medications. LPN C stated to Surveyor R27's blood glucose was 104 and R27 didn't need any insulin. LPN C also stated R27's Lacosamide medication was not in the medication cart. LPN C left the cart to check the medication storage area. LPN C returned to the cart and stated R27's lacosamide medication was not available so she will not be administering it. After completion of the medication pass, Surveyor reviewed R27's physician orders and May 2023 MAR (medication administration record). The May 2023 MAR indicates…

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 an effective infection control program was being implemented for 2 (R87, R27) residents reviewed. *The facility did not ensure staff properly utilized PPE (Personal Protective Equipment) and conducted hand hygiene in accordance with standards of practice when providing care to R87. *The facility did not ensure staff properly provided medications to residents (R27) in a sanitary manner. Findings include: Surveyor reviewed facility's Hand Hygiene policy with an implementation date of 10/24/22. Documented was: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance…

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.