Geneva Lake Manor

Based on interview and record review, the facility did not ensure they implemented their antibiotic stewardship program potentially affecting all 53 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics indicated antibiotic use without documentation of appropriate use of the antibiotic. Findings include: The facility policy and procedure titled Surveillance for Infections from MED-PASS © 2001 revised 9/2017 documents: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. On 3/3/2025 at 11:14 AM, Surveyor met with Assistant Director of Nursing (ADON)-F to discuss the facility Infection Prevention (IP) program. ADON-F stated ADON-F had been responsible for the IP program since 10/2024 and was still learning the process. Surveyor reviewed ADON-F'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 Interview and record review, the facility did not provide transfer notices to 3 (R5, R47, R13) of 4 residents reviewed for discharge. The facility did not provide transfer notice information to the Ombudsman on a consistent basis. *R5 was hospitalized on [DATE] and did not receive a transfer notice. *R47 was hospitalized on [DATE], 12/24/24 and 1/19/25. R47 did not receive a transfer notice for all 3 hospitalizations. * R13 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information including appeal rights. * Monthly discharge summaries were not sent to the Ombudsman in a timely manner for the months of December and January. Finding include: 1.) R5 was admitted to the facility on [DATE]. On 1/24/25, R5 was transferred to the hospital due to a change of condition. R5 was readmitted to the facility on [DATE]. On 2/27/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-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 record review and staff interviews, the facility did not ensure that 5 out of 5 residents (R44, R26, R16, R34 and R5) drug regimen was free from unnecessary medications. R44, R26, R16, R34 and R5 received recommendations from the Pharmacy Consultant via the monthly review and the facility did not address the recommendations by having the physician review and sign acknowledge of receiving the recommendations and if they accept or want to modify the recommendation for each individual resident. Findings include: Policy review: Medication Regimen Reviews , revised 5/2019 Policy statement: The consultant pharmacist reviews the medications regimen of each resident at least monthly. Policy Interpretation and Implementation: 8.) Within 24 hours of the MRR (medication regimen review), the consultant pharmacist provides a written report to the attending physicians for each resident identified as having non-life-threatening medication irregularity. The report contains the resident's name, the name 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.

Based on observation and interview, the facility did not ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect a pattern of the facility 53 residents who receive food served in the facility common dining room. * A dietary staff member was observed taking temperatures and serving food in the common dining room for breakfast service on 3/3/25 and not wearing a hair net. * Food temperatures were not obtained prior to providing breakfast service on 3/3/25 and throughout breakfast serving times, in the common dining room. Findings include: The facility Policy and Procedure titled, Food Preparation and Service with no date, documents: Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Food Distribution and Service: 2. The temperature of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. 8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint,…

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 written notice including the reason for the room change to a resident and offer a choice in a change of room for 1 (R13) of 1 residents reviewed for room change. R13 returned from the hospital on 2/24/2025 and was placed into a different room, the Facility did not take resident preference into account or offer to show possible rooms to the resident/resident representative prior to the change. There is no documentation R13 received prior written notice for the reason for the transfer. Findings include: The Facility's Policy and Procedure titled, Transfer, Room to Room, last revised December 2016 documents, in part: .Preparation 1. Orient the resident to the transfer in a form and manner that the resident can understand. Provide the resident with information about: a. Where the room is located. b. Who the resident's new roommate, if any, will be. c. Who will be providing the resident's care. d. That his or her family and visitors 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 observation, interview and record review, the Facility did not promote or facilitate the resident's choice for a sleep schedule. This was observed with 1 (R13) of 14 residents reviewed. * R13's morning preference of time to get up was not followed by staff. Findings include: R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are documented. R13…

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 are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms and document ongoing re-evaluation of the need for restraints for 1 (R13) of 1 residents reviewed for restraints. R13 has an abdominal binder in place which cannot be removed easily by R13 and restricts R13's freedom of movement or normal access to body. The Facility did not have a Physician order or signed consent form, did not provide evidence that the use of the abdominal restraint is the least restrictive alternative, did not document scheduled time binder should be on and did not document on-going evaluation of the need for the abdominal binder. Findings include: R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility did not provide bed hold notices to 3 (R5. R47, R13) of 3 residents reviewed for hospitalization. *R5 was hospitalized on [DATE] and did not receive a bed hold notice. *R47 was hospitalized on [DATE], 12/24/24 and 1/19/25. R47 did not receive bed hold notices for all 3 hospitalizations. *R13 was hospitalized on [DATE] and did not receive a bed hold notice. Findings include: 1.) R5 was admitted to the facility on [DATE]. On 1/24/25, R5 was transferred to the hospital due to a change of condition. R5 was readmitted to the facility on [DATE]. On 2/27/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R5's bed hold notice was not found in R5's medical record. Surveyor requested a copy of R5's bed hold notice for 1/24/25. On 3/4/2025 at 8:00 AM, DON-B told Surveyor that R5 did not have any bed hold notice for the requested date. No additional information was supplied by the facility at this time. 2.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not complete a Pre-admission Screening & Resident Review (PASARR) assessment for 1 (R37) of 1 residents reviewed. R37 was admitted to the facility on [DATE], and did not have a PASARR Level I completed at time of admission. Findings include: The facility's Policy and Procedure titled admission Criteria, not dated, documents: All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. R37 was admitted to the facility on [DATE] with a diagnosis that includes Bipolar disorder, Depression, Anxiety, and Post Traumatic Stress Disorder (PTSD). R37's hospital documentation dated 12/20/24, documents R37 with a history of chronic bipolar,…

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 1 (R50) of 1 residents reviewed for discharge received a thorough discharge summary in order to communicate necessary information to care for the resident. *R50 discharged from the facility on 1/13/25. The facility did not complete a discharge summary or a recapitulation of their stay that was available to R50. Findings include: R50 was admitted to the facility for rehabilitation on 1/7/25 with dehydration, weakness and congestive heart failure. On 1/13/25, R50 had a planned discharge from the facility into the community. Surveyor reviewed R50's physician orders and noted no discharge order documented by a physician. Surveyor reviewed R50's electronic medical record. R50 was discharged from the facility on 1/13/25. Surveyor could not identify a completed recapitulation of R50's stay at the facility or a completed discharge summary. On 3/3/25 at 9:45 AM, Surveyor conducted interview with Social Worker-S. Social worker-S informed Surveyor that they were hired by the facility in July of 2023 in a Social Services role.…

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 interviews, the facility did not always ensure that 1 (R44) out of 3 residents reviewed for accident hazards, received the care and services to prevent a further accident from happening. R44 had a history of swallowing difficulties and experienced a choking episode. The facility did not get a referral for R44, immediately following the incident, to identify the cause of the choking and provide supervision and assistance devices to prevent further choking incidents from happening. Findings include: R44 was originally admitted to the facility on [DATE] with diagnoses that included neuropathy, dementia, muscle weakness, hypothyroidism, gastroesophageal reflux disease (GERD), anxiety disorder and depression, The most recent significant change of condition MDS (Minimum Data Set) dated 1/14/25, indicates that R44 does not have any swallowing disorders or oral concerns. R44 did not participate in the BIMs (brief interview for mental status) assessment but is documented to have long 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, and record review, the facility did not ensure residents received appropriate treatment to restore continence to the extent possible for 1 (R47) of 2 residents reviewed for bladder incontinence. R47 had an indwelling urinary catheter that was removed while at the facility. The facility did not comprehensively assess R47's bladder pattern to develop a toileting program to restore R47's urinary continence. R47's Care Plan was not revised when the catheter was removed. Findings include: The facility policy and procedure titled Behavioral Programs and Toileting Plans for Urinary Incontinence from MED-PASS © 2001 revised 10/2010 documents: The purpose of this procedure is to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Conduct a thorough assessment of the resident and his or 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 record reviews and interviews, the facility did not adequately address Nutrition needs for 1 (R19) of 1 residents reviewed for Nutrition. *R19 sustained a 9.2% weight loss from October 2024 to December 2024. The facility did not monitor R19's weight or implement proper interventions per RD (Registered Dietician) recommendations. Findings include: *R19 was admitted to the facility on [DATE] with diagnoses including left femur fracture, hemiparesis of left side, polyneuropathy and cerebrovascular disease. R19's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/30/24 indicated that R19 has a Brief Interview for Mental Status (BIMS) score of 12, indicating that R19 is moderately cognitively impaired. R19's admission MDS with ARD of 10/30/24 indicated that R19 is dependent upon staff for bed mobility, transfers, bathing, dressing and toileting. R19's admission MDS with an ARD of 10/30/24 indicates that R19 did not have any pressure injuries or an active risk 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 interview and record review the Facility did not ensure residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments for 1 (R46) of 1 residents reviewed for dialysis. R46 has a physician order for dialysis on Tuesday, Thursday and Saturday. Communication between the Facility and the dialysis center was not being shared with each visit. Findings include: The Facility Policy titled Dialysis Policy and Procedure last reviewed 9/17/2024 documents (in part): Procedure .: -Communicate with dialysis facility before and after treatment via the Dialysis Communication form . R46 was admitted to the facility on [DATE], pertinent diagnoses include dementia, pleural effusion, end stage renal disease, and dependence on renal dialysis. R46's Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/7/25 indicated R46 had a Brief Interview for Mental Status score…

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 (R13) of 1 residents were free from significant medication errors. R13 had a physician order to receive one 100 mg Amantadine HCl capsule (Per Drugs.com Amantadine is used to treat Parkinson's disease and Parkinson-like symptoms such as stiffness or tremors, shaking, and repetitive uncontrolled muscle movements that may be caused by the use of certain drugs) one time a day. It was documented that R13 did not receive three administrations of Amantadine between 2/28/2025 and 3/3/2025. Findings include: The Facility's Policy and Procedure titled, Adverse Consequences and Medication Errors, last revised February 2023 documents, in part: Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services . 2. Examples of medication errors…

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 address and resolve grievances conveyed on behalf of 4 (R2, R5, R10 and R12) of 4 residents reviewed for grievances. * R2's dialysis social worker contacted the Facility on numerous occasions with concerns that were not recorded or investigated. * R5's Power of Attorney (POA) filed a grievance related to medication administration that was not thoroughly investigated. * R10 expressed care concerns. There was not documentation they the concerns were thoroughly investigated, along with appropriate resolution. * A grievance was filed on behalf of R12 by Hospice for neglect when R12 was found in bed soiled and wet. The grievance was not thoroughly investigated. Findings include: The Facility Policy titled Grievance with no implementation or revision date documents (in part): Policy: It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without…

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 2.) R9 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, poly neuropathy, hypertension and atrial fibrillation. The significant MDS (minimum data set) dated 8/30/24 indicate R9 is cognitively impaired. Surveyor reviewed the facility self report dated 8/17/24 which indicated on 8/17/24 R9 was observed with bruising to the left side of her face. The investigation indicate on 8/17/24 at 12:30 a.m. CNA (certified nursing assistant) DD observed R9 in bed with facial bruising to the left side of the head. It indicates CNA-DD notified RN (registered nurse) EE regarding the bruising and RN-EE Stated R9 had a fall on 8/13/24. The investigation indicates it wasn't until the first shift staff came on shift that R9 was assessed and was discovered to have bruising to the left side of her face. The nurses note dated 8/17/24 at 6:21 a.m. indicate at 0600 writer went into room to take resident vitals and give Synthroid. Observed patient in bed lying on her side. Patient had a hand sized bruise noted…

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 allow the resident representative the right to exercise their rights as delegated to the representative for 1 (R7) of 2 residents reviewed with an activated power of attorney. R7's power of attorney was not present for the admission of R7 into the facility and did not sign any admission consents or contracts. R7 had been deemed incapacitated by a physician and a psychologist prior to admission. R7 signed all admission consents and contracts while assessed to be incapacitated. Findings include: The facility policy and procedure titled Resident Representative and revised 2/2021 documents: The facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated by the resident or to the extent required by the court, in accordance with applicable law. Policy Interpretation and Implementation . 2. If the resident is determined to be incompetent under the laws of the state by a court of competent jurisdiction,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R5) of 2 allegations of abuse or neglect reviewed. * R5 had an injury of unknown origin that was not thoroughly investigated. Findings include: The Facility Policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022, documents (in part) . Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. 4. The administrator is responsible 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 interview and record review, the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person centered care for 2 (R16 and R7) of 2 residents reviewed. * R16 was admitted to the facility on [DATE] and did not have a baseline care plan initiated. * R7's baseline care plan did not include individualized, person-centered interventions. Findings include: The facility policy, entitled Care Plans-Baseline, revised March 2022, documents: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident . 2. The baseline care plan is used until the staff can…

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 a discharge plan was in place to effectively transition the resident to post-discharge care for 1 (R7) of 2 residents reviewed for discharge. R7 was discharged to home while incapacitated with no appointed decision maker. R7 did not receive home health services upon discharge due to no appointed Power of Attorney (POA) to sign contracts for services and no medications were available for R7 upon return to home. Findings include: The facility Policy and Procedure titled Discharge Summary and Plan revised 10/2022 documents: 3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside; b. arrangements that have been made for follow-up care and services; c. a description of the resident's stated discharge goals;…

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 medically related social services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (R7) of 2 residents reviewed for discharge. R7 had an activated Power of Attorney (POA) on admission that was not included in the admission process, social services did not assist R7 in obtaining a decision-maker or guardian prior to R7 revoking the POA, R7 was not assisted in applying for Medicaid after changing payor sources from Medicare, and social services did not ensure R7 had a safe discharge. Findings include: The facility policy and procedure titled Social Services from the publication Med-Pass ©2001 revised 9/2021 documents: Policy Interpretation and Implementation: . 3. The facility staff is able to identify and address factors that have a potentially negative effect on psychosocial functioning of a resident, for example: a. situations that impede the resident's dignity and sense of control;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure a medication administration errors were thoroughly investigated to prevent reoccurrence. This was observed with 2 (R6 and R2) of 4 residents reviewed with medication administration errors. * R6 received potassium 40 (milliequivalents) meq that was not prescribed for R6. There is not documentation to how this occurred and preventative action. * R2 did not have a reported medication error investigated by the Facility. Findings include: The facility's policy and procedure Administering Medications, dated April 2019. The policy under 6. Medication errors are documented, reported, and reviewed by the (Quality Assurance and Performance Improvement) QAPI committee to inform process changes and or the need for additional staff training. 1.) R6 was readmitted to the facility on [DATE] and was discharged to the hospital on 5/29/24. R6's progress note on 5/15/24 at 2:46 PM documents: Patient administered 40 meq of potassium this morning by medication error.…

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 (R17) of 1 resident were free of significant medication errors. R17 did not receive various medications from September 2024 through November 2024 because the medication was not available. The medications that were not administered were Trulicity (diabetic medication), losartan hydroclorothiazide 100/25 mg (milligrams) (blood pressure medication), allopurinol 300 mg (medication to treat gout), latanoprost (eye drops for glaucoma), sertraline 50 mg (depression), toprol xl 100 mg (blood pressure medications), pantoprazole EC 40mg (for GERD-gastro-esophageal reflux disease), and fluticasone (treat asthma). Findings include: R17 was admitted to the facility on [DATE] with diagnoses of cellulitis of abdomen wall, morbid obesity, type 2 diabetes and COPD (Chronic obstructive pulmonary disease). The admission MDS (minimum data set) dated 9/3/24 indicate R17 is cognitively intact and independent with eating, bed mobility and transfers with a walker. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection. This had the potential to affect all 53 of the 53 residents residing in the facility at the the time of the survey. -The facility did not maintain surveillance data to monitor communicable diseases within the facility. -Registered Nurse (RN) performed wound care for resident (R31) who was on transmission-based precautions (TBP), without wearing appropriate personal protective equipment (PPE). - Dietary staff were observed not wearing their PPE appropriately. Dietary staff were observed wearing their mask below their nose and mouth. - The December 2023 monthly infection control log does not include baseline rates by infection. Surveyor was not provided with monthly infection control surveillance logs for June 2023, July 2023, August 2023, September 2023, October 2023 or November 2023. No surveillance long was provided…

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, record review and interviews, the facility did not ensure Residents had an individualized comprehensive plan of care. This was observed with 5 (R15, R20, R40, R300, and R2) of 21 Residents comprehensive care plan reviews. *R15 has a repositioning bar on R15's bed and has an active history of refusing showers. There was no comprehensive plan of care with individualized interventions to address the repositioning bar or the refusal of showers. *R20 has bilateral half side rails on R20's bed and there was no comprehensive plan of care with individualized interventions to address the half side rails. *R40 is a smoker and there was no comprehensive plan of care with individualized interventions to address smoking safety. *R300 returned from the hospital on 1/7/24 with a new diagnosis of Type 2 Diabetes and there was no comprehensive plan of care with individualized interventions to address R300's new diagnosis of Type 2 Diabetes. *R2 was admitted with an indwelling foley catheter and there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not have evidence that it attempted appropriate alternatives prior to installation of bed rails, did not have evidence it assessed residents at risk of entrapment from bed rails prior to installation, and did not have evidence the risks and benefits of bed rails were discussed with the resident and/or resident representatives and informed consent was obtained prior to installation for 4 (R15, R20, R300 and R38) of 4 Residents reviewed for repositioning bars. *R15 does not have a completed assessment done quarterly which documents that risks and benefits were discussed with the Resident and/or Resident representatives and informed consent was obtained prior to the installation, or a care plan was in place for R15's repositioning bars. *R20 does not have a completed assessment done quarterly which documents that risks and benefits were discussed with the Resident and/or Resident representatives and informed consent was obtained prior 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 observation and interview the Facility did not ensure insulin was dated when opened, eye drops were dated when opened & labeled with a Resident's name, medications belonging to residents who no longer resided in the facility were disposed of properly, and pharmacy labels were not removed from medications. This has the potential to affect R6, R8, R349, R21, R14, R39, R249, R28, R250, R251, R403, R252, R253, and a pattern of residents residing on the rehab unit who utilize metamucil. Findings include: The Insulin Administration policy and procedure 2001 Med-Pass Inc (Revised [DATE]) under Steps in the Procedure for #4 documents Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). The Ophthalmic Administration Policy and Procedure not dated under Procedure for Multi-dose Ophthalmic Drops and Ointments Action Rationale for #16 documents Label 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 ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 of 5 residents reviewed (R42). * R42 is prescribed Seroquel, an antipsychotic medication for agitation related to Alzheimer's disease and dementia diagnosis. The facility did not have a written, signed consent explaining the risks and benefits of to R42's power of attorney (POA). This is evidenced by: Surveyor reviewed R42's physician orders and noted that R42 is currently prescribed Seroquel 25 mg tablet twice a day with start date of 11/22/23 and ending on R42's date of discharge 01/09/24. R42 has an activated power of attorney (POA) for health care decisions. Surveyor reviewed R42's electronic health record (EHR) and could not locate a written consent for the reason for the antipsychotic medication, alternative modes of treatment, the risks of taking the medication and the benefit of taking the medication. On 01/11/24, at 8:50 AM, Surveyor requested documentation for signed consent of Seroquel from Director 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 2 of 2 resident-to-resident incidents of physical abuse involving R36 towards R32 and R7 were reported to the State Agency within 2 hours, when the allegation involves abuse, and did not submit the results of their investigation within 5 working days to the State Agency. * On 12/26/23 at 2:00 pm, R36 struck R32 on the hand, when R32 wheeled past R36's wheelchair. The facility did not report this resident-to-resident physical abuse incident between R36 and R32 to the State Agency within 2 hours. The facility did not provide their investigation results within 5 working days to the State Agency. * On 12/27/23, R36 struck R7 on the shoulder when R36 was being wheeled past R7. The facility did not report this resident-to-resident physical abuse incident to the State Agency. The facility did not report this resident-to-resident physical abuse within 2 hours and did not submit their investigation results within 5 working days 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 observation, interview and record review, the facility did not ensure 2 resident-to-resident incidents (involving R32 and R7) of 2 incidents of physical abuse by a resident (R36), had a thorough investigation completed. * The facility self-report Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 1/4/24 indicates, on 12/26/23 at 2:00 pm, R36 struck R32 on the hand, when R32 wheeled past R36's wheelchair. The facility did not complete a thorough investigation of this incident. * On 12/27/23, R36 struck R7 on the shoulder when R36 was being wheeled past R7. The facility did not report this resident-to-resident physical abuse incident to the State Agency and did not complete a thorough investigation. Findings include: The facility's Abuse Investigation and Reporting policy dated July 2017, indicate: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local,…

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 the PASARR (Pre-admission Screen and Resident Review) for 1 (R5) of 2 Residents reviewed was completed accurately upon admission to the Facility and was appropriately referred for a Level II screen. R5 has a diagnosis of bipolar disorder and being treated with antidepressants of Trazadone & Effexor. The Facility did not complete Section C Questions pertinent for an abbreviated Level II screen and did not refer R5 for a Level II screen on or before the 30th day of stay at the Facility as required. A required Level II screen which would indicate if R5 needs nursing home placement and if R5 needs specialized service related to developmental disability and/or serious mental illness which is defined by federal PASARR regulations. Findings include: The admission Criteria policy 2001 Med-Pass Inc. (Revised March 2019) under policy interpretation and implementation documents; 9. All new admissions and readmissions are screened for mental disorders…

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 residents who are dependent on staff for personal hygiene/showering were provided the necessary care. This was observed with 1 (R15) 2 Residents reviewed who were dependent on staff for personal hygiene/showering. * On 1/9/24 at 9:58 AM, R15 informed Surveyor that R15 has not been getting showers on a regular basis and is scheduled for Tuesdays and Fridays. There is no documentation or comprehensive care plan of R15 refusing showers. The facility was not able to provide documentation that R15 has received showers. Findings Include: Surveyor reviewed the facility's Bath, Shower/Tub policy and procedure revised February 2018 and notes the following: .Purpose The purposes of this procedure are to promote cleanliness, provide comfort to the Resident and to observe the condition of the Resident's skin. Documentation 1. The date and time the shower/bath was performed. 2. The name and title of the individual(s) who assisted the 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 record review and interview, the facility did not ensure the resident's record reflected the accurate resuscitation code status as identified in the resident's advanced directive for 2 of 2 residents (R3 and R40) reviewed for a Do Not Resuscitate (DNR) code status. * R3's Emergency Care Do Not Resuscitate Order (DNR) was signed [DATE]. R3's current physician orders for [DATE]-[DATE] documents that R3 is a full code with a start date of [DATE]. * R40's Emergency Care Do Not Resuscitate Order (DNR) was signed [DATE]. R40's current physician orders for [DATE]-[DATE] documents that R40 is a full code with a start date of [DATE]. Surveyor requested during the survey process the facility's policy and procedure for documenting a Resident's preference for CPR but did not receive a policy and procedure. Findings Include: 1. R3 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Failure and Stage 1 Through Stage 4 Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Diastolic…

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 quality of care was provided for 2 (R5 & R300) of 3 Residents reviewed for neurological checks. * R5's neurological checks were not completed after unwitnessed falls on 12/8/23, 12/20/23, 12/28/23, & 12/30/23. * R300's neurological checks were not completed after unwitnessed falls on 9/13/23 & 10/4/23. Findings include: The Neuro Check Assessment form documents for Policy: All resident who experience a head injury or an unwitnessed fall will have Neuro Checks completed. Under Procedure documents Neuro checks, vitals and assessments will be completed every 15 minutes X (times) (1) hour, every 30 minutes for (1) hour, every 1 hour X 4 hours and then every 4 hours X 24 hours and every shift X 48 hours. This form is dated on the date of a Resident's fall. 1. R5 has diagnoses which include diabetes mellitus, depression, hypertension, generalized anxiety disorder, and bipolar disorder. R5's power of attorney for healthcare was activated on 10/25/23. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure daily diabetic foot inspections was provided in accordance with professional standards of practice for 1 Resident (R) (R20) of 2 Residents reviewed with a diagnosis of Diabetes. * R20 who has Type 2 Diabetes Mellitus with diabetic neuropathy. R20's care plan and care card does not address performing daily foot care and inspection. R20 reported R20 has been taught to do diabetic foot checks but is not able to physically check his own feet. R20 reported staff do not check his feet daily. According to Director of Nursing (DON)-B foot checks are not completed daily but are completed weekly. Findings Include: According to the American Medical Directors Association (AMDA), Diabetes Management in the Post-Acute and Long Term Care Setting Clinical Practice Guideline. [NAME], MD: AMDA 2015 page 32-33 states in part: Train caregivers to perform daily foot care and inspection . The American Medical Directors Association (AMDA) - The Society 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 interview and record review, the Facility did not ensure ongoing communication with a dialysis facility for 1 (R24) of 1 resident who received dialysis care and services. * R24 received dialysis three times per week. The Facility did not ensure ongoing communication occurred between the nursing facility and the dialysis facility prior to and following R24's dialysis appointments. Findings include: The nursing home dialysis transfer agreement between the nursing home and [Name of] Dialysis Center dated 5/18/22 under Now, Therefore, the Owner and Company agree to the following documents: 3. Designated Resident Information. Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center. This information, shall include, but is not limited to, where appropriate, the following: (a) Designated Resident's name, address, date of birth and Social Security Number; (b) Name, address and telephone number 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 self-administration assessments were completed prior to leaving medication at the bedside to ensure safe medication delivery for 1 of 1 resident (R403) reviewed for self-administration. * R403 was observed to have medication left at bedside to self-administer and did not have a physician order or an assessment to self-administer medications. This is evidenced by: The facility's Medication Self-Administration of Medications policy states in part . Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform…

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 keep 1 (R5) of 1 Residents reviewed for antibiotic use free from unnecessary drugs. * On 11/3/23 R5 was ordered & received Macrobid 100 mg (milligrams) BID (twice daily) x (times) 5 days for UTI (urinary tract infection) when R5 did not have/ appropriate signs and symptoms for use of the antibiotic. Findings include: The Urinary Tract Infection/Bacteriuria-Clinical Protocol 2001 Med-Pass Inc. (Revised April 2018) under assessment and recognition includes documentation of; 2. The staff and practitioner will identify individuals with possible signs and symptoms of a UTI. a. Signs and symptoms of a UTI may be specific to the urinary tract and/or generalized. The presentation of symptomatic UTIs varies. b. Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions. c. New onset of nonspecific or general symptoms alone (change in mental status, decline in appetite, etc)…

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 33 opportunities which resulted in a medication error rate of 6.06%. Medication errors were identified for R351 & R38. * R351 did not receive PreserVision AREDS-2 on 1/10/24 as this medication was not available. * R38 did not receive Colchicine 0.6mg on 1/11/24 as this medication was not available. Findings include: 1. On 1/10/24 at 9:21 a.m. Surveyor observed LPN (Licensed Practical Nurse)-S prepare R351's medication which consisted of Carvedilol 3.125 mg one tablet, Finasteride 5 mg one tablet, Torsemide 10 mg one tablet and Vitamin D3 25 mcg (micrograms) one tablet. On 1/10/24 at 9:24 a.m. Surveyor verified the number of pills in R351's medication cup with LPN-S. On 1/10/24 at 9:24 a.m. LPN-S administered R351 the medication whole with water. LPN-S cleansed her hands after administering R351's medication. On 1/10/24 at 9:35 a.m. Surveyor reviewed R351's physician order and noted an order dated 1/6/24 which documents…

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 adequate supervision and interventions to prevent accidents for 4 (R17, R300, R32 and R5) of 4 sampled Residents identified by the facility to be at risk for falls. *On 1/19/24, R17 was not transferred per plan of care (including the care card), which indicates the use of 2 staff assist when transferring with the hoyer lift. *R300 had 4 falls all from R300's recliner on 9/13/23, 10/4/23, 11/12/23, and 12/30/23. The facility did not complete a thorough investigation and determine a root cause analysis for R300's falls. *R32 had 2 falls on 7/29/23 and 11/30/23. The facility did not complete a thorough investigation and determine a root cause analysis for R32's falls. *R5 had 5 six falls in December 2023: 12/4/23, 12/8/23, 12/20/23, 12/27/23, 12/28/23, & 12/30/23. The Facility did not thoroughly investigate these falls. There is no evidence staff were interviewed to determine when R5 was last observed, when R5 was provided cares, 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, the facility did not ensure the privacy and confidentiality of protected health information (PHI) for 2 of 2 residents (R2 and R9). This is evidenced by: On 01/09/24, at 10:37 AM, Surveyor observed a medication cart in hallway in front of R2's room. The computer screen was up with R2's medication administration screen viewable. R2's door was closed, and Licensed Practical Nurse Q (LPNQ) was in R2's room. LPNQ was observed coming out of R2's room and started setting up R2's medications. At 10:40 AM, LPNQ completed R2's medication set up. LPNQ locked the medication cart and went back into R2's room. LPNQ left the medication cart computer screen up with R2's PHI visible. At 10:45 AM, Surveyor observed LPNQ pushing the medication cart throughout the hallways with the computer screen up and R9's PHI viewable. On 01/11/24, at 8:50 AM Director of Nursing (DON) B was asked to provide a Policy & Procedure for resident PHI during medication pass. Surveyor did not receive a Policy & Procedure from DON.

Based on interview and record review the Facility did not ensure 3 (CNA (Certified Nursing Assistant)-N, CNA-O, & CNA-Q) of 5 randomly selected CNAs had a performance (competency) review at least once every 12 months. This has the potential to affect all 48 Residents residing in the Facility as staff work throughout the facility. A performance (competency) review was not completed for CNA-N, CNA-O, & CNA-Q in 2021. Findings include: On 9/12/22 at 7:30 a.m. Surveyor reviewed the competency reviews for CNA-N, CNA-O, CNA/Med Tech-P, CNA-Q and CNA-R and noted the following. CNA-N was hired on 12/6/06. The competency reviews for CNA-N are dated 3/17/08, 7/29/13, & 4/16/14. CNA-N did not have a performance (competency) review in 2021. CNA-O was hired on 4/3/13. The competency reviews for CNA-O are dated 6/11/15, 8/11/16, and one dated 11/26 with the year not documented. Surveyor noted the competency review is not signed by the current DON (Director of Nursing) who started in 2020 at the Facility as the signature for the first name initial is M and the current DON's first name initial is…

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 upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order potentially impacting 48 of 48 Residents residing in the Facility. Surveyor observed the left dryer in the laundry and observed the top flat surface and wires above the dry screen had a large accumulation of lint, which is a potential fire hazard. Findings include: On 9/8/22 at 8:28 a.m. Surveyor toured the laundry with LA (Laundry Aide)-M who has worked in the laundry since February 2022. Surveyor observed there are two working commercial dryers. Surveyor asked LA-M how often she cleans the dryers to remove lint. LA-M informed Surveyor she cleans the lint every other load unless the load would have a lot of lint, like towels, then she cleans the lint after every load. LA-M showed Surveyor a white erase board which she writes the time when she has cleaned the lint from the dryers. At 8:35 a.m. LA-M opened the bottom door of the left dryer where the lint screen is located. Surveyor observed there is a large amount of lint accumulated on flat portion above the…

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

Based on interview and record review the Facility did not ensure 4 (CNA (Certified Nursing Assistant)-O, CNA/Med Tech-P, CNA-Q, & CNA-R) of 5 randomly sampled CNA's (Certified Nursing Assistant) who had been employed for over a year received dementia management & resident abuse prevention training. This has the potential to affect all 48 Residents residing at the Facility as staff work throughout the facility. Findings include: On 9/8/22 at 3:38 p.m. Surveyor reviewed in-service education records for CNA-O, CNA/Med Tech-P, CNA-Q, and CNA-N and noted the following: CNA-O was hired on 4/3/13. Surveyor reviewed CNA-O's in-service record for the period of 4/3/21 to 4/3/22. Surveyor noted CNA-O received abuse, neglect & exploitation training but did not receive dementia training. CNA/Med Tech-P was hired on 2/7/07. Surveyor reviewed CNA/Med Tech-P's in-service record for the period of 2/7/21 to 2/7/22. CNA/Med Tech-P did not receive dementia training or abuse, neglect, & exploitation training. CNA-Q was hired on 9/2/20. Surveyor reviewed CNA-Q's in-service record for the period of 9/2/21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the Facility did not ensure 4 (R2, R12, R41, & R43) of 5 Residents reviewed for COVID-19 vaccination had documented risk and benefits. Findings include: The COVID-19 Vaccination Education, Offering, and Documentation policy & procedure updated 5/25/21 under COVID-19 Immunizations Requirements includes documentation of The resident's medical record includes documentation that indicates, at a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and b. Each dose of COVID-19 vaccine administered to the resident. c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusals. On 9/8/22 at 1:12 p.m. during the infection control interview with ADON (Assistant Director of Nursing)-C who is the Facility's infection preventionist, Surveyor asked where Surveyor would be able to locate documentation the Resident was educated on 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 notify the resident or resident's representative in writing of the transfer and the reasons for the move including the effective date of transfer, the location to which the resident is transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form as well as the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman for 1 (R22) of 1 residents reviewed for transfer to the hospital. *R22 was transferred and admitted into the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. No documentation was found indicating a transfer notice was provided to R22 or R22's representative. Nursing Home Administrator-A was not aware of the requirement to provide transfer notices to residents and their representative for facility initiated transfers. Findings: The facility policy and procedure entitled…

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 notify at the time of transfer the resident or resident's representative in writing the state bed-hold policy, the duration of the bed hold, the reserve bed payment policy, and the return to the facility for 1 (R22) of 1 residents reviewed for bed hold notice. *R22 was transferred and admitted into the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. No documentation was found indicating a bed hold notice was provided to R22 or R22's representative. Findings: The facility policy and procedure entitled Bed-Holds and Returns dated 3/2017 states: 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid resident), or to hold a bed beyond the state bed-hold…

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 residents received treatment and care in accordance with professional standards of practice after an unwitnessed fall for 2 (R22 and R8) of 4 residents reviewed for falls. *R22 had unwitnessed falls on 12/16/2021, 1/29/2022, 2/9/2022, 2/16/2022, 2/21/2022, 2/26/2022, 3/3/2022, and 7/9/2022. Neurological checks were not completed following the fall to assess for a change in mentation. *R8 had unwitnessed falls on 2/23/2022, 4/28/2022, and 6/4/2022. Neurological checks were not completed following the fall to assess for a change in mentation. Findings: The facility policy and procedure entitled Neurological Assessment dated 10/2010 states: General Guidelines: 1. Neurological assessments are indicated: a. Upon physician order; b. Following an unwitnessed fall; c. Following a fall or other accident/injury involving head trauma; or d. When indicated by resident's condition. The facility Neuro Check Assessment form states: Policy: 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 Residents with pressure injuries receives appropriate care, treatment, & preventative measures to promote healing for 1 (R99) of 2 Residents with pressure injuries reviewed. R99 was admitted to the facility on [DATE] with a right buttocks Stage 2 pressure injury. There was no assessment of the pressure injury until after Surveyor spoke with ADON (Assistant Director of Nursing)-C on 9/12/22. The physician order dated 8/26/22 documents may apply medseptic cream to areas of concern every shift - PRN (as needed). There is no documentation in R99's Treatment Administration Record (TAR) from 8/26 to 9/11/22 of R99 receiving the medseptic cream, even though the Assistant Director of Nursing (ADON) -C informed Surveyor staff had been applying it. On 9/7, 9/8, and 9/12/22, R99 was observed sitting in a chair without a pressure relieving cushion in the chair. Findings include: The Pressure Ulcers/Skin Breakdown - Clinical Protocol 2001…

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 residents received adequate supervision to prevent falls for 3 (R9, R8, and R22) of 4 residents reviewed for falls. *R9 had a fall on 7/4/2022 due to staff not following interventions per the Falls Care Plan. *R8 had six falls in eight months. R8's Falls Care Plan was not revised timely after falls to prevent future falls, interventions were not implemented as stated per the Fall Care Plan, and no documentation was found in R8's medical record of having a fall yet staff statements of a fall were provided. *R22 had eleven falls in eight months. R22's Falls Care Plan was not revised timely after falls to prevent future falls with resident-centered interventions. Findings: The facility policy and procedure entitled Falls - Clinical Protocol dated 3/2018 states: Assessment and Recognition: . 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any…

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

Based on observation, interview and record review, the facility did not ensure that 1 (R36) of 1 residents reviewed received dialysis services consistent with professional standards of practice. R36 did not have a physician's order documenting the frequency of dialysis treatments, the location of the dialysis center in the community, the care, monitoring, and location of the dialysis access site. R36's care plan did not document the location of the dialysis access site or the monitoring of the dialysis site for complication such as bleeding. Findings include: The Dialysis policy and procedure revised 1/2017 under policy documents [name of facility] will use the Critical Element Pathway from CMS (Centers for Medicare & Medicaid Services) to provide quality dialysis services to our clients. [name of facility] does not provide in-house dialysis. If any resident needs dialysis, Admissions or Social Worker will set up the appointments and arrange for transportation, either with our van or with an outside vendor. Under procedure documents; Obtain physician order for hemodialysis or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 (R35) of 1 residents reviewed for mood and behavior received appropriate treatment and the services to attain the highest practicable mental and psychosocial well-being. The facility did not ensure that R35 received a psychiatric consult as requested by R35's POA (Power of Attorney). Findings include: R35 was admitted for rehabilitation on July 23rd, 2022, and has diagnoses that include: fracture of unspecified part of the neck of the left femur, dementia, and depression. R35's MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 07/29/22 documented R35 has a BIMS (Brief Interview for Mental Status) of 4, indicating R35 is cognitively impaired; R35 used anti-depressant medication six days during the reference period, and documented a PHQ-9 (Patient Health Questionnaire-9) score of 00, indicating no depression; however, the PHQ-9 assessment contains an area for staff to assess residents' level of depression if…

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 each Resident's drug regimen was free from unnecessary drugs for 2 (R31 & R35) of 6 Residents reviewed. * R31 receives metoprolol tartrate 25 mg (milligrams) with instructions to hold the medication if R31's systolic blood pressure is less than 100. R31's PM (evening) blood pressure was not taken before administering the medication on 8/12/22, 8/18/22, 8/19/22, 8/20/22, 8/21/22 & 9/3/22. * R35 receives a prophylactic antibiotic for UTI (urinary tract infection) without adequate indications for its use. Findings include: R31 was admitted to the facility on [DATE] with diagnoses which includes hypertension. The physician orders dated 7/15/22 include metoprolol tartrate 25 mg (milligrams) with directions to administer twice a day 6:30 a.m. -10:00 a.m. and 7:00 p.m. - 9:30 p.m. Special instructions document HTN (hypertension) Hold Med for SBP (systolic blood pressure less than 100. On 9/8/22 at 12:20 p.m. Surveyor asked RN (Registered Nurse)-U where…

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 1 (R31) of 4 Resident's medications reviewed were free from unnecessary drugs. * R31 receives Risperidone (Risperdal) 0.5 mg twice a day. The Facility is not monitoring R31's behavior and an AIMS (Abnormal Involuntary Movement Scale) was not completed. Findings include: R31 was admitted to the facility on [DATE] with diagnoses which includes multiple sclerosis, depression, anxiety disorder, and Alzheimer's disease. The physician orders dated 7/15/22 includes Risperidone 0.5 mg (milligrams) with directions to administer twice a day for Alzheimer's dementia. Risperidone (Risperdal) is an antipsychotic medication. The admission MDS (minimum data set) with an assessment reference date of 7/18/22 is coded as having received an antipsychotic 3 days in the last 7 days. The quarterly MDS with an assessment reference date of 8/31/22 is coded as having received an antipsychotic for 7 days in the last 7 days. On 9/8/22 at 12:02 p.m. Surveyor asked…

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 (R16) of 5 residents reviewed for medication administration were free of significant medication errors. R16 was administered an extra 4 units of long-acting insulin before lunch time instead of the prescribed 4 units of short-acting insulin. Findings include: Surveyor reviewed facility's Administering Medications policy with a revision date of April 2019. Documented was: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . R16 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, severe sepsis with septic shock,…

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 (CNA-V & CNA-H) of 5 unvaccinated Facility staff including individuals providing services under arrangements were tested for COVID 19 according to Facility's outbreak protocol and [NAME] County community transmission rates. This had the potential to affect all 48 Residents residing at the Facility. Findings include: On 9/8/22 at 12:36 p.m. Surveyor conducted the infection control interview with ADON (Assistant Director of Nursing)-C, who is the infection preventionist at the Facility. During this interview Surveyor discussed with ADON-C the Facility's COVID-19 outbreaks. Surveyor inquired how often employees who have been granted an exemption are tested. ADON-C informed Surveyor they have been tested twice a week due to their COVID-19 outbreaks & the county's transmission rates. Surveyor inquired if there was a time since May 2022 these employees were not tested twice weekly. ADON-C informed Surveyor she didn't think there was a time when they…

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