Autumn Lake Healthcare at Greenfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to provide a fish-free meal to one resident (Resident (R) 13) with a documented fish allergy out of three residents reviewed for food allergies from a sample of 17 residents. This failure had the potential for R13 to experience a severe anaphylactic reaction.Findings include:Review of R13's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R13 was admitted to the facility on [DATE] with diagnoses of osteoarthritis and diabetes mellitus. R13's Face Sheet also included documentation of R13 having an allergy to . Fish Allergy, fish products . Review of R13's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 10/09/25 indicated R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R13 was cognitively intact.Review of R13's Nursing Progress Notes located under the Progress Note tab in the EMR…

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, interviews, and policy review, the facility failed to maintain a complete and accurate medical record for one of 17 sampled residents (Resident (R) 5). This failure resulted in the medical record not accurately showing whether R5's medication was administered.Findings include:Review of R5's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R5 was admitted to the facility on [DATE] with diagnoses of fracture of the left femur and malignant neoplasm of the prostate with secondary neoplasm of the bone.Review of R5's Physician Orders located under the Orders tab in the EMR indicated an order dated 10/30/25 for apalutamide (a hormone blocker used to treat prostate cancer) 240 milligrams by mouth one time a day.Review of R5's Medication Administration Record (MAR), dated November 2025 and located under the Orders tab in the EMR, revealed that on 11/08/25 at 12:00 PM, the nurse documented code 9, which indicated that additional details should be…

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 resolve a grievance as outlined in the facility's grievance policy for 1 (R1) of 3 residents reviewed for grievances. R1's [family member] filed a grievance on 2/22/25 with concerns related to oxygen levels too high, staff not re-approaching R1 when R1 refuses to take medication or personal cares, R1 not getting out of bed due to refusals, broken laundry basket and two missing night gowns.The facility did not resolve R1's grievance related to the broken laundry basket or the two missing night gowns.Findings include:The facility policy titled Resident and Family Grievances, date implemented, 1/4/25, documents:Policy: It is the policy of this facility to support each resident's and family right to voice grievances, without discrimination, fear of reprisal or free of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgement of complaint/grievance and actively working toward resolution of that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not report 1(R2) of 2, reportable incidents reviewed, to the State survey agency and/or Law Enforcement within the required timeframe. *On 02/24/2025, The facility was made aware of R2's missing money. The facility did not notify the local Law Enforcement within the required timeframe. Findings include: The facility policy, titled [Facility Name] abuse, neglect and exploitation, dated 6/1/2024, documents, 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. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, Adult Protective Services and to all other required agency (E.G., law enforcement when applicable. 1.) R2 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 1 (R2) of 1 allegations of mistreatment involving residents were thoroughly investigated. * R2 reported allegations of retaliation from a staff member and the allegations were not reported to the Nursing Home Administrator (NHA)-A in a timely manner. Certified Nursing Assistant (CNA)-O continued to work in resident care the rest of the shift. Findings include: The facility's policy titled, [NAME] Lake healthcare at [NAME] Abuse, Neglect and Exploitation dated: 6/1/2024 documents under the policy: . V. Investigation of alleged abuse, neglect and exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation of curb. VI. Protection of resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: 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 observation, interview, and record review, the facility did not implement a comprehensive person-centered care plan to meet a resident's mental and psychosocial needs that are identified in the comprehensive assessment for 1 (R2) of 6 residents reviewed. * R2 had interventions documented in the focus area of R2's care plan which documented, Attempt to limit the assignment of new staff to the resident or have established staff members slowly introduce new staff to her, when possible, to help set positive tone. The care plan was not observed to be in place during survey or as being utilized in the resident's cares. The focused intervention was not on the resident's care card for Certified Nursing Assistant (CNA) staff to be aware of the intervention. Findings include: The facility policy titled Comprehensive Care Plans dated on 9/1/2024, documents, Policy: It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with 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 observation, interview and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R1) of 2 residents reviewed for pressure injuries. R1 was admitted to the facility on [DATE] with a Stage 3 sacrum pressure injury. There was not a comprehensive assignment until 2/11/25 and a wound treatment was not started until 2/11/25. R1 was transferred to the hospital on 2/26/25 & returned to the facility on 3/5/25. R1's weekly pressure injury assessment dated [DATE] incorrectly stages R1's right & left buttocks pressure injuries. On 3/24/25 during R1's treatment observation, Surveyor observed the adhesive portion of the dressing being applied over R1's right buttocks pressure injury. Observations were made during the survey of R1 not wearing or being offered pressure relieving boots 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 each resident received adequate supervision and assistive devices to prevent accidents for 2 (R3 & R1) of 2 residents reviewed. * R3 fell on 3/3/23. The facility did not thoroughly investigate the fall including whether prior fall interventions to prevent falls were in place. R3 was observed to be transferred without a gait belt by Certified Nursing Assistant (CNA)-F whom unaware R3 required the use of a gait belt during transfers. * R1's fall on 12/23/24 was not thoroughly investigated. Findings include: The facility's policy titled, Falls and Fall Risk, Managing and revised 1/2020 documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under Policy Interpretation and Implementation documents 6. Fall investigation occur during the Fall meeting, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R4) of 2 residents reviewed for nutritional concerns maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance. R4 was admitted to the facility on [DATE] and discharged to the hospital due to a change in condition on 2/15/25. While R4 was at the facility, the facility did not have any evidence how much R4 was eating at every meal, despite R4 being a diabetic and requiring a food for insulin administration. Findings include: On 2/13/25 at 12:00 p.m., R4 was admitted to the facility with diagnoses of right femur fracture, type 1 diabetes, Parkinson's disease and anxiety. R4 was discharged to the hospital on 2/15/25 and did not return back to the facility. R4's 5 day MDS (minimum data set) dated 2/15/25 indicates R4 is cognitively intact and needs supervision for ADLs (activity of daily living). It also indicates R4 is a set up for meals. Surveyor reviewed R4'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 and record review, the facility did not ensure 1 (R4) of 1 resident prescribed insulin received the insulin as ordered. R4 was admitted to the facility on [DATE] at 12:00 p.m. with orders for sliding scale insulin at all meals and at bedtime. The MAR(medication administration record) reveals a blood glucose level was not checked at supper and the sliding scale insulin was not given to R4. The MAR reveals the bedtime blood glucose level was checked and it was 288. R4 received lantus 30 units at bedtime but did not receive the bedtime sliding scale insulin that was ordered. Findings include: 1.) On 2/13/25 at 12:00 p.m., R4 was admitted to the facility with diagnoses of right femur fracture, type 1 diabetes, Parkinson's disease and anxiety. R4 was discharged to the hospital on 2/15/25 and did not return back to the facility. The 5 day MDS (minimum data set) dated 2/15/25 indicates R4 is cognitively intact and needs supervision for ADLs (activity of daily living). R4's admission insulin orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1(R5) of 3 residents reviewed for lab results had obtain it in a timely manner. The facility obtained an order on 12/19/24 for a UA (urinalysis) and C&S (culture and sensitivity) for R5. The facility collected the urine, but the lab facility did not receive it and the facility had to obtain another sample on 12/21/24. The laboratory facility did not receive the lab specimen until 12/22/24. On 12/25/24 the lab results revealed a UTI (urinary tract infection) and R5 received an order for antibiotics. Findings include: 1.) R5 was admitted to the facility on [DATE] with diagnoses of acute cerebrovascular insufficiency, anxiety, depression and alcohol use. R5's Quarterly MDS (minimum data set) dated 12/12/24 documents that R5 is cognitively intact and needs supervision with toilet transfer and toilet hygiene. It also indicates R5 is frequently incontinent of bladder and bowel. R5's physician order dated 12/19/24 documents: UA C&S, obtain specimen by…

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 maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R1) of 2 Residents. * Appropriate hand hygiene was not observed during incontinence cares for R1. Facility staff were not wearing gowns during R1's care & treatment observations while R1 is on EBP (enhanced barrier precautions). There was not a sign posted for enhanced barrier precautions on R1's door nor was there a PPE (personal protective equipment) cart outside the room on 3/24/25 & early morning of 3/25/25. Findings include: The facility's policy titled, Hand Hygiene and dated 10/1/24 under policy documents 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. Under Policy Explanation and Compliance Guidelines documents 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards 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 observations and interview, the facility did not store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 80 of 80 residents residing in the facility. Findings include: The facility's policy titled Storage of Foods dated 4/1/24 documents: Food supplies received will be stored in a manner that will ensure preservation of nutritive value and quality. Refrigerated foods: Foods in the refrigerator will be covered, labeled and dated. Spot checks will be done periodically to ensure foods are held in refrigeration at 41 degrees or below. Raw foods will be stored below cooked foods, and ready to eat foods. All foods should be stored at least 6 inches from the floor. Dry storage: Will be in a room designated for the storage of dry goods. Will be stored and handled to maintain the integrity of the packaging until they are ready to use. 1.) On 12/9/24 at 9:05 AM, during the initial tour of the kitchen, Surveyor observed the following: In a freezer, on the floor under the metal rack, Surveyor observed an unopened…

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 their abuse policy and procedure was implemented for 3 of 8 employees reviewed for 4-year background checks. Certified Nursing Assistant (CNA)-U, Medication Technician (MT)-V, and Cook-W did not have up to date background checks completed within the four year time frame. CNA-U and MT-V worked on specific units of the facility while Cook-W did not have direct contact with residents. This deficient practice has the potential to affect 1 unit of residents where CNA-U and MT-V could potentially be providing care. Findings include: The facility policy and procedure titled Abuse, Neglect and Exploitation dated 6/1/2024 documents: 1. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contacted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself,…

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 the medical record reflected the advanced directive wishes for 1 (R47) of 18 residents reviewed. R47's Cardiopulmonary Resuscitation (CPR) Preference form indicated that R47 did not want CPR attempts, however R47's electronic medical record (EMR) indicated R47 was to have CPR performed. Findings include: The Facility Policy titled Advance Directives last revised [DATE] documents: Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives . 3. Prior to or upon admission of a resident, the Social Services Director or designee 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 complete a Quarterly Minimum Data Set (MDS) assessment timely for 2 (R71 and R45) of 2 residents reviewed for timely assessments. *R71 had a Quarterly MDS assessment dated [DATE] with sections signed as completed on 11/20/2024, 11/21/2024, and 11/24/2024. The assessment was signed in Section Z: Assessment Administration as being completed on 11/12/2024. *R45 had a Quarterly MDS assessment dated [DATE] with sections signed as completed on 12/2/2024, and 12/3/2024. The assessment was signed in Section Z: Assessment Administration as being completed on 11/13/2024. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated 10/2024 documents: 2.6 Required OBRA Assessments for the MDS . Non-Comprehensive Assessments and Entry and Discharge Reporting . 05. Quarterly Assessment . The MDS completion date (item Z0500B) must be no later than 14 days after 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 interview and record review, the facility did not transmit a Quarterly Minimum Data Set (MDS) assessment within 7 days after the assessments was completed for 2 (R71 and R45) of 2 residents reviewed for timely assessments. *R71 had a Quarterly MDS assessment dated [DATE]. The assessment was signed in Section Z: Assessment Administration as being completed on 11/12/2024. The assessment was not submitted to the Centers for Medicare and Medicaid Services (CMS) until 12/10/2024. *R45 had a Quarterly MDS assessment dated [DATE]. The assessment was signed in Section Z: Assessment Administration as being completed on 11/13/2024. The assessment was not submitted to CMS until 12/10/2024. Findings include: The facility policy and procedure titled MDS 3.0 Completion dated 10/1/2024 documents: 7. Transmission Requirements: a. All assessments shall be transmitted to the designated CMS system (iQIES) within 14 days of completion. 1.) R71 was admitted to the facility on [DATE]. R71 had a Quarterly MDS assessment dated…

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 accurately screen residents for a mental disorder for 1 (R8) of 1 residents reviewed for PASSAR (Preadmission Screen and Resident Review) Level I and requiring a Level II screening. R8 was admitted to the facility with diagnoses of mental disorders and was not evaluated on the PASSAR Level I screen as having any mental disorders. The Level 2 PASSAR screen was never completed due to the inaccurate PASSAR Level I screen. Findings include: The facility's policy and procedure titled, Pre-admission Screening for Mental Illness (MI) and Mental Retardation (MR) and dated 4/1/24, documents: The facility will complete a pre-admission screening on all new residents. A Level I, and a Level II if indicated. The screening will note: (a) the resident requires the level of services provided by a nursing facility; and (b) if the resident requires such a level of services, whether the resident requires specialized services for mental illness or mental retardation. 1.) R8…

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 comprehensive person-centered care plan for 2 (R8 and R36) of 18 residents reviewed to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R8 has Chronic Obstructive Pulmonary Disorder (COPD) and receives oxygen therapy. R8 receives Torsemide for diuresis. R8 does not have a comprehensive care plan that addresses oxygen or diuretic therapy. * R36 did not have a catheter care plan implemented when returning from the hospital with a foley catheter in place. Findings include: The Facility Policy titled Care Plans-Comprehensive last revised 1/2023 documents (in part): Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team,…

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 observation, the facility did not ensure 1(R27) of 1 resident reviewed with limited range of motion, received appropriate treatment to prevent further contractures and decreased range of motion in R27's upper and lower extremities. * The facility failed to implement R27's range of motion restorative program ordered and initiated on 9/30/24 by the physical therapy department. Finding include: The facility's policy dated 4/1/24 and titled, Prevention of Decline in Range of Motion documents: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrate that a reduction in range of motion is unavoidable. Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/Explain the procedure occupational therapists shall establish an approach for prevention of decline in range of motion,…

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 (R335) of 3 residents reviewed for falls had adequate supervision and assistance devices to prevent accidents. R335 did not have a care plan for falls, even after a post fall on 9/28/2024, developed that contained interventions in place to prevent falls and accidents. Findings include: The Facility Policy titled Care Plans-Comprehensive last revised 1/2023 documents (in part): Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (guardian), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the comprehensive assessment of a resident, the facility did not ensure that residents received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management for 1 of 4 (R38) residents reviewed for pain. R38 is a hospice patient and was not administered his scheduled pain medication as ordered. Findings include: The facility policy titled Pain Management dated 4/1/24 documents (in part): .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, 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 the accurate and safe administration of medication for 1 (R47) of 5 residents reviewed. R47 had a Consultant Pharmacist Recommendation to Physician form that was signed by the Nurse Practitioner ordering a medication change be initiated that was not acted upon by the facility. Findings include: The Facility Policy titled Pharmacy Services implemented 6/1/2024 documents (in part): Policy: It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice . 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R37) of 5 residents that are on antipsychotic medications received a gradual dose reduction. R37 has a diagnosis of dementia with psychotic disturbance and major depressive disorder. R37 receives olanzapine 2.5 mg (milligram) daily, an antipsychotic medication. R37 receives olanzapine for sundowning with dementia. The 10/16/24 pharmacy recommendation documents that there should be a gradual dose reduction (GDR) attempt for R37 olanzapine. The NP (nurse practitioner) (unknown) noted a GDR was not needed due to psychiatric disorder. There is no evidence R37 has a psychiatric diagnosis and a GDR was not attempted. Findings include: 1.) R37 was admitted to the facility on [DATE] with diagnosis of dementia with psychotic disturbance and major depressive disorder. The annual MDS (minimum data set) dated 11/1/24 indicates that R37 has severe cognitive impairment. It also documents that R37 does not exhibit any physical and verbal aggression and does…

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 received care consistent with professional standards of practice to promote healing for 2 (R14 and R13) of 3 residents reviewed with pressure injuries. *R14 was admitted to the facility on [DATE] with a Stage 3 pressure injury to the right buttock. The pressure injury was comprehensively assessed and documented on 9/24/2024 when R14 was seen by Wound Physician-I, four days after admission. *R13 was observed sitting in a Broda chair without heel boots on and the feet pressed up against the footboard of the Broda chair. R13 was to have bilateral heel boots on per the Skin Integrity Care Plan. Findings include: The facility policy and procedure entitled Skin Assessment dated 6/1/2024 documents: Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily. The assessment may also be…

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 adequate assistance devices to prevent accidents for 1 (R13) of 3 residents reviewed for accidents. *R13's At Risk for Falls Care Plan had the intervention of bilateral fall mats on the floor. Observations were made of R13 having one fall mat on the floor and not two fall mats. Findings include: 1.) R13 was admitted to the facility on [DATE] with diagnoses of osteoarthritis, malnutrition, anxiety, chronic kidney disease, and Alzheimer's disease. R13's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R13 was severely cognitively impaired per staff assessment. R13 has been receiving hospice services since admission on [DATE] with a diagnosis of senile degeneration of the brain. R13 has an activated Power of Attorney. R13's Risk for Falls Care Plan was initiated on 1/28/2022 with the following interventions: -Anticipate and meet R13's needs. -Bed to be in lowest position and bilateral floor mats.…

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 interviews, the facility did not ensure 1 (R10) of 1 residents reviewed for catheters received appropriate care and treatment of the catheter. R10 did not have physician orders for the care and treatment of their Foley catheter. Findings include: *The facility policy entitled, Catheter Care, Urinary dated 10/10, states: . Input/Output, 1: observe the residents urine level for noticeable increases or decreases. If the level stays the same, or increase rapidly, report it to the physician or supervisor. Maintaining the unobstructed urine flow: 1: Check the resident frequently to be sure he or she is not lying on the catheter to keep the catheter and tubing free of kinks. 2: Unless specifically ordered, do not apply a clamp to the catheter. 3: The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Empty the bag as needed to prevent backflow into the bladder. R10 was…

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

Based on interview and record, the facility did not ensure 1 (R5) of 1 residents was assessed by the interdisciplinary team to determine it was clinically appropriate to self administer medication. R5 was applying medihoney on her left posterior wound without being assessed for her ability to self administer treatments. Findings include: The facility's policy titled, Resident Self-Administration of Medication and dated 4/15/24, under Policy documents: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Under Policy Explanation and Compliance Guidelines include documentation of: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 4. The results of the interdisciplinary team assessment are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R1 and R3) of 4 Residents reviewed received a prompt resolution to grievances filed, including steps taken to investigate the grievance, a summary of pertinent findings, conclusion, statements as to whether the grievance was confirmed or not confirmed, corrective actions taken by the facility, and the date the written decision was issued. *R1's representative filed a grievance with the facility and there is no evidence if the grievance was confirmed or not or if R1's representative was informed of the corrective actions taken by the facility and resolution. The facility did not have any documentation this grievance was investigated promptly and resolved. *R3's activated Health Care Power of Attorney (HCPOA) filed grievances with the facility and there is no evidence if the grievances were confirmed or not or if R3's HCPOA was informed of the corrective actions taken by the facility and resolution. The facility did not have any documentation 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 staff interview, the facility did not ensure all allegations involving potential abuse were thoroughly investigated and residents were protected from further abuse while alleged abuse investigations were conducted for 2 of 2 self report reviewed. * A Facility Misconduct Incident self-report submitted to the State Agency on 4/2/24 documents R7 and R6 had a resident to resident altercation where R7 had approached R6 and pulled their hair and possibly slapped R6 in the head. The facility did not conduct a thorough investigation into this allegation of abuse when the facility's investigation did not include documented interviews from other Residents in order to determine a possible pattern of abuse. *A Misconduct Incident Report was submitted to the State Agency on 7/5/24 documenting R2 was told by Certified Nursing Assistant (CNA)-F on 6/28/24, at about 8:30 AM, to Go in her incontinent product and slammed the bedpan down on the table. CNA-F stated to R2 You do this on purpose. You can do…

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.) The facility's Elopements and Wandering Residents policy and procedure implemented 5/10/24 documents: . Policy: This facility ensures that Residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care. Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systematic approach to monitoring and managing Residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 3. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person centered care plan. The facility's Resident Smoking policy and procedure…

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 (R7) of 1 residents reviewed was receiving psychoactive medications with proper indications. *R7 is receiving Donepezil and Olanzapine for Dementia behaviors without any documented behavior monitoring. Findings include: 1.) R7 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia with Agitation, Anxiety Disorder and Disorientation. R7's Quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 5/24/24 indicates an BIMS (Brief Interview for Mental Status) score of 04, indicating R7 has severe cognitive impairment and is non-interview able. On 8/12/24, at 8:58 AM, Surveyor observed R7 in their room. R7 was resting quietly in bed without signs or symptoms of distress. Surveyor did not observe R7 experiencing any adverse behaviors at this time. On 8/12/24, at 11:20 AM, Surveyor observed R7 in their room. R7 was resting quietly in bed without signs or symptoms of distress. Surveyor did not observe…

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 maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R10) of 1 Residents. * Appropriate hand hygiene was not observed during incontinence cares for R10 and staff were not wearing gowns during this care observation for R10 who is on EBP (enhanced barrier precautions). There was not a sign posted for enhanced barrier precautions on R10's door nor was there a PPE (personal protective equipment) cart outside the room. Findings include: The facility's policy titled, Enhanced Barrier Precautions and revised 12/1/23 under Policy Explanation and Compliance Guidelines for 1. prompt recognition of need includes documentation of c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions documents: a. Nursing staff may place…

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, medication audit review, and facility policy review, the facility failed to ensure medication administration was timely resulting in an error rate of 74.07% with 20 errors for 4 residents (R16, R17, R18, and R2) out of a possible 27 opportunities. Licensed Practical Nurses (LPN C and LPN D) and Certified Medication Technician (CMT) E failed to provide medication within the specified/allowed administration time limit. Findings include: Review of the facility policy titled, Medication Administration, dated 12/01/23, showed: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines .11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by…

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 personnel record review, interview, and facility policy review, the facility failed to provide training to staff regarding abuse, neglect, exploitation, and dementia management for 4 of 4 agency staff (Licensed Practical Nurse (LPN) D, Certified Nursing Assistant (CNA) F, CNA8, and CNA9) personnel records reviewed. This training oversight could negatively impact the care provided to all 85 residents residing at the facility. Findings include: During personnel record review there was no documentation regarding abuse, neglect, and dementia care training/education for LPN D, CNA F, CNA G, and CNA H. During an interview on 02/14/24 at 12:50 PM, Nursing Home Administrator (NHA) A stated she was unable to obtain documentation of abuse, neglect, and dementia training from the staffing agency for LPN D, CNA F, CNA G, and CNA H. NHA A explained the staffing agency should have been providing education/training to the staff regarding abuse, neglect, and dementia care prior to the agency employee working at the facility. Review of the facility's policy titled, Abuse, Neglect 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 interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R)1) of one reviewed was free from abuse from another resident (R2) out of a sample of 18 residents. Findings include: 1. Review of R1's Face Sheet EMR Data Collection; admission Data tab showed an admission date of 09/25/20. Review of R1's annual Minimum Data Set, with an ARD of 09/16/23 showed a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated that R1 was cognitively intact. During an interview with R1 on 11/21/23 at 8:45 AM R1 confirmed that the incident occurred. R1 stated R2 came up behind her and pulled her hair. R1 said it was a surprise. R1 said there were three staff members in the area, and they immediately separated them and removed R2 from the area. R1 confirmed that there have not been any further incidents with R2. R1 denied any injury from her hair being pulled. Review of R2's quarterly MDS with an ARD of 08/09/23 showed a BIMS score of five out of 15 which indicated that R2 was severely cognitively impaired. R2 no longer resided at…

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 conditions in the kitchen were sanitary in accordance with professional standards for food safety. This deficient practice had the potential to effect 73 out of 75 Residents who receive food from the facility kitchen. *The grease trap below the food serving table was covered with food particles. *The kitchen staff were not verifying the internal temperature of the dishwashing machine at the utensil rack to ensure the machine was operating properly. Findings include: 1.) The FDA Food Code 2022 documents at 4-602.13 Nonfood-Contact Surfaces. Non-food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 09/05/23 at 8:45 AM, Surveyor observed the kitchen and noted there was a large black container under the food serving table. This container was square on the bottom and had a round top. The container was closed. Surveyor noted multiple areas on the outside of the container were covered in food particles. Surveyor could not make out what 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.

Based on observation, interview and record review the facility did not ensure medications were stored at the proper temperature. This had the potential to affect 29 of 29 residents residing on the 1st floor. *The medication room refrigerator had a temperature log that was not filled out. The last date on the log was from 08/26/23. The September temperature log had not been started. This refrigerator contained seven residents individually labeled medications, a container with stock insulins, two boxes of Bisacodyl Suppositories to be used as needed for any resident on the 1st floor. Findings include: Facility policy entitled, Storage of Medications, documented, .2) The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. On 09/07/23 at 10:00 AM, Surveyor observed the 1st floor medication room Surveyor noted sheets of paper on top of the refrigerator documenting Temperature Log. The last temperature on the log was 08/26/23. Surveyor noted the September temperature log had not been started. Surveyor noted 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 quality of care was provided for 2 (R175 & R4) of 18 Residents. * On 6/27/23 Advanced Practical Nurse Practitioner (APNP)-D's note documents to hold R175's Metoprolol succinate ER (extended release) 25 mg (milligrams) for 48 hours. The medication was administered. Metoprolol succinate ER 25 mg does not include parameters of when to hold this medication. * R4 was prescribed medication for edema. The edema was not assessed by the facility and a care plan not developed for management of edema. On 9/7/23 R4 had a 17.3 pound weight gain in one week that was not reported to her physician and assessed until 9/11/23. Findings include: 1.) R175 was admitted to the facility on [DATE] and discharged on 6/29/23. Diagnosis includes hypertension. R175's physician orders include with an order date of 5/17/23 Metoprolol Succinate ER Oral Tablet Extended Release 24 hour 25 mg (Metoprolol Succinate) Give 25 mg by mouth one time a day for HTN…

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 proper interventions to prevent pressure injuries for 2 (R41, R43) of 8 Residents reviewed for pressure injuries. *R41 was admitted to the facility with an unstageable pressure injury. Surveyor made observations of R41's air mattress operating at an improper setting. *R43 is at risk for pressure injuries. Surveyor made observations of R43's air mattress operating at an improper setting. Findings include: 1.) R41 was readmitted to the facility on [DATE] with diagnoses of Alzheimer's Dementia and unstageable pressure injury to the sacrum. On 9/05/23 at 9:19 AM, Surveyor made observations of R41 in bed wearing offloading heel boots. Surveyor noted R41's air mattress with a setting of 210 pounds. On 9/06/23 at 10:22 AM, Surveyor made observations of R41 in bed wearing offloading heel boots. Surveyor noted R41's air mattress with a setting of 210 pounds. On 9/07/23 at 7:39 AM, Surveyor made observations of R41 in bed wearing offloading…

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 (R4) of 3 residents reviewed for weight received the necessary services to assist with nutritional maintenance. * R4 had a significant weight loss that was not comprehensively assessed, R4's physician was not updated and a comprehensive assessment was not completed. Findings include: On 8/11/23 the facility's policy titled, Weight Monitoring dated 6/2/23 was reviewed and read: a significant change of weight is defined as a 5% change in weight in 1 month, 7.5% change in weight in 3 months or 10% change in weight in 6 months. The physician should be notified of a significant change in weight and may order nutritional interventions. The Registered Dietitian should be consulted to assist with interventions, actions are recorded in the nutrition progress notes. R4 was admitted to the facility on [DATE] with diagnosis that included dysphasia and hemiplegia. On 9/7/23 R4's weights were reviewed and were recorded as follows: 6/04/2023: 230…

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 the physician acted upon recommendations by the pharmacist for 2 (R2, R52) of 5 Residents reviewed for unnecessary medications. *On 6/17/23, pharmacy recommendations were given for R2 and not followed up upon in a timely fashion. The facility could not provide documentation of Monthly Pharmacy Review for March 2023, April 2023, May 2023 and July 2023 for R2. * The facility could not provide documentation of Monthly Pharmacy Review for March 2023, April 2023, May 2023 and July 2023 for R52. Findings include: 1.) R2 was admitted to the facility on [DATE]. R2's diagnoses include diabetes mellitus, bipolar disorder and atrial fibrillation. Surveyor requested to review R2's Pharmacist MRR (Medication Regimen Reviews) from March 2023-August 2023. The facility could not provide Surveyor with R2's MRR for March 2023, April 2023, May 2023 and July 2023. Surveyor reviewed the June 2023 MRR. Pharmacy recommendations were noted for R2 to receive lab work…

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 3 medication errors in 35 opportunities which resulted in a medication error rate of 8.57%. Medication errors were identified for R10 and R69. *R69 had a physician's order for 1000 mg (Milligrams) of Metformin. R10 was given 500 mg of Metformin. *R10 had a physician's order for Tamsulosin 0.4 mg, give 2 tablets daily. R10 only received 1 tablet of Tamsulosin 0.4 mg. *R10 had a physician's order for Oxybutin ER (extended release) 10 mg tablet. R10 did not receive this medication and there was a lack of follow up by the Medication Technician (MT), MT-G. Findings include: Facility policy entitled, Administering Medications, states: .3) Medications must be administered in accordance with the orders . 1.) On 9/6/23 at 7:45 AM, Surveyor observed MT-H administer medications to R69. R69 received Clopidogrel 75 mg, Losartan 25 mg, Metformin 500 mg, Metoprolol Succinate ER (extended release) 25 mg, Paroxetine 30 mg, and Aspirin 81 mg ER. Surveyor 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 maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure proper cleaning and disinfecting of shared glucometers. This deficient practice had the potential to affect 4 residents (R13, R53, F56 and R73) residing on the same unit who utilized the shared glucometer. The facility did not clean and disinfect the glucometer, which is shared between residents, after use. Findings include: The Facility Policy and Procedure, entitled Cleaning and Disinfection of Resident Care Items and Equipment, dated 08/2009, documents (in part) . .Policy Statement: Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. 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 record reviews and interviews, the facility did not develop a comprehensive person-centered care plan for 1 (R4) of 3 residents reviewed for Nutrition. * The Facility did not develop a comprehensive, person-centered care plan to acknowledge R4's Nutritional needs and address R4's severe weight loss. Finding includes: R4 was admitted to the facility on [DATE] with diagnoses including Lymphedema, Diabetes Mellitus, and Major Depression. Surveyor reviewed R4's comprehensive nutrition care plan dated 9/2/21 with a revision date of 4/13/22 reads : Increased nutritional risk due to significant weight loss, vascular open areas, DM (Diabetes Mellitus)-therapeutic diet-diuretic use-need for supplements Interventions include Diet as ordered. Monitor intake and record q (every) meal, Monitor weight, intake, and labs. Surveyor reviewed R4's weights from November 2021 to May 2022. On 11/05/21 R4 had a recorded weight of 248.0 pounds. On 12/08/21, R4 had a recorded weight of 248.0 pounds. On 01/13/22, R4 had 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 interview, the facility did not ensure 1 (R246) of 1 residents reviewed for bathing assistance did not receive appropriate services to maintain or improve his/ her ability to carry out her bathing activities of daily living. This is evidenced by: R246 was admitted to the facility on [DATE] for short-term rehabilitation and discharged on 2/14/22. R246 had diagnosis that include Alzheimer's Disease. The admission Minimum Data Set (MDS), dated [DATE] states the following: Section F04000- Interview for daily preferences: C. How important is it to you to choose between a tub bath, shower, bed bath or sponge bath? 2- somewhat important. Section: G0110 Activities of Daily Living Assistance J. Personal hygiene- Supervision, Set-up only. Section G0120 Bathing- Self-performance- Supervision, 1-person physical assist. Section GG0130 Self- Care Shower/ bathing partial/ moderate assistance- Supervision or touching assistance. Surveyor reviewed R246's individual plan of care and noted that R246 has…

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 2 (R346, R247) of 2 Residents reviewed who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good hygiene. * R346 did not receive assistance from staff with personal hygiene, including toileting in accordance with their plan of care * R247 did not receive assistance from staff with bathing in accordance with their plan of care. Findings include: 1. R346 was admitted to the facility on [DATE] with diagnoses of dementia, cerebral infarction and diabetes mellitus. R346 was discharged from the facility 3/16/22 after a respite stay at the facility. R346's Minimum Data Set (MDS) assessment dated [DATE] indicates R346 requires extensive assistance with personal hygiene and total assistance with toileting. Surveyor reviewed R346's CNA (Certified Nursing Assistant) care records from 3/7/22-3/16/22. Surveyor noted that R346 did not receive assistance with personal hygiene on all 3 shifts on 3/7/22,…

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 2 (R12 & R52) of 5 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. * R12 was observed not wearing a palm guard to prevent a decrease in range of motion per R12's plan of care. * R52 was observed not wearing prevalon boots and a knee brace to prevent a decrease in range of motion per R52's plan of care. Findings include: The facility's policy dated as implement December 2021 and titled Use of Assistive Devices documents; 2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care; 3. The facility will provide assistive devices for residents who need them; 4. Facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices. 1. R12 was readmitted to the facility on [DATE] with a diagnosis that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that 1 (R6) of 4 residents reviewed received appropriate treatment and services to prevent urinary tract infections. * R6 was observed to her catheter drainage tubing on the floor. Findings include: The facility's policy dated as revised 12/20/21 and titled, Catheter Care, Urinary documents under the Infection Control section, 2. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag; (b.) Be sure the catheter tubing and drainage bag are kept off the floor. R6 was admitted to the facility on [DATE] with a diagnosis that included Hemiplegia & Hemiparesis, Dementia without Behavioral Disturbance and Neuromuscular Dysfunction of Bladder. R6's Quarterly MDS (Minimum Data Set) dated 4/13/22 documents a BIMS (Brief Interview for Mental Status) score of 5, indicating that R6 is severely cognitively impaired. Section G (Functional Status) documents that R6 requires extensive assistance and two person…

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 2 (R4, R52) of 3 residents reviewed for Nutrition. * The Facility did not monitor R4's weight per Physician's orders and sustained a severe weight loss of 76.8 pounds or 31% weight loss in 6 months. * The Facility did not monitor R52's weight per Physician's orders and sustained a severe weight loss 23.2 pounds or 13.2% weight loss in 6 months. Finding includes: According to the State Operations Manual, suggested parameters for evaluating significance of unplanned and undersired weight loss are: A weight loss greater than 10% in 6 months is considered severe loss. A weight loss of 10% in 6 months is a considered a significant weight loss. 1. R4 was admitted to the facility on [DATE] with diagnoses including Lymphedema, Diabetes Mellitus, and Major Depression. Surveyor reviewed R4's comprehensive nutrition care plan dated 9/2/21 with a revision date of 4/13/22 reads : Increased nutritional risk due to significant…

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 this facility did not act timely or did not act on recommendations based on a pharmacist medication regimen review report for 3 (R90, R53, and R77) of 5 residents reviewed. *R90 had pharmacist recommendations to add directions to R90's Arnuity Ellipta inhaled corticosteroid to rinse R90's mouth with water after use, and do not swallow to prevent thrush. The recommendation was not added. *R53 had pharmacist recommendations for a hemoglobin A1C level since an A1C level was not available in R53's medical record in the past 6 months. The lab draw was not completed. *R77 had pharmacist recommendations for R77 to receive a calcium supplement due R77 taking medication to treat osteoporosis. The calcium supplement was not added to R77's medications in a timely matter. Findings include: The facility policy titled, Medication Regimen Review, with implemented date of, 12/21, and no date reviewed/revised reads under, Policy Explanation and Compliance Guidelines: 5. The pharmacist shall…

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 this facility did not ensure that 1 (R90) of 5 resident's medications reviewed were free from unnecessary drugs. *R90 had a PRN (as needed) order for an anxiolytic medication, Alprazolam, that did not have a documented rationale in R90's medical record that indicated the duration for the PRN order beyond 14 days. Findings include: The facility policy titled, Antipsychotic Medication Use, with policy revision date, 12/2021 reads under, Policy Interpretation and Implementation: PRN Antipsychotic Drug Use: 10.PRN dosages should only be physician ordered for 14 days, the physician and the IDT (Interdisciplinary Team) will then re-evaluate the need for the medication. R90 was admitted to the facility on [DATE] with diagnoses that include, anxiety disorder, unspecified. R90's physician order dated 4/2/22 reads, ALPRAZolam Tablet 0.5 MG Give 0.5 mg by mouth every 8 hours as needed for anxiety, with start date, 4/2/22, and end date, indefinite. R90's MAR (Medication Administration…

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 its medication error rate was below 5%. The facility error rate was 7.41% affecting 2 of 4 (R56 and R40) residents observed during the medication pass. R40 received Vitamin B12, however R40's physicians orders did not indicate a dosage of the medication. R56 did not receive Flonase Sensimist Suspension as ordered. Findings include: The Facility Policy and Procedure, titled: Administering Medications dated 12/21, documented (in part) . .Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 3. Medications must be administered in accordance with the orders, including any required time frame . 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication . On 5/11/22 at 7:41 AM, Surveyor observed Licensed Practical Nurse (LPN)-H prepare the following medications for R40: Guaifenesin extended…

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 drugs and biologicals used in the facility were not expired and were labeled in accordance with currently accepted professional principles, to include the expiration date for 2 of 2 medications rooms and 1 of 3 medications carts observed. Stock medications were found to be expired and insulin pens were not dated when opened. Findings include: The facility policy titled: Storage of Medications revised April, 2007 documents (in part) . .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed. 7. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station 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.