Chi Franciscan Villa

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident potentially affecting 86 of 86 residents in the Facility. * The Facility had documented low staffing ratios in the month of October. Findings include: Due to a complaint received alleging October 2025 the facility was constantly understaffed Surveyor reviewed the PBJ (Payroll Based Journal) report for July 1 to September 30, 2025, and the facility triggered for one star staffing and excessively low weekend staffing. Surveyor reviewed PBJ report for October 1 to December 31, 2025, provided by the facility, and the facility again triggered for low weekend staffing. On 02/17/26, at 8:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H and was told staffing is no different here than anywhere else, they are short because of the call ins. When asked about doing transfers with the mechanical…

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 (R7) of 7 residents reviewed was treated with respect and dignity.On 2/17/26, at 9:58 AM, Surveyor observed R7 being wheeled down the hallway in a shower chair to the shower room wearing a hospital gown with R7's left hip and side of buttocks exposed.Findings include:The facility's policy titled, Dignity, not dated, documents the following:Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times.Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.R7 was admitted to the facility on [DATE], with diagnoses that include Congestive Heart Failure (weakened heart muscle), lymphedema (chronic buildup of fluid in the arms or legs causing swelling), morbid obesity,…

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 establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights, ensuring that all written grievance decisions include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, and any corrective action taken or to be taken by the facility as a result of the grievance for 1 of 2 (R4) residents reviewed for grievances.R4's family filed a grievance on 8/14/25. There was no evidence of follow-up or resolution of the grievance with R4's family.Findings include:R4 admitted to the facility on [DATE] and has diagnoses that include anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder and anxiety.R4's Brief Interview for Mental Status (BIMS) documented a staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, the facility did not report 1 of 1 allegations of misappropriation to the State Survey Agency during the required timeframe.R1's spouse reported to the facility on [DATE] that R1's wedding ring was missing. The wife contacted the police department 12/3/25. This was delayed in being reported to the State Survey Agency until 12/9/25.Findings include:The Facility Policy titled Abuse, Neglect, and Exploitation, effective 5/22/25, documents (in part):IV. Identification of Abuse, Neglect and Exploitation.B. Possible indicators of abuse include, but are not limited to4. Resident reports of theft of property, or missing property.R1 was admitted to the facility on [DATE] with pertinent diagnoses that include Alzheimer's disease (a progressive, neurodegenerative brain disorder and the most common cause of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 9 (R5) residents reviewed. R5 has been sent to the hospital repeatedly for behavior of pulling out her own tracheostomy tube. A care plan with interventions for this behavior was not developed or implemented. In addition, tracheostomy care and treatment are not included in the Facility Assessment.Findings include:R5 admitted to the facility on [DATE] and has diagnoses that include chronic respiratory failure, tracheostomy (trach) status, laryngeal hypoplasia, epilepsy, anxiety disorder, obesity, functional quadriplegia, dysphagia and type 2 diabetes mellitus.The facility policy titled Care Plan Revisions Upon Status Change dated 5/22/25 documents (in part):The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R3) of 2 residents reviewed for Activities of Daily Living (ADL) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene.R3 is scheduled for showers twice a week and did not receive showers on 7/26/25, 8/9/25, 8/13/25, 8/23/25, 8/27/25, 8/30/25, 9/6/25, 9/10/25, 9/17/25, 9/20/25, 10/4/25, 10/8/25, 10/11/25, and 10/15/25.Findings include:The facility's policy titled Activities of Daily Living (ADLs), Supporting, dated 3/6/22, last approved 5/22/25, documents the following:Residents will be provided with care, treatment and services as appropriate to maintain or improve their own ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 (R1) of 2 residents reviewed for quality of care. R1 pulled out their catheter prior to a fall on 11/30/25. The catheter was reinserted and hematuria was noted. R1 was on an antiplatelet and an anticoagulant. There is lack of documentation that R1 was being monitored for bleeding due to being on blood thinning medications. R1 was sent to the hospital later for hematuria.Findings include:R1 was admitted to the facility on [DATE] with pertinent diagnoses that include Alzheimer's disease (a progressive, neurodegenerative brain disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), delirium (an acute, fluctuating disturbance in attention, awareness, and cognition that develops rapidly (hours to days), often caused by underlying medical conditions, infections, or medication side effects),…

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 resident representative written request for a medical record was granted. This was observed with 1 (R3) of 1 resident record requests reviewed. * R3's Representative requested, in writing, a copy of R3's medical record. When initially requested, R3 was responsible for themself and decisions and R3's Representative was not eligible to receive the records. In the day's following the request and denial, R3's Power of Attorney for Health Care (POAHC) status was reviewed and activated naming R3's Represebtative as the POAHC. The facility did not address the request for records given the change in R3's POAHC status. Findings include:The facility policy and procedure (Name of facility) administrative standards for medical record release dated 5/22/2025. Under 4.) Information from a medical record is released to individuals only upon receipt of a properly executed authorization from the resident for their legal representative.Findings include:R3 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 record review, interview and policy review, the facility failed to notify the resident's representative (RR) of a newly developed pressure ulcer injury for one (Resident (R)1) of four residents reviewed for pressure ulcer review in the sample of five.Findings include:Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was originally admitted on [DATE] and readmitted to the facility on [DATE] with the diagnoses of acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure. Review of R1's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment reference Date (ARD) of 07/28/25 indicated R1 was coded to be in a persistent vegetative state with no discernable consciousness. Review of R1's N ADV – Skin Check – V 18 located under the Assessments tab in the EMR and dated 08/19/25 indicted R1 did not have a wound to her left posterior ankle. Review of the hospital Discharge 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 record review and interview, the facility failed to maintain a complete and accurate medical record for one (Resident (R)1) of five sample residents. Findings include:Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnoses of acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure. Review of R1's admission Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment reference Date (ARD) of 07/28/25 indicated R1 was coded to be in a persistent vegetative state with no discernable consciousness. The MDS indicated that R1 was coded as having a tracheostomy. Review of R1's Treatment Administration Record (TAR) located under the Orders tab in the EMR and dated for the months of August through October 2025 indicated missing documentation to reflect the care was performed and completed for 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, record review, interview and policy review, the facility failed to follow infection control guidelines during tracheostomy care for one resident (Resident (R)1) out of five residents that were reviewed.Findings include:Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was admitted on [DATE] and readmitted to the facility on [DATE] with the diagnoses of acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure. Review of R1's admission Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment reference Date (ARD) of 07/28/25 indicated R1 was coded to be in a persistent vegetative state with no discernable consciousness. R1's MDS was coded as having a tracheostomy. Review of R1's Care Plan located under the Care Plan tab in the EMR indicated, Focus dated 08/01/25 indicated, I have a Tracheostomy r/t [related to] Impaired [sic] breathing mechanics/prolonged cardiac arrest,…

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 resident was free from misappropriation of property for 14 of 14 residents reviewed for misappropriation.*The Facility identified multiple medication discrepancies involving Registered Nurse (RN)-D. The Facility did not ensure misappropriation of resident's narcotic medications did not occur and did not ensure resident's narcotic medications were accounted for appropriately.Findings include:Surveyor reviewed the Facility Reported Incident submitted to the State Agency on 06/02/2025 regarding medication diversions. Surveyor noted the Facility documented on 05/30/2025, multiple controlled medication errors were brought to the Facility's attention.The Facility documented that Registered Nurse (RN)-D was identified as the nurse responsible for the multiple discrepancies with the controlled medications. Surveyor reviewed the Facility provided document titled, CONTROLLED DRUG PROCESS AUDIT, completed on 06/05/2025 through 06/06/2025. 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.

Based on interviews and record review, the facility did not ensure an allegation of Narcotic Medication Misappropriation was thoroughly investigated for 1 of 2 Facility Self Reports to the State Agency.* 9 (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14 and R15) of 14 residents were not interviewed by the Facility for pain outcomes after the Facility identified narcotic medication discrepancies.Findings include:Surveyor reviewed the Facility Reported Incident submitted to the State Agency on 06/02/2025 regarding medication diversions. Surveyor noted the Facility documented on 05/30/2025, multiple controlled medication errors were brought to the Facility's attention. The Facility documented that Registered Nurse (RN)-D was identified as the nurse responsible for the multiple discrepancies with the controlled medications. Surveyor reviewed the Facility provided document titled, CONTROLLED DRUG PROCESS AUDIT, completed on 06/05/2025 through 06/06/2025. Surveyor noted the following residents had controlled medication signed out in the control log but was not documented in the…

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

Based on interview and record review, the facility did not ensure 1 of 2 Facility Reported Incidents was submitted to the State survey agency timely. *On 05/30/2025, The Facility was made aware of a possible diversion of narcotic medications. The facility did not report this to the State Survey Agency until 06/02/2025.Findings include:Surveyor reviewed the Facility Reported Incident submitted to the State Agency on 06/02/2025 regarding medication diversions. Surveyor noted the Facility documented on 05/30/2025, multiple controlled medication errors were brought to the Facility's attention. The Facility documented that Registered Nurse (RN)-D was identified as the nurse responsible for the multiple discrepancies with the controlled medications. On 07/14/2025, at 3:00 PM, Surveyor interviewed NHA-A regarding the late reporting of medication misappropriation to the State Agency. NHA-A indicated that NHA-A spoke with corporate and was told not to report and indicated that the Facility was still investigating if it was truly a misappropriation at that time. NHA-A indicated that 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 interview, record review, and review of the Scope of Practice for Nutrition and Dietetics Technician, Registered (NDTR), the facility failed to ensure the Dietary Technician (DT) had oversight/supervision by the Registered Dietician (RD) to meet the assessment and ongoing needs of the residents for two residents (Residents (R)3 and R6) out of a total sample of 13 residents. This failure placed all residents at risk of unidentified nutritional needs. Findings include: Review of the 2024 Scope and Standards of Practice for the Nutrition and Dietetics Technician, Registered by the Commission on Dietetic Registration; pages 15-16 revealed, .NDTRs work under the clinical supervision of an RDN .NDTRs may work independently in providing general nutrition education to healthy populations .Conducting nutrient analysis, collecting data and conducting research, and managing food and nutrition services in a variety of settings .As a member of the NDTR/RDN team, the NDTR supports the RDN by providing key oversight…

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, review of the facility policy, and the resident assessment instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one (Resident (R3) in a total sample of 13. The facility failed to accurately code the correct weight on the quarterly assessment and the correct documentation of the number of wounds on the discharge return anticipated assessment. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings include: Review of the facility policy, titled MDS 3.0 Completion, dated 03/04/23 revealed, .Correction of Error on the Assessment .A Modification Request is used when an MDS record (assessment, entry tracking record or death in facility tracking record) .(already transmitted and accepted by CMS [Center for Medicaid and Medicare Service], but the information in the record contains clinical or demographic errors. It must be corrected within 14 days after identifying the errors . Review 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, record review, and review of the facility policy , the facility failed to ensure showers were provided for two residents dependent on staff for care (Residents (R1, R3) out of a total sample of 13 residents. This failure placed the residents at risk of skin breakdown and a diminished quality of life. Findings include: Review of facility procedure titled, Bath, Tub/Shower, dated February 2018 revealed, .Documentation .The date and time the shower/tub bath was performed .The name and title of the individual(s) who assisted the resident with the shower/tub bath .All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath .If the resident refused the shower/tub bath, the reason(s) why and the interventions taken .How the resident tolerated the shower/tub bath .The signature and title of the person recording the data .Reporting .Notify the supervisor if the resident refuses the shower/tub bath .Notify the physician of any skin areas 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, record review, and review of the facility policy, the facility failed to ensure there was oversight/supervision from the Registered Dietician (RD) of the Dietary Technician (DT) for one resident (Resident (R)6) of three residents reviewed in a total sample of 13 residents. This failure placed the resident at risk of further weight loss and a diminished quality of life. Findings include: Review of the facility policy titled, Nutritional Assessment, dated 11/28/22 revealed, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with a diagnosis of a stroke with left side paralysis, difficulty swallowing and dementia. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to utilize enhanced barrier precautions (EBP) during wound care for one resident (Resident (R)8) of three sampled residents reviewed for pressure ulcers out of a total sample of 13. This failure placed the residents at risk of developing complications from an infection. Findings include: Review of the facility policy titled, Enhanced Barrier Precautions, dated 02/13/25 revealed, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organism] as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .Wounds generally include chronic wounds, not shorter-lasting wounds,…

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 3.) R4 was readmitted to the facility on [DATE] with diagnosis that includes new pressure injuries, an unstageable to left plantar foot, a stage 4 pressure injury right dorsal first toe, neuromuscular dysfunction of the bladder, urogenital implants dysphagia, resistance to multiple antibiotics. R4's Quarterly Minimum Data Set (MDS) assessment, dated 12/22/2024, documents a brief interview for mental status (BIMS) score of 7, indicating that R4 has severe cognitive impairment R4's Urinary Catheter care plan, dated 10/29/2022 (revision on: 9/23/2024) with a target date of: 3/29/2025, documents: I have a 16 F (French) cubic centimeter suprapubic catheter: neurologic bladder, retention. Under the Interventions section in the urinary catheter care plan, it documents: Position catheter bag and tubing below the level of the bladder and away from entrance room door. Surveyor had multiple observations of R4's catheter facing the entrance of R4's room door. R4's urinary catheter care plan above stated that the catheter…

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 who are unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene for 2 (R33 & R45) of 18 residents reviewed for bathing. * R33 was observed to have dirty fingernails, facial hair, uncombed hair and had not had a shower or bed bath in 30 days. * R33 was not offered or assisted with repositioning. * R33 was not assisted with cutting up R33's food per R33's plan of care. * R45 was observed to have long dirty fingernails, poor oral hygiene and only had 3 bed baths or showers in the last 30 days. Findings: 1.) R33 was admitted to the facility on [DATE] with diagnoses that includes cerebral palsy, hemiplegia affecting left side, dysphagia, and mild cognitive impairment. R33 has a activated Power of Attorney (POA). R33's Annual Minimum Data Set (MDS) dated [DATE], documents that R33 has a Brief Interview for Mental Status (BIMS) of 15, indicating R33 is cognitively…

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 received treatment and care in accordance with professional standards of practice for 1 (R22) of 18 reviewed for change of condition. On 10/21/2024 R22 had blood noted in R22's brief. No assessment was completed, and R22's physician was not notified. On 10/23/2025 R22 had another episode of blood in R22's brief. No assessment was completed, and R22's physician was not notified. Findings include: The facility's policy titled, Notification of Changes, with a last revision date of 08/10/2022documents: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The Facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change…

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 necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R45, R41, R73) of 5 residents reviewed with pressure injuries. *R45's wound treatments were not consistently being marked as completed in R45's Treatment Administration Record (TAR) or documented in R45's Electronic Health Record (EHR) as being completed. * R41 was readmitted to the facility on [DATE] and was assessed to have a pressure injury to the sacrum area. A treatment was not initiated until 12/18/2024 and the facility did not document wound treatments as being completed per physician orders. R41 did not have refusals documented or a revised care plan to indicate R41 refused wound treatments. * R73 was admitted to the facility on [DATE] with multiple pressure injuries. The facility did not complete comprehensive wound…

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 the necessary services to provide respiratory care were consistent with professional standards of practice for 1 (R10) of 2 residents reviewed for respiratory care. * R10 had continuous oxygen via nasal canula set at 3 L (liters)/min (minute) during the survey. R10's oxygen tubing was not labeled and did not have humidification attached. There was no respiratory/oxygen care plan for R10, despite R10 having an order for oxygen 2-5 L via face mask as needed. Findings include: The facility policy titled Oxygen Administration revised October 2010 documents: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify the physician order . 2. Review the resident's care plan to assess for any special needs of the resident. Equipment and Supplies: . 2. Nasal canula, ., mas (as ordered) 3. Humidifier bottle. 1.) R10 was admitted to the facility on [DATE] with diagnoses that includes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to report an allegation of abuse immediately to the Administrator. Failure to report an allegation placed all residents at risk as the accused staff person was allowed to work throughout the building. CNA D refused to provide cares to R1, removed R1's puff activated call light, and shut R1's room door. CNA D reported her actions to RN E. RN E did not report the allegation of abuse to NHA A (Nursing Home Administrator). CNA D was allowed to continue to work with residents for an additional 3 shifts before it was reported to administration. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation, dated 10/24/22, revealed, .The facility will have written procedures that include .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not…

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

Based on interview and facility policy review, the facility failed to ensure only licensed nursing staff administered medications to residents who resided on one of two units (Heritage). This failure placed the residents on the Heritage unit at risk for negative outcomes due to the potential for medication errors. Findings include: Review of the facility policy titled, Medication Administration, revised 05/03/22 revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state ordered by the physician and in accordance with professional standards of practice. During an interview on 06/18/24 at 12:03 PM, CNA G (Certified Nursing Aide) stated she had been a CNA for the last 17 years and has been working at the facility since October of 2023. CNA G was asked if she had been asked to pass medication in the facility. CNA G stated, One time I was asked to pass medication. It was a holiday and several nurses called in that day. The DON (Director of Nursing) came in and asked me to. She did push and pass. The DON pushed 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, record review, and facility policy review, the facility failed to ensure residents were free from verbal abuse for three of seven sampled residents (Resident (R) 3, R4, and R5). All three residents sustained verbal abuse from two different staff members. These failures placed the residents at risk of psychosocial harm. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, implemented on 10/24/22 revealed, Policy: It is the policy of this facility to provide protection for the health, welfare and tights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Policy Explanation and compliance Guidelines: The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; .3. The facility will provide ongoing…

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 interview and record review, the facility did not ensure they provided consistent staff to meet the resident needs for the 76 residents residing in the facility at the time of the survey. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered in the fiscal year quarter 3, 2023 (April-June) for low weekend staffing. Findings include: Review of the facility PBJ data, as part of the survey offsite process, indicates during the 3rd quarter of the federal fiscal year (April 1-June 30) the facility was triggered for excessively low weekend staffing. On 11/30/23 at 1:05 p.m., Surveyor interviewed Director of Human Resources (DHR)-D and Administrator-A regarding the PBJ entries for Fiscal Year 2023 quarter 3 (April 1- June 30). DHR- D stated that the company called (name of) is where they import the information from. The hourly staff are automatically uploaded from the time sheets. Staff that are not hourly (for example Administrative staff), their time is added manually. Additional hours that are added manually include 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, observation and record review, the facility did not ensure 4 (R70, R48, R68 and R56) of 7 residents reviewed for pressure injuries received care, consistent with professional standards of practice, to prevent pressure injuries and promote healing. ~ R56 had a pressure injury to her coccyx that healed 4/27/23. The facility documented the treatment continued until 7/23/23 when R56 was admitted to the hospital, except for many refusals documented. When R56 was readmitted on [DATE], the coccyx wound was not assessed until 8/3/23. During survey, wound care to multiple wounds and pressure injury to coccyx was observed. The nurse never completed the wound care to the coccyx wound. Also, Pressure Reducing Mattress was not set to the correct settings making pressure reduction ineffective. ~ R70's air mattress was set to 180 pounds on several observations during the survey and R70's most recent weight is 201.5 pounds. ~ R48's air mattress was set to 350 pounds on several observations during the survey…

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 all medications were labeled in accordance with standard of practice for 3 of 3 medication carts (Skylight East, South, North) and 1 of 2 medication storage rooms (Skylight South) with the potential to affect 35 of 76 residents residing in those units. Findings include: On 11/30/23 the facility's policy titled Storage of Medication dated 8/20 was reviewed and read: When the original seal of the manufacturers container or vial is broken, the container or vial will be dated. 1. On 11/29/23 at 8:30 AM the medication cart on the Skylight East wing was observed and the following was found: * a bottle of partially used saline nasal spray was not dated when open and had no resident name. * a bottle of lubricant eye drops partially used with no resident name or date open. * a bottle of [NAME] tears eye drops partially used with no resident name or date open. * a bottle of refresh eye eye drops partially used with no resident name or date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation and interview, the facility did not ensure 1 (R29) of 1 residents reviewed for self administration of medications was assessed prior to staff leaving medications at bedside for a resident. Facility nursing staff were observed preparing R29's medications and leaving them with R29 when R29 stated they wanted to take the medications when they had breakfast. R29 was not assessed to self administer their medications. Findings include: R29 was admitted to the facility on [DATE] with diagnosis that included Dementia. R29 Quarterly Minimum Data Set, dated [DATE] indicated R29 had a Brief Interview for Mental Status score of 10 indicating moderate cognitive impairment. On 11/29/23 at 8:06 AM Licensed Practical Nurse (LPN)-Q was observed administering medication to R29. LPN-Q placed a B Complex vitamin, Aspirin 81 milligrams (MG), Cinacalcet 60 MG, Renvela 1,600 MG, Venlafaxine 25 MG. Carvedilol 25 MG, and Hydralazine 25 MG in a medication cup and placed it on R29's over bed table. R29 indicated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility did not ensure 1 (R70) of 18 residents sampled were reasonably accommodated to provide access to a call light. R70's call light was not accessible to R70 on 5 observations during the survey. Findings include: On 11/27/2023 at 10:06 AM Surveyor observed R70's call light clipped to the call light cord by the call light device on the wall out of R70's reach. Surveyor asked R70 if R70 was able to reach the call light that was pinned to the call light cord. R70 replied no, R70 is unable to reach the call light. Surveyor asked how R70 how R70 asks for help. R70 replied R70 usually calls out for someone. On 11/27/2023 at 3:15 PM Surveyor observed R70's call light clipped to the call light cord by the call light device on the wall out of reach of R70's reach. R70's activities of daily living (ADL) self-care performance deficit related to impaired balance, pain, obesity, history of falls and weakness, impaired mobility and gait care plan initiated 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 record review and interview the facility did not ensure advanced directives were in the residents medical record for 1 (R68) out of 18 sampled residents. * R68's Do not resuscitate consent form was not placed in her medical record after it was signed. It was found in a pile waiting to be scanned into the computer in medical records which are not always accessible to nursing staff. Findings include: R68 was readmitted to the facility on [DATE] with diagnosis that included Hemiplegia and right below the knee amputation. R68's Quarterly Minimum Data Set, dated [DATE] indicated R68 had a Brief interview for mental status score of 14 (Fully intact memory.) R68 was able to make decisions for herself. On 11/28/23 R68's medical record was reviewed and no advance directives could be found. On 11/28/23 at 12:36 PM Administrator-A was interviewed and indicated R68's code status should have been in the computer on admission and was not. Administrator-A indicated R68's advanced directives were found in a pile of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R9) of 4 residents with allegations of abuse or injuries of unknown origin had these allegations reported to the state agency. On 10/4/23 R9 was discovered to have a bruise to the left breast and left forearm. R9 wasn't able to tell staff how the bruise occurred. R9's bruises meet the definition of an injury of unknown origin and the facility did not report this to the state agency. Findings include: The facility's Abuse, Neglect and Exploitation policy with date of 10/24/22 indicate: 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 agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R9) of 4 residents with allegations of abuse or injuries of unknown origin had a thorough investigation completed. On 10/4/23 R9 was discovered to have a bruise to the left breast and left forearm. R9 wasn't able to tell staff how the bruise occurred. R9's bruises meet the definition of an injury of unknown origin and the facility did not conduct a thorough investigation into R9 bruise. Findings include: The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy dated 10/24/22 indicate: . d. Injuries of unknown source: include circumstances when both the following conditions are met; i. The source of the injury was not observed by any person or could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. 6. Investigation: The facility 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 ensure that 1 (R56) of 2 residents reviewed for non-pressure injuries received care based upon acceptable standards of practice. R56 had 2 areas of Moisture Associated Skin Damage (MASD) to her Left Buttocks and Upper Left Thigh. When R56 was readmitted from the hospital, the wounds were not assessed timely. R56 refused to see the Wound MD for assessments but agreed to weekly head to toe assessments by staff. The staff did not measure or assess the wounds during these weekly assessments and the wound team did not reapproach R56 for the weekly assessments, leading to missing multiple weeks of measurements. During survey, observations of infection control breaks during wound care were observed. 2 new wounds were noted during wound care that were not reported to Wound MD or Wound Team. The wounds were treated with a dressing. The Wound Team discovered the 2 wounds two days later. Findings include: R56 was admitted to the facility 3/26/20 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the Facility did not ensure 3 (R2, R56 and R68) of 3 Residents reviewed received appropriate treatment and services related to catheter care. *R2 has a suprapubic (SP) catheter. R2's collection bag was observed multiple times laying directly on the floor by R2's bed and without an anchor device to hold the tubing in place. R2's catheter tubing was observed stretched with tension in the tubing line and R2 was pulling at tubing. R2 has MD orders for a dry dressing to suprapubic site. R2's suprapubic site observed multiple times with no dressing on it. *R56 has an indwelling urinary foley catheter. R56's catheter bag was observed being emptied with multiple breaks in infection control. *R68 has an indwelling urinary foley catheter. R68's collection bag was observed laying directly on the floor. Findings include: Surveyor reviewed the facility's Catheter Care policy with a date of 5/10/23. Policy: It is the policy of this facility to ensure that resident with…

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 it maintained a medication error rate below 5 percent during observations of medication administration affecting 2 (R8 and R29) of 2 residents observed. Three medication errors were observed out of twenty-six opportunities, for a total error rate of 11.54 %. * R8 was administered Cetirizine 10 milligrams (MG) from a bottle where the expiration date rubbed off bottle in addition R8's order was for 5 MG and she was given 10 MG. R8 was also not given her Flonase as ordered. R29 was given Monifloxacin eye drops after the discontinue date of 11/25/23. Findings include: On 11/30/23 the facility's policy titled General Guidelines for Medication Administration dated 8/20 was reviewed and read: Medications are administered in accordance with the written orders of the prescriber. On 11/29/23 at 8:20 AM Medication Aide (MA)-Z was observed administering medication to R8. MA-Z poured the medication Cetirizine 10 milligrams (MG) from a stock bottle. The expiration date on the bottles label was rubbed off and not…

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

Based on observation, interview, and record review the facility did not ensure that staff performed proper hand hygiene and infection control for 2 (R8, R70) of 3 residents observed during the medication pass observation. * A Medication Aide was observed not wearing gloves to administer eye drops to R8 and did not wash her hands after the administration. The Medication Aide then went and preformed a blood glucose check for R70 without washing her hands between residents Findings include: On 11/29/23 at 8:20 AM Medication Aide (MA)-Z was observed administering medication to R8. After Administering R8's nasal spray and oral medication MA-Z did not wash her hands or apply gloves and administered R8's Sustaine eye drops to both eyes. MA-Z did not wash her hands and completed a blood glucose check for R70. MA-Z did apply gloves before completing the blood glucose check but did not wash her hands before applying the gloves. On 11/30/23 the facility's policy titled eye drop administration dated 08/20 which read: put on examination gloves. After administration remove and dispose of gloves,…

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 its policy and procedure to inhibit abuse, neglect, and mistreatment of residents which had a potential to affect all 11 residents residing on the unit. The facility did not implement its policy and procedures to safeguard residents by removing the certified nursing assistant (CNA)-H from patient care when R1 accused CNA-H of abuse on 8/12/2023. R1 did not have monitoring or care plan revision to monitor psychosocial or long term effects from the accusation of abuse. Findings include: The facility policy entitled Abuse, Neglect, and Exploitation implemented 10/24/2022 states: 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. Policy Explanation and Compliance Guidelines: 1. The facility will implement develop 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.