Suring Health and Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R20) of 3 sampled residents.Staff did not ensure R20's cigarettes, lighter, and e-cigarette were kept in a secure location. In addition, a smoking evaluation completed for R20 was not accurate and indicated R20 could store smoking materials independently.Findings include:The facility's Smoking policy, dated 10/25/22, indicates: Facilities may permit residents to smoke tobacco products. In these facilities, assessment of capabilities and deficits determines whether or not supervision is required. If the facility identifies that the resident needs assistance and supervision for smoking, the facility includes this information in the care plan, and reviews and revises the plan periodically as needed. The facility must ensure precautions are taken for residents' individual safety, as well as the safety of others 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide the necessary tube feeding services for 1 resident (R) (R7) of 2 sampled residents. Certified Nursing Assistant (CNA)-D turned off R7's tube feeding before it was complete and without checking with a nurse. Findings include: The facility's Care and Treatment of Tube Feedings policy, revised 8/21/24, indicates: The resident's plan of care will address the use of feeding tube, including strategies to prevent complications. From 1/26/26 to 1/28/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had a diagnosis of gastrostomy status. A care plan, revised 1/8/26, indicated R7 had an alteration in nutrition because R7 required tube feeding following a hospital stay. The care plan contained an intervention for Osmolite 1.2 474 milliliters (ml) via gastrostomy (G) tube three times daily .Observe .toleration to tube feeding.On 1/27/26 at 9:38 AM, Surveyor observed CNA-D exit R7's room and tell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 2 residents (R) (R36 and R22) of 7 sampled residents. R36's vital signs were not completed on 1/27/26 prior to administering metoprolol and clonidine. R36's vital signs were not completed timely on 1/27/26, 1/22/26, 1/21/26, 1/20/26, 1/19/26, 1/18/26, and 1/17/26 prior to administering and/or holding metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine for a low pulse. R36's physician and standing orders to hold metoprolol and clonidine when R36's pulse was less than 50 were not followed on 1/22/26, 1/21/26, 1/20/26, 1/19/26, and 1/16/26. In addition, R36's metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine were not administrated timely on 1/27/26, 1/22/26, 1/21/26, 1/20/26, 1/18/26, and 1/17/26.R22's physician and standing orders were not followed when staff held lisinopril and hydrochlorothiazide on 1/27/26.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility did not ensure a stock medication was labeled and administerd in accordance with manufacturer's recommendations for 1 resident (R) (R54) and 1 staff (Registered Nurse (RN)-R). On [DATE], the medication room contained Tuberculin Purified Protein Derivative, Mantoux (an injectable solution used for skin testing to diagnose latent tuberculosis (TB) infections) which had a handwritten date of 4/25 or 4/28 on the outer package. Staff confirmed the medication should contain an open date and that once opened, the solution should be used within 30 days. The solution was used to administer TB tests for R54 and RN-R. Findings include: The Centers for Disease Prevention and Control (CDC) Mantoux Tuberculin Skin Test Facilitator Guide 2003 instructs to date the tuberculin vial when opening and discard it after 30 days. The facility's policy Medication Administration policy, with a review date of [DATE], indicates: .13. Identify expiration date. If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure the resident environment was free from abuse for 5 residents (R) (R3, R5, R6, R10, and R11) of 10 sampled residents. R3, R5, R6, R10, and R11 reported to staff on multiple occasions that Certified Nursing Assistant (CNA)-D was rough with cares and they did not want CNA-D to provide care or enter their rooms. The facility did not implement measures to ensure R3, R5, R6, R10, R11 and other residents were free from abuse. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/1/25, indicates: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse .V. Investigation of Alleged Abuse: A. An immediate investigation is warranted when suspicion of abuse .or reports of abuse occur .VI. Protection of Resident: The facility will make efforts to ensure all residents are protected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff, resident, and resident representative interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 5 residents (R) (R3, R5, R6, R10, and R11) of 10 sampled residents. R3, R5, R6, R10, and R11 reported to staff that Certified Nursing Assistant (CNA)-D was rough with cares. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/1/25, indicates: Reporting/Response: Report 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 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 than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff, resident, and resident representative interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 6 residents (R3, R1, R5, R6, R10, and R11) of 10 sampled residents. R3 reported an allegation of abuse to Nursing Home Administrator (NHA)-A regarding Certified Nursing Assistant (CNA)-D. The facility did not thoroughly investigate the allegation of abuse. R1's Power of Attorney for Healthcare (POAHC) reported allegations of abuse to the local police department. The facility did not thoroughly investigate the allegations of abuse. R5 and R5's family reported that CNA-D was rough with cares and R5 did not want CNA-D to provide care or enter R5's room. The facility did not thoroughly investigate the allegation of abuse. R6 reported that CNA-D was rough with cares and did not want CNA-D to touch R6. The facility did not thoroughly investigate the allegation of abuse. R10 reported that CNA-D was aggressive with cares and pushed a urinal into R10'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 staff interview and record review, the facility did not ensure notifications were completed in a timely manner following a fall with injury for 1 resident (R) (R1) of 7 sampled residents. R1 incurred a head injury during a Hoyer lift transfer on 11/14/24 when the lift tipped over on R1 and a metal bar struck R1 in the forehead. The facility did not notify R1's Hospice agency until 11/19/24 or R1's physician until 11/21/24. Findings include: The facility's Incidents and Accidents policy, dated 12/29/22, indicates: .5. The following incidents/accidents require an incident/accident report but are not limited to: .equipment malfunction, observed accidents/incidents, resident injuries due to staff handling .9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies) .12. Documentation should include the date,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 3 sampled residents. R1 was transferred from bed to Broda chair via Hoyer lift on 11/14/24. Staff did not ensure R1's catheter bag was disconnected from the bed prior to the transfer which created resistance and caused the Hoyer lift to fall and strike R1 in the head. R1 exhibited signs and symptoms of a head injury but was not offered the opportunity to seek medical evaluation at the hospital. Findings include: The facility's Accidents and Supervision policy, revised 12/29/22, indicates: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident .3. Implementation of Interventions: Use specific interventions to try to reduce 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, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R4) of 4 sampled residents. R4 had an indwelling Foley catheter. Enhanced Barrier Precautions (EBP) were not initiated for R4. In addition, R4's uncovered catheter drainage bag was in contact with the floor during provision of cares on [DATE]. Findings include: The facility's undated Enhanced Barrier Precautions (EBP) policy indicates an order for EBP will be obtained for residents with any of the following: .indwelling medical devices such as urinary catheters. Implementation of EBP will include making gowns and gloves available immediately outside the resident's room. Personal protective equipment (PPE) will be worn during high-contact resident care activities, such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, etc.…

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

Based on observation, staff interview, and record review, the facility did not ensure food was prepared in a sanitary manner. This practice had the potential to affect all 34 residents residing in the facility. Staff did not perform proper hand hygiene while plating food. Staff did not wear a beard net that covered all facial hair while plating food. Staff did not check the water temperature of the sanitizing solution prior to testing the parts per million (ppm). Findings include: On 9/2/24 at 8:24 AM, Surveyor began an initial tour of the kitchen with [NAME] (CK)-E who stated the facility followed the Federal Food Code. Hand Hygiene: The 2022 Food and Drug Administration (FDA) Food Code documents at 3-304.15 Gloves Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The facility's Handwashing policy, with a review date of 3/14/24, indicates: 1. When to wash hands: a. When entering…

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

Based on observation, staff interview, and record review, the facility did not ensure diet orders and menus were followed to ensure nutritional needs were met for 13 residents (R) (R30, R16, R1, R11, R12, R20, R24, R2, R10, R4, R6, R5, and R7) of 13 residents. During the 9/3/24 lunch meal, the facility served full serving desserts and did not offer diet desserts or ¼ size servings for R30, R16, R1, R11, R12, R20, R24, R2, R10, R4, R6, R5, and R7 who were ordered carbohydrate-controlled diets. During the 9/3/24 lunch meal, the facility did not ensure all menu items were served to residents. Findings include: The facility's Therapeutic Diet Orders document, dated 4/9/24, indicates: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the Interdisciplinary Team (IDT) to support the resident's treatment/plan of care, in accordance with his/her goals and preferences .therapeutic diet is a diet ordered by a physician, or delegated registered or licensed dietician, as part 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 staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R26) of 16 sampled residents. R26 was under guardianship. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R26's nursing home stay exceeded 60 days. Findings include: From 9/3/24 to 9/5/24, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. R26's Minimum Data Set (MDS) assessment, dated 8/17/24, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R26 had severely impaired cognition. R26 had a guardianship that was activated on 1/24/22. R26's medical record did not contain protective placement paperwork. On 9/4/24 at 8:55 AM, Surveyor interviewed Social Worker (SW)-H who confirmed R26 had a guardian but did not have protective placement in the facility. SW-H indicated a law firm completed R26'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 staff, resident, and family interview and record review, the facility did not provide the necessary care and services to prevent and/or promote healing of pressure injuries for 1 resident (R) (R5) of 4 sampled residents. R5's plan of care indicated R5 had left buttock and right sacral moisture-associated skin damage (MASD) and contained an intervention to turn/reposition R5 every 2-3 hours. The intervention was not consistently implemented. Findings include: The facility's Turning and Repositioning policy, with an implementation date of 6/25/24, indicates: All residents at risk of or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed. Turning and repositioning is a primary responsibility of nursing assistants; however, all nursing staff are expected to assist with turning and repositioning. From 9/3/24 to 9/5/24, Surveyor reviewed R5's medical record. R5 was admitted 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 observation, staff interview and record review, the facility did not ensure a cervical collar was implemented per the physician's order for 1 resident (R) (R32) of 1 sampled resident. R32 was admitted to the facility following a neck fracture. During an observation on 9/3/24, R32's cervical collar (neck brace) was on R32's bed. R32 indicated the collar should be on. R32's plan of care did not indicate when R32 should wear the collar or if the collar could be removed. Findings include: From 9/3/24 to 9/5/24, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with a diagnosis of unspecified displaced fracture of second cervical vertebra (fracture in upper neck). R32's Minimum Data Set (MDS) assessment, dated 7/27/24, stated R32's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R32 had intact cognition. R32's medical record indicated R32 was responsible for R32's healthcare decisions. On 9/3/24 at 10:10 AM, Surveyor entered R32's room. R32…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide necessary treatment and services related to nutrition for 2 residents (R) (R17 and R13) of 3 sampled residents. R13 was at risk for weight loss and R13's dentures were missing. R13's diet was not altered until the R13's dentures were found. Registered Dietitian (RD)-J was not contacted per the physician's request to review R17's tube feeding when a new medication was started. Findings include: 1. From 9/3/24 to 9/5/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had a diagnosis of moderate protein calorie malnutrition. R13's Minimum Data Set (MDS) assessment, dated 8/3/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R13 had intact cognition. R13's medical record indicated the following: ~ A mini-nutritional assessment, dated 7/29/24, indicated R13 was malnourished. ~ R13's plan of care indicated R13 had altered nutrition, a history of chewing problems,…

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

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection during the provision of care for 2 residents (R) (R12 and R29) of 2 sampled residents. On 9/4/24, staff did not complete proper hand hygiene during medication pass for R12 and R29. Findings include: The facility's Hand Hygiene policy, dated 12/23/24, indicates: 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 .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. The hand hygiene table attached to the policy indicates staff should perform hand hygiene before preparing or handling medication. On 9/4/24 at 8:20 AM, Surveyor observed Registered Nurse (RN)-F prepare medication for R12. After medication preparation, RN-F did not perform hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a vaccination was offered for 1 resident (R) (R10) of 5 sampled residents. R10 was not offered the PCV20 vaccination in accordance with Centers for Disease Control and Prevention (CDC) guidelines and the facility's policy. Findings include: The facility's Pneumococcal Vaccine (Series) policy, with an implementation date of 6/2023, indicates: It is our policy to offer residents .immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders .7. A pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations: For adults 65 years or older who have received PCV13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a potential allegation of misappropriation was reported timely to the State Agency for 1 Resident (R) (R5) of 5 residents reviewed. R5 notified staff that R5's checkbook was missing. Staff did not report R5's missing checkbook to administration who in turn did not report the potential allegation of misappropriation to the State Agency. Findings include: The facility's Abuse, Neglect, and Exploitation policy, with a copyright of 2023, indicated: Reporting/Response: 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: b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R5 was admitted to the facility on [DATE]. R5's most recent Minimum Data Set (MDS) assessment, dated 10/30/23, contained a Brief Interview for Mental…

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

4. On 7/31/23, Surveyor reviewed R20's medical record. R20's medical record did not contain a written notification of transfer for a hospital transfer on 5/18/23. Based on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 6 Residents (R) (R23, R32, R47, R20, R15, and R39) of 6 residents reviewed for hospitalization. R23 was not provided a written transfer notice when R23 was transferred to the hospital on 6/5/23, 7/12/23, and 7/26/23. R32 was not provided a written transfer notice when R32 was transferred to the hospital on 7/10/23. R47 was not provided a written transfer notice when R47 was transferred to the hospital on 6/27/23. R20 was not provided a written transfer notice when R20 was transferred to the hospital on 5/18/23. R15 was not provided a written transfer notice when R15 was transferred to the hospital on 5/23/23 and 5/26/23. R39 was not provided a written transfer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility did not ensure the accurate and safe administration of pharmaceuticals for 5 Residents (R) (R34, R27, R18, R40, and R5) of 5 sampled residents and with the potential to affect all 22 residents residing on the 100 wing. On [DATE], Surveyor intervened before R34 was administered an inaccurate and expired dose of docusate sodium (used to promote bowel movements). On [DATE], R27 was administered an inaccurate and expired dose of docusate sodium. On [DATE], R18 was administered an inaccurate and expired dose of docusate sodium. R40 was administered outdated Artificial Tears (used to treat dry eyes) eye drops from [DATE] through [DATE]. In addition, on [DATE], R40 self-administered six oral medications. The facility did not assess R40 for safe self-administration of medication and did not obtain a physician's order for R40 to self-administer medication. On [DATE], Surveyor observed medications left at R5's bedside. R5 did not have 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 staff interview and record review, the facility did not ensure a physician was notified timely of a change in condition for 1 Resident (R47) of 7 residents reviewed for hospitalization. R47's physician was not notified when there was blood in R47's urine. Findings include: The facility's Notification of Changes policy, copyright 2022, indicated: 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 requiring notification. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in heath, mental or psychosocial status. This may include: b. Clinical complications. R47 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, dementia, and urge incontinence. Between 8/1/23 and 8/2/23, Surveyor reviewed R47's medical record which indicated R47 had an indwelling catheter. A progress note, 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 staff interview and record review, the facility did not document, investigate, and/or record resolution of a grievance for 1 Resident (R) (R198) of 17 residents reviewed for grievances. The facility did not document and investigate a grievance expressed by R198. Findings include: The facility's Resident and Family Grievances policy, copyright 2023, indicated: 10. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. i. Take immediate actions needed to prevent further potential violations of any resident right. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. R198 was admitted to the facility on [DATE] with diagnoses that included stage 4 pancreatic cancer. R198 was admitted to hospice services on 3/17/23. R198 was R198's own person. Between 7/31/23…

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 staff interview and record review, the facility did not implement their abuse policy in regard to screening 3 of 8 employees reviewed for background checks. An out of state background check was not completed for Driver (DR)-F who resided in another state within 3 years of hire. Hospitality Aide (HA)-H's Background Information Disclosure (BID) form was not dated. Certified Nursing Assistant (CNA)-G's background check was not completed within the last four years. Findings include: The facility's Abuse, Neglect and Exploitation policy indicated: 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 .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, contracted temporary 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 observation, staff interview and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 4 errors occurred during 29 opportunities which resulted in a 13.79% medication error rate affecting 2 Residents (R) (R34 and R40) of 3 residents observed during medication pass. On [DATE], Surveyor intervened before R34 was administered an inaccurate and expired dose of docusate sodium (used to promote bowel movements). In addition, on [DATE], R34 was not administered a scheduled dose of Coenzyme Q10 (used to promote heart health in certain patients). On [DATE], Surveyor intervened before R40 was administered an expired dose of Artificial Tears (used to treat dry eyes) eye drops. In addition, on [DATE], R40 was not administered a scheduled dose of cyclosporine emulsion (used to treat dry eyes caused by inflammation). Findings include: The facility's Medication Administration policy, dated 06/2023, indicated: Medications 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 staff interview and record review, the facility did not ensure coordination of hospice services for 1 Resident (R) (R198) of 2 residents reviewed for hospice services. The facility did not receive hospice notes or a hospice care plan for R198 which resulted in R198's medications not being adjusted per hospice's request. Findings include: A contract between the facility and Hospice Company (HC)-L indicated: Hospice plan of care definition: written care plan established, maintained, and reviewed and modified, at intervals identified by the Hospice interdisciplinary team in coordination with Facility and each Hospice patient's attending physician. The Hospice plan of care will reflect (iv) drugs and treatment necessary to meet the needs of the Hospice Patient. Responsibilities of Facility: Provision of services: Facility Services: .Facility shall comply with each Hospice Patient's Hospice plan of Care .Coordination of Care: Hospice and Facility shall communicate with one another regularly and as needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility did not ensure staff performed proper hand hygiene for 1 Resident (R) (R34) of 7 residents observed during the provision of care. During an observation of care for R34 on 8/1/23, Registered Nurse (RN)-M did not consistently perform appropriate hand hygiene. Findings include: The facility's Hand Hygiene policy, dated 06/2023, indicated: 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 .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .The attached Hand Hygiene Table indicated either Soap and Water or Alcohol Based Hand Rub (ABHR), with ABHR…

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.