Samaritan Nursing and Rehab

Based on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 2 residents (R) (R59 and R6) of 8 sampled residents.R59's medical record indicated R59 had urinary tract infections (UTIs) in April and May 2026 and was treated with antibiotic therapy. R59's UTIs were not included on the facility's infection surveillance line list, including criteria for antibiotic therapy. R6's medical record indicated R6 was started on antibiotic therapy for a UTI in May 2026 without completed criteria that indicated R6 had a UTI.Findings include: The facility's Infection Prevention and Control Program, revised 3/26, indicates: This facility maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection .The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room…

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 influenza and pneumococcal vaccines were administered for 1 resident (R) (R10) of 5 sampled residents.R10 signed consent for influenza and pneumococcal vaccines on 2/24/26. R10 did not receive the vaccines.Findings include:The facility's Influenza Vaccination policy, revised 1/19/26, indicates: Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refused to receive the vaccine .Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record or the staff's medical file.The facility's Pneumococcal Vaccine policy, revised 1/2026, indicates: Each resident will be offered a pneumococcal immunization .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 screen, educate, or offer the COVID-19 vaccination to 3 residents (R) (R10, R59, and R7) of 5 sampled residents.R10's COVID-19 vaccination form signed on 6/13/25 was incomplete. The form did not indicate whether R10 consented to or declined the vaccination. R10's medical record did not indicate whether or not a COVID-19 vaccine was provided.R59's medical record did not indicate R59 was offered or declined a COVID-19 vaccination since admission on [DATE].R7's medical record did not indicate R7 was offered or declined a COVID-19 vaccination since admission on [DATE].Findings include:The facility's Infection Prevention and Control Program, revised 3/2026, indicates: Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. The resident's medical record includes documentation that indicates, at a minimum, the following: i. The resident or resident representative was provided education regarding 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 staff interview and record review, the facility did not have a qualified Social Worker. This practice has the potential to affect all 75 residents residing in the facility. Social Services Designee (SSD)-G did not meet the necessaray requirements for a qualified Social Worker in a facility licensed for 131 beds. Findings include: On 4/1/26 at 1:25 PM, Surveyor interviewed SSD-G who started working at the facility in June of 2025 and confirmed SSD-G was the facility's Social Services Designee. SSD-G verified SSD-G was not certified or licensed as a Social Worker and did not have a degree in a related field. SSD-G stated SSD-G had previous experience working in another facility where a Social Worker worked with SSD-G. On 4/1/26 at 1:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the facility has 131 licensed beds. NHA-A confirmed SSD-G is not a licensed or certified Social Worker. NHA-A was aware a facility with more than 120 beds requires a full-time qualified Social Worker.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 6 residents (R) (R6, R1, R10, R9, R7, and R8) of 9 sampled residents. On 2/15/26, Certified Nursing Assistant (CNA)-J observed R6 touching R1's breast. The facility did not report the allegation of abuse to the SA. On 2/11/26, CNA-N observed R10 touching R9's pubic area and thigh. The facility did not report the allegation of abuse to the SA. On 9/14/25, staff observed R1 and R7 in a verbal dispute. R1 stated R1 hit R7 and showed staff R1's reddened left palm. The facility did not report the allegation of abuse to the SA.On 12/23/25, staff observed R8 punch R1 in the arm after R1 grabbed R8's walker. The facility did not report the allegation of abuse to the SA. On 3/6/26, R1 struck and threw a glass of orange juice at R9. The facility did not report the allegation of abuse to the SA. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 1/5/24,…

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 and record review, the facility did not ensure allegations of abuse were thoroughly and accurately investigated for 6 residents (R) (R6, R1, R9, R10, R7, and R8) of 9 sampled residents. On 2/15/26, Certified Nursing Assistant (CNA)-J observed R6 touching R1's breast. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated. In addition, the facility did not ensure ongoing behavior monitoring was thoroughly completed. On 2/11/26, CNA-N observed R10 touching R9's pubic area and thigh. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated. In addition, the facility did not ensure ongoing behavior monitoring was thoroughly completed. On 9/14/25, staff observed R1 and R7 in a verbal dispute. R1 told staff R1 hit R7 and showed staff R1's reddened palm. The facility did not ensure the allegation of abuse was thoroughly investigated or ensure safety interventions to prevent recurrence were appropriate. 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.

Based on staff interview and record review, the facility did not implement policies and procedures for 1 of 8 sampled staff to prevent abuse, neglect, misappropriation, and exploitation of residents. The facility did not ensure a thorough background check was completed for Licensed Practical Nurse (LPN)-H. Findings include: The facility's Abuse, Neglect, and Exploitation policy, dated 1/5/24, indicates: .The components of the facility's abuse prohibition plan are discussed herein: 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, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement .3. The facility will maintain…

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 bathing/showering assistance was provided for 2 residents (R) (R5 and R2) of 5 sampled residents. R5 and R2 did not receive weekly baths/showers as scheduled.Findings includeThe facility's Activities of Daily Living (ADLs) policy, dated 5/7/20, indicates: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Hygiene: Bathing .1. On 3/30/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including fracture of right lower leg, morbid obesity, and type 2 diabetes. R5's Minimum Data Set (MDS) assessment, dated 3/20/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. On 3/30/26 at 11:00 AM, Surveyor interviewed R5 who indicated the facility does not always complete showers on R5's scheduled day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure physician orders were followed and treatment was not provided without an order for 1 resident (R) (R4) of 3 sampled residents.R4 had an order for bilateral Tubigrips (elasticized tubular bandages designed to provide firm, sustatined support for general edema). The order was not consistently followed. In addition, R4 had a Kerlix (woven gauze) wrap dressing around R4's lower left leg. R4 did not have an order for the dressing.Findings include:The facility's policy Wound Care Prevention and Program Management policy, dated 11/13/24, indicates: .1. Interventions will be implemented to mitigate the risk for skin breakdown, based on individual risk factors .On 3/30/26,, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes with diabetic chronic kidney disease, congestive heart failure (CHF), venous infusion, polyneuropathy, morbid obesity, peripheral…

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 adequate supervision and assistance to prevent accidents was provided for 1 resident (R) (R6) of 2 sampled residents. R6 had a history of inappropriately touching residents and staff. The facility did not implement an appropriate intervention to prevent recurrence. On 4/13/26, staff placed R6 within reach of R13. R6 touched and grabbed R13. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 4/2026, indicates: .The facility will develop and implement written policies and procedure that: a. Prohibit and prevent abuse, neglect, and exploitation of residents .3. The facility will provide ongoing oversight and supervision of staff in order to assure its policies are implemented as written .Employee Training: .5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect .Prevention of Abuse, Neglect and Exploitation: .A. Establishing a safe environment that supports, 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 it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 29 opportunities which resulted in a 6.8% medication error rate that affected 2 residents (R) (R11 and R12) of 4 residents observed during medication pass. R11 and R12 did not receive medications as ordered because the medications were not reordered or available. Findings include: The facility's Administering Medications policy, revised 5/2025, indicates: Medications shall be administered in a safe and timely manner and as prescribed .3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 1. On 3/30/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had a diagnosis 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 it was free from a significant medication error for 1 resident (R) (R3) of 6 sampled residents.R3 was admitted to the facility on [DATE] and had an order for vancomycin HCl intravenous (IV) 1250 milligrams (mg) twice daily for a right knee infection. R3 did not receive the antibiotic as ordered on 2/13/26, 2/20/26, 2/23/26, and 3/9/26. Findings include:The facility's Administering Medications policy, revised 5/2025, indicates: Medications must be administered in accordance with the orders, including any required time frame .if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the reason for it.On 3/30/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] post knee replacement with an infected joint and had diagnoses including hemiplegia, history of stroke, epilepsy, and chronic pain. R3's Minimum Data Set (MDS) assessment,…

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 prescribed diet was provided for 1 resident (R) (R4) of 2 sampled residents. R4 had an order for a consistent carbohydrate (CCHO) diet. R4 was not provided with the designated CCHO diet dessert.Findings include: On 3/30/26, Surveyor requested the facility's policy related to residents receiving prescribed diets. The facility provided an Order Entry by Dieticians policy, dated 3/12/18, that detailed the process for entering a diet order and ensuring the order is correct in the resident's electronic health record (EHR).On 3/30/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes with diabetic chronic kidney disease. A care plan, initiated 12/12/25, indicated R4 had type 2 diabetes mellitus. A care plan, initiated 11/30/25, indicated R4 had a nutritional problem or potential nutritional problem related to diet restrictions .obesity, diabetes mellitus,…

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 ensure in-service training of at least 12 hours for 2 of 5 sampled Certified Nursing Assistants (CNAs). CNA-Z was hired on 6/14/21. CNA-Z did not receive at least 12 hours of in-service training during CNA-Z's most recent anniversary hire year.CNA-AA was hired on 10/23/23. CNA-AA did not receive at least 12 hours of in-service training during CNA-AA's most recent anniversary hire year.Findings include:1. On 4/13/26, Surveyor reviewed the required education training hours for CNA-Z who was hired by the facility on 6/14/21. Surveyor noted CNA-Z had not completed the required 12 educational training hours during CNA-Z's most recent anniversary hire year.(See interview under example 2)2. On 4/13/26, Surveyor reviewed the required education training hours for CNA-AA who was hired by the facility on 10/23/23. Surveyor noted CNA-AA had not completed the required 12 educational training hours during CNA-AA's most recent anniversary hire year.On 4/13/26 at 3:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and policy review, the facility failed to ensure 2 residents (R) (R10 and R14) of 15 sampled and supplemental sampled residents received meals at a palatable temperature. R10 and R14 reported receiving cold food. A test tray on 3/10/26 revealed food items were served below the required temperatures for food service and palatability. Findings include:The facility's Safe Food Handling policy, dated 9/1/21, indicates: All foods are prepared in accordance with the Food and Drug Administration (FDA) Food Code .3. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time food items are exposed to temperatures greater than 41 degrees and/or less than 135 degrees.1. Review of R10's admission Record revealed R10 was admitted to the facility on [DATE]. R10's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/6/26, revealed R10 had a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure care and treatment was provided to prevent the development of pressure injuries and/or promote healing for 2 residents (R) (R2 and R1) of 3 sampled residents. R2 had a stage 3 pressure injury on the right lateral chest. The facility did not ensure R2's wound care order was consistently followed. R1 had a deep tissue injury (DTI) on the left hip. The facility did not ensure R1's wound care order was consistently followed.Findings include:The facility's Wound Treatment Staff Education, initiated 11/5/25, indicates treatments should be recorded in the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) at the time completed. The MAR/TAR should not contain any late or missed entries unless properly documented per policy.1. On 12/16/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis of vertebra lumbar region, wedge compression fracture 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, staff and resident interview, and record review, the facility did not ensure adequate assistive devices were in place to prevent falls for 1 resident (R) (R5) of 3 sampled residents.R5 had falls on 7/2/25, 7/7/25, 7/23/25, and 10/20/25. R5's care plan was not updated with appropriate interventions. Findings include:The facility's Falls and Fall Risk, Managing policy indicates: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Prioritizing Approaches to Managing Falls and Fall Risk: .4. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.On 11/4/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure with hypoxia, insomnia,…

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 1 resident (R) (R2) of 3 sampled residents was free of a significant medication error. R2 was prescribed an intravenous (IV) antibiotic for 28 days for a diagnosis of cellulitis of lower extremity with sepsis. The facility did not ensure R2's antibiotic and corresponding flushes were administered as ordered on multiple occasions.Findings include:The facility's Administering Medications policy, revised May 2025, indicates: Medications shall be administered .as prescribed .3. Medications must be administered in accordance with the orders, including any required time frame .20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; .g. The signature and title of the person administering the drug. On 12/16/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses…

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 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 for 2 Residents (R) (R1 and R17) of 4 sampled residents.A grievance filed on 9/2/25 by R1's Power of Attorney for Healthcare (POAHC) indicated R1's iPad was missing. The allegation of misappropriation was not reported to law enforcement or the State Agency (SA).A grievance filed on 9/24/25 by R17's POAHC indicated R17's watch was missing. The allegation of misappropriation was not reported to law enforcement or the SA. Findings includeThe facility's Abuse, Neglect and Exploitation policy and procedure, dated 1/5/24, indicates: .A. The facility will have written procedures to assist staff in identifying the different type of abuse - [NAME]/verbal, sexual abuse, physical abuse and the deprivation by an individual of goods and services. B. Possible indicators of abuse include but are not limited…

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 ensure allegations of misappropriation were thoroughly investigated for 2 Residents (R) (R1 and R17) of 4 sampled residents.R1 and R1's Power of Attorney for Healthcare (POAHC) notified the facility that R1's iPad was missing. The facility did not thoroughly investigate the allegation of misappropriation.R17's POAHC notified the facility that R17's watch was missing. The facility did not thoroughly investigate the allegation of misappropriation. Findings include:The facility's Abuse, Neglect and Exploitation policy and procedure, dated 1/5/24, indicates: V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation; 3. Investigating different types of alleged…

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, resident, and resident representative interview, and record review, the facility did not ensure 3 Residents (R) (R2, R8, and R11) of 17 sampled residents received care and treatment in accordance with physician orders. R2's edema assessments and weights were not completed as ordered to monitor for fluid retention. In addition, R2's thrombo-embolic deterrent (TED) hose and tubular support bandages (Tubigrips) were not applied as ordered. R8 and R11's Tubigrip stockings were not removed at night as ordered. Findings include:The facility's Care Plans - Comprehensive policy, dated 2010, indicates: .3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; .4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. 5. Care plan interventions 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 observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 Resident (R) (R1) of 4 sampled residents.R1 received supplemental oxygen. R1 did not have an order for oxygen or a care plan for oxygen therapy. Findings include:On 10/8/25, Surveyor requested the facility's oxygen policy and procedure from Director of Nursing (DON)-B who provided an undated Oxygen Guideline Policy Interpretation and Implementation and Fire Prevention form that addressed oxygen safety and fire prevention. DON-B indicated the facility did not have another oxygen policy. From 10/7/25 to 10/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of the bladder, secondary neoplasm of the bone, toxic encephalopathy, and osteoporosis with current pathological fractures. R1's most recent Minimum Data Set (MDS) assessment, dated 9/25/25, had a Brief Interview for Mental Status…

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 pharmaceutical services to ensure the accurate administration of medication for 1 Resident (R) (R2) of 4 sampled residents.D-Mannose (a simple sugar related to glucose considered effective for treating carbohydrate-deficient glycoprotein syndrome and can help with digestive issues, low blood sugar and blood clotting disorders), nateglinide (an oral medication used to manage type 2 diabetes), and pregabalin (an anticonvulsant medication) were not administered to R2 in accordance with physician orders. Findings include:The facility's Administering Medications policy, dated 5/2025, indicates: Medications shall be administered in a safe and timely manner and as prescribed .3. Medications must be administered in accordance with the orders, including any required time frames. 4. Medications must be administered within one hour of their prescribed time, unless otherwise specified .From 10/7/25 to 10/8/25, Surveyor reviewed R2's medical record. R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 8 residents (R) (R2, R4, R10, R9, R5, R6, R7, and R8) of 10 sampled residents.On 8/12/25, R2 was administered sevelamer. R2 did not have an order for the medication. On 7/31/25 and 8/1/25, multiple medications for R2 were administered late or not in accordance with physician orders.On 8/4/25, 8/20/25, 8/21/25, and 8/22/25, multiple medications for R4 were not administered in accordance with physician orders. In addition, R4's AM medications were not administered timely on 8/25/25.On 8/25/25, R10's ropinirole was not administered in accordance with the physician order.On 8/25/25, R9's Protonix and potassium chloride were not administered in accordance with physician orders.On 8/25/25, R5, R6, R7, and R8's AM medications were not administered timely.Findings include:The facility's Administering Medications policy, dated 5/2025,…

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 drugs and biologicals were stored in accordance with the facility's policy. This practice had the potential to affect more than 4 of the 67 residents residing in the facility.On 8/26/25. the 400 North medication cart was left unlocked and unattended.Findings include:The facility's Storage of Medications policy, dated 4/2007, indicates: .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others .On 8/26/25 at 9:23 AM, Surveyor observed agency Registered Nurse (RN)-J leave a medication cart unlocked and unattended with an open computer screen on top of the cart that displayed resident information. The medication cart drawers faced the hallway. Surveyor observed one resident self-propel in a wheelchair in the hallway.On 8/26/25 at 9:23 AM, Surveyor interviewed…

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 and resident interview, and record review, the facility did not ensure food was served at a palatable, safe, and appetizing temperature for 4 residents (R) (R1, R3, R2 and R4) of 6 sampled residents. This practice had the potential to affect more than 4 of the 67 residents residing in the facility.R1 and Anonymous Person (AP)-E (on behalf of R3) indicated hot and cold foods were not always served at palatable temperatures. R2 and R4 indicated the food was not palatable. During the lunch meal on 8/25/25, the facility served food that appeared to be burned. During the lunch meal on 8/26/25, food was not held at a palatable temperature.Findings include:The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and (C) of this section, time/temperature control for safety food shall be maintained: (1) At 57…

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 the necessary care and services to prevent pressure injuries from developing and/or promote healing for 4 residents (R) (R2, R7, R14, and R15) of 4 sampled residents. R2 had a pressure injury on the sacrum and deep tissue damage to the right heel. R2's June 2025 Treatment Administration Record (TAR) contained orders for staff to monitor R2's bilateral feet wounds, offer changes of position during the day, apply zinc cream to the sacrum, encourage R2 to wear soft boots at all times, ensure sheep skin is in place at the foot of R2's bed, and good change of position with toileting schedules. The orders were not consistently completed.R7 had a pressure injury on the sacrum. R7's June 2025 Medication Administration Record (MAR) and TAR) contained orders for staff to reposition R7 every 2 hours, encourage change of position every 1-2 hours, and apply silver sulfadiazine (wound cream) to R7's coccyx. The orders were not consistently completed. R14…

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 prevent the transmission of communicable disease and infection for 2 residents (R) (R5 and R7) of 11 residents observed during the provision of care. Staff did not ensure enhanced barrier precautions (EBP) were followed during transfers and cares for R5.Staff did not ensure EBP was followed during catheter care for R7. In addition, staff did not ensure a catheter collection bag was stored properly and a collection bag exchange was completed appropriately. Staff did not ensure medical equipment was sanitized after use and before being placed in storage.Findings includeThe facility's Enhanced Barrier Precautions (EBP) policy, dated 4/1/24, indicates: .3. Implementation of EBP: .b. Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities .4. High-contact resident care activities include: a. dressing, .c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting 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 staff interview and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R2) of 1 sampled resident. R2 was not assessed or provided pain medication during the night (NOC) shift of 3/11/25 into 3/12/25. Findings include: The facility's Pain Management Guidelines policy, dated 2/24/25, indicates: .Based on the comprehensive assessment of a resident, the facility must ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management .Strategies for the prevention and management of pain may include but are not limited to: Assessing the potential for pain, recognizing the onset, presence, and duration of pain, and assessing the characteristics of the pain .Expressions of pain may be verbal or nonverbal and are subjective . On 4/23/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 3 residents (R) (R9, R1 and R3) of 9 sampled residents. R9 had an order for Tresiba (long-acting insulin) and self-administered the medication. R9 did not have a physician order to self-administer Tresiba or a self-administration of medication assessment that indicated R9 could self-administer Tresiba. In addition, 444 units of R9's Tresiba were unaccounted for and allegedly borrowed from other residents' supplies for administration. R1's medical record indicated R1 did not receive multiple doses of medication, including controlled substances and pain medication. In addition, R1 did not receive Rosuvastatin on 4/23/25 and had to request the medication from Registered Nurse (RN)-G. R3's medical record indicated R3 did not receive an injection as ordered. Findings include: The facility's Administering Medications policy, revised 12/2024,…

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 and resident interview, and record review, the facility did not ensure food preferences were honored for 2 residents (R) (R1 and R3) of 2 sampled residents. R1 was not provided R1's preferred breakfast item of fried eggs and was told by kitchen staff that eggs were not available. R3's meal ticket indicated R3's food preference for breakfast was 3 fried eggs if available. R3 did not receive fried eggs and was told by kitchen staff that eggs were not available. Findings include: 1. On 4/23/25, Surveyor reviewed R1's medical record. R1 had diagnoses including chronic obstructive pulmonary disease (COPD), pulmonary embolus, edema, venous thrombosis and embolism, wedge compression fracture of unspecified thoracic vertebra subsequent encounter for fracture with routine healing, iron deficiency, and borderline personality disorder. R1's Minimum Data Set (MDS) assessment, dated 1/25/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was not cognitively impaired. On 4/23/25 at 5:17 AM, Surveyor interviewed R1 who indicated…

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 stored and prepared in a sanitary manner. This practice had the potential to affect all 69 residents residing in the facility. Staff did not monitor and document cooling temperatures. Staff did not consistently monitor and document food cooked temperatures Staff did not wash and sanitize dishes in the three-compartment sink per manufacturer's guidelines or the facility's policy. Findings include: Cooling Method: The facility's Previously Cooked Food Saved for Future Service policy, dated 9/1/21, indicates: All foods are prepared in accordance with the Federal Food and Drug Administration (FDA) Food Code .Previously cooked foods must be cooled to an internal temperature of 70 degrees within 2 hours from the start of the process . The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57° Celsius (C) (135° Fahrenheit) (F) to 21° C (70° F); and (2) Within a total of 6 hours from 57° C (135° F) to 5° C…

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

Based on observation, staff interview, and record review, the facility did not ensure nutritional needs were met or diet orders were followed for 5 residents (R) (R7, R26, R16, R24, and R48) of 5 sampled residents. This practice had the potential to affect multiple other residents in the facility. Residents on pureed diets did not receive the correct serving size for lunch on 1/27/25 and 1/28/25 and breakfast on 1/28/25. Residents on carb controlled (CCHO) and low concentrated sweets (LCS) diets did not receive their diets as ordered for lunch on 1/27/25 and 1/28/25 and breakfast on 1/28/25. R26's meal ticked indicated R26 should receive double portions, diet Jell-O and sugar-free cereal. R26's meal ticket was not followed during lunch on 1/27/25 and breakfast on 1/28/25. R48 had an order for ground meat when served roasts. R48 did not receive ground pork roast for lunch on 1/28/25. Residents on the fourth floor did not receive the ordered serving size of corn casserole for lunch on 1/28/25. Findings include: The facility's Therapeutic Diets policy, dated 9/1/21, indicates: All…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R48) of 2 sampled residents. R48 had a legal Guardian. The facility did not obtain court-ordered protective placement to ensure R48 resided in the least restrictive environment at the facility. Findings include: The facility did not provide a policy regarding protective placement. State Statute Chapter 55.03(4) indicates court-ordered protective placement should be obtained for any resident admitted to a nursing home who has a legal Guardian and whose nursing home stay exceeds ninety days. State Statute Chapter 55.18 indicates protective placement is reviewed annually. On 1/27/25, Surveyor reviewed R48's medical record. R48 had a legal Guardian when R48 was admitted to the facility on [DATE]. R48 had court-ordered Guardianship, dated 2006, with a successor Guardian appointed on 9/26/23. R48's medical record did not contain protective placement documentation. On 1/27/25,…

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 and resident representative interview and record review, the facility did not ensure 3 residents (R) (R13, R15, and R168) of 3 sampled residents received a copy of the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form or were provided a Notice of Medicare Non-Coverage (NOMNC) form in a timely manner. The facility did not provide R13 and R15 with an ABN form or a timely NOMNC form when R13 and R15's Medicare services ended and R13 and R15 remained in the facility. The facility did not provide R168 with a timely NOMNC form when R168's Medicare services ended on 11/18/24. Findings include: The facility did not provide a policy regarding Medicare coverage/liability notices. The Centers for Medicare & Medicaid Services (CMS)-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicates: The ABN provides information to the beneficiary so the beneficiary can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .The ABN is only issued if the beneficiary intends 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 provide privacy during showers for 1 resident (R) (R7) of 1 sampled resident. R7 indicated staff interrupted R7 and entered the shower room during R7's showers. R7 filed a grievance with the facility on 1/23/25. Staff created a sign for R7 to use while R7 showered, however, staff were not educated about the sign and interrupted R7 again on 1/27/25. Findings include: On 1/27/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including chronic heart failure, chronic obstructive pulmonary disease (COPD), and pulmonary embolus. R7's Minimum Data Set (MDS) assessment, dated 7/25/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cognition. R7's medical record indicated R7 was responsible for R7's healthcare decisions. On 1/27/25 at 10:45 AM, Surveyor interviewed R7 who indicated a male Certified Nursing Assistant (CNA) enters the shower…

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 provision of safe and comfortable water temperatures for 2 residents (R) (R7 and R16) of 23 sampled residents. R7 reported to staff that R7 did not have warm water while showering on multiple occasions. R16 reported that staff gave R16 a bath with cool water. Findings include: 1. On 1/27/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD) and pulmonary embolus. R7's Minimum Data Set (MDS) assessment, dated 7/25/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cognition. R7's medical record indicated R7 was responsible for R7's healthcare decisions. On 1/27/25 at 11:46 AM, Surveyor interviewed R7 who indicated there was often no hot water from 7:00 AM to 7:00 PM in the fourth floor shower room. R7 was informed hot water was an issue because the laundry and kitchen used…

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 family interview and record review, the facility did not make a prompt effort to resolve a grievance for 1 resident (R) (R25) of 2 sampled residents. R25 had a lab culture obtained on 1/2/25. On 1/3/25, 1/4/25, 1/5/25, and 1/6/25, R25's Family Member ((FM)-N) called the facility for the culture results but staff were unable to provide the results. FM-N filed a grievance with the facility on 1/6/25. At a care conference for R25, FM-N was notified the grievance was resolved, however, the facility did not provide an explanation of what happened or the resolution. Findings include: The facility's Grievance Guideline policy, dated 4/23/18, indicates: The facility will ensure prompt resolution (within five calendar days) to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process .G. Response: Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure treatment and services were provided to prevent the development of pressure injuries and/or promote healing for 1 resident (R) (R44) of 4 sampled residents. R44 had impaired skin integrity and multiple wounds, including a chronic ulcer of the buttocks. R44's pressure-relieving air mattress was not correctly set to R44's body weight. In addition, R44's care plan did not contain an individualized setting for the mattress. Findings include: The facility's Wound Care Prevention and Program Management policy, dated 11/13/24, indicates: Interventions will be implemented to mitigate the risk for skin breakdown, based on individual risk factors, and may include, but are not limited to: a. The use of pressure redistribution device such as mattresses .Interventions should be documented in the resident's electronic medical record, including in the resident's individualized resident-centered plan of care .Residents with risk…

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 2 residents (R) (R15 and R368) of 3 sampled residents received the appropriate care and services to prevent urinary tract infections (UTI). R15's uncovered catheter bag was observed on the floor underneath R15's wheelchair on multiple occasions. R368 was on enhanced barrier precautions (EBP). R368's uncovered catheter bag was observed on the floor underneath R368's bed. Findings include: The facility's Catheter Care, Urinary Policy, dated 9/2014, indicates: The purpose of this procedure is to prevent catheter-associated urinary tract infections .1. Use standard precautions when handling or manipulating the drainage system. b. Be sure the catheter tubing and drainage bag are kept off the floor. 1. From 1/27/25 to 1/29/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including cerebral palsy, epilepsy, mutism, obstructive uropathy, and multidrug-resistant organism (MDRO).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure accurate administration of drugs and biologicals for 3 residents (R) (R7, R114, and R15) of 8 sampled residents. R7 did not receive eight doses of scheduled medication because the medication was not available. R114 did not receive a scheduled medication because the medication was not available. Licensed Practical Nurse (LPN)-U dispensed an expired medication for R15 and did not dispose of the medication according to the facility's policy. Findings include: The facility's Administering Medications policy, dated 12/2024, indicates: Medications shall be administered in a safe and timely manner, and as prescribed .3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one hour of their prescribed time, unless otherwise specified .9. The expiration/beyond-use date on the medication label must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure prompt laboratory services for 1 resident (R) (R25) of 1 sampled resident. R25 had an order for a wound culture on 1/2/25. R25's wound culture was obtained on 1/2/25 and again on 1/5/25. Due to a delay in submitting the culture sample timely, R25 did not start antibiotic therapy until 1/8/25. Findings include: The facility's Cultures, Specimen Collection policy, dated October 2011, indicates: Correct collection and handling of culture specimens helps ensure more accurate and timely results and subsequent treatment .1. Labeling of specimen must include: a. resident name .d. Date and time specimen collected .5. Label the specimen correctly and send it to the laboratory .Special Considerations: .3. Document the time, date, and site of specimen collection. Note any unusual appearance or odor of the specimen . On 1/27/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including T12 compression…

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 resident and staff interview and record review, the facility did not provide pharmaceutical services to meet the needs of 1 resident (R) (R1) of 6 sampled residents. R1 was admitted to the facility on [DATE] and had an order for Vyvanse. The facility did not provide R1 with prescribed medication from 11/9/24 through 11/11/24. Findings include: The facility's admission Criteria Policy, dated October 2012, states the facility will admit only those residents whose medical and nursing care needs can be met .1. The objectives of the policy are to: .b. Admit residents who can be cared for adequately by the facility; .e. Assure the facility receives appropriate medical and financial records prior to or upon a resident's admission .2. Prior to or at the time of admission, a resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: b. Medication orders. On 12/5/24, Surveyor reviewed R1's medical record. R1 was…

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

Based on observation, staff interview, and record review, the facility did not ensure nutritional needs were met for 1 resident (R) (R3) of 1 resident who had an order for double entree portions at all meals. R3's diet order included double entrees at all meals for wound healing. R3 did not receive a double entree during the lunch meal on 12/5/24. Findings include: The facility's Therapeutic Diets policy, revised November 2015, indicates: Therapeutic diets shall be prescribed by the attending physician. The facility will strive for the fewest possible dietary restrictions .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnoses alone will not determine whether the resident is prescribed a therapeutic diet .A therapeutic diet must be prescribed by the resident's attending physician. The physician's diet order should match the terminology used by food services .The clinical dietitian, nursing staff, and attending physician will review, along with other orders, the need for and resident's acceptance of a prescribed…

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

Based on observation and interview the facility did not ensure that food was stored, prepared and served under sanitary conditions. Staff were observed touching ready to eat food after touching non-sanitized food surfaces with no barrier or handwashing. This deficient practice had the potential to affect 42 of 43 residents served food from these kitchenettes. On 10/31/23, Dietary Aide-S was observed touching ready to eat food (cupcakes) with a bare hand after touching non-sanitized food surfaces (counter and steam table lid covers) and place the food item onto trays for residents to eat. Findings include: The facility policy, entitled Bare Hand Contact with Food and Use of Plastic Gloves, from Policy and Procedure Manual, 2013 [Name of Company], states, Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hand to the food product being served. Bare hand contact with food is prohibited. #2. Staff use clean barriers such as single-use gloves, tongs, deli paper and spatulas to prevent food borne…

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 establish and maintain a comprehensive Water Management Plan (WMP), to reduce the growth and spread of Legionella, which has the potential to affect 43 of the 43 residents residing in the facility at the time of the survey. The facility's Water Management Plan (WMP) did not address components of a complete water management plan to include; the names, titles, contact information and roles of the water management program team, the buildings water systems, identification of external hazards and plans for mitigating or managing these events, identifying areas where biofilms may be present and where pathogens may grow and spread in the plumbing systems, conduct an infection control risk assessment, identify control point locations and determine how control measures will be applied using both the environment assessment and the infection control assessment. The facility's WMP did not address control limits for control measures that will be monitored (water temperature, etc.), outbreak and contingency response plans, verification the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review the facility did not ensure incidents of potential abuse were investigated thoroughly for 1 (R10) of 2 residents reviewed for potential abuse. *R10 was discovered with a large bruise. The facility completed an investigation and reported the incident to the state agency; however, the facility's investigation did not include resident interviews or like resident assessments to identify the scope of the allegation. Findings include: The facility policy entitled, Abuse Prevention Policy, revised on 2/12/2021, documented, Objective: To protect and maintain each resident/tenant's right to be treated with courtesy, respect, and recognition of one's dignity and individuality by all employees of the facility .1) Reporting and Investigation .Investigations may include: resident statements . R10 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not ensure that residents received care and treatment in accordance with professional standards of practice for 1 (R342) of 12 residents reviewed for Quality of Care. R342's admission orders, which included insulin and blood sugar monitoring, were not correctly transcribed onto the Medication Administration Record (MAR). R342 sustained a fall related to a hypoglycemic (low blood sugar) episode. Findings include: R342 admitted to the facility on [DATE] for respite care. Diagnoses included: Alzheimer's disease, liver cell carcinoma, hypertension, Type 2 Diabetes Mellitus, major depressive disorder, anxiety disorder, cervical disc degeneration and obstructive sleep apnea. The facility policy and procedure titled Administering Medications dated revised 11/3/21 documents (in part) . Objective: To ensure that medications are administered in a safe and timely manner, as prescribed. 3) Medications must be administered in accordance with the orders, including any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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, prevent infection and prevent new ulcers from developing for 1 (R38) of 3 residents reviewed for pressure injuries. R38 was admitted to the facility with an identified pressure injury to the sacrum. The wound was not comprehensively assessed and was staged incorrectly. In addition, treatment for the pressure injury was not implemented upon admission. Findings include: The facility policy and procedure titled Wound Care, revised 10/27/23 documents (in part) . It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Ulcer Advisory Panel (NPUAP). 4) Wound documentation guidelines. a) Document size measurements in centimeters b) Document any undermining/tunneling/sinus tracts c) Describe any exudates -…

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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 (R1) of 2 residents reviewed for weight loss. R1 had daily weights ordered which were not consistently completed. R1 sustained weight loss over 9 days of 8.6 pounds (6.06%). Neither the Physician or Dietician were notified of R1's weight loss. Findings include: R1 admitted to the facility on [DATE] with diagnoses that include Covid-19, Type 2 Diabetes Mellitus, Gastroesophageal Reflux Disease, Heart Failure and Anemia. The facility policy and procedure titled Resident Weights and Nutrition dated 1/14/21 documents (in part) . [Facility name] will provide a program to assist residents in maintaining acceptable parameters of nutritional status such as body weight, unless his/her clinical…

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.