Ansted Center

Based on resident interview and staff interview the facility failed to provide reasonable accommodations of needs for Resident #39. This was found true for one (1) of 29 residents reviewed. Resident identifier: #39. Facility census: 59. Findings included:a) Resident #39. During an interview with Resident #39 on 03/27/26 at 10:45 AM, the resident reported that his reclining chair, in which he slept, did not function properly. Observation and interview revealed the leg/foot rest of the recliner did not deploy. The resident stated he elevates his legs in a wheelchair at night due to the malfunctioning recliner.This concern was brought to the attention of the Director of Nursing (DON). Documentation provided by the on 03/23/26 at 3:55 PM. DON confirmed that a new reclining chair was ordered for the resident following surveyor intervention.

Based on record review and staff interview the facility failed to ensure two (2) of two (2) residents were provided quarterly statements. Resident identifiers: #41, and #24. Facility census: 59.Findings included: a) Resident #41 On 03/23/26 at 2:00 PM during an interview with Resident #41 and the resident's daughter they mentioned they had not received a quarterly statement to show the amount in the resident's account. During an interview with Business Office Advisor (BOA) #82 on 03/25/26 at 11:00 AM the BOA said the former business office manager had left the job and she did not think she could verify the quarterly statements had been provided. On 03/26/26 at 1:00 PM a letter dated 07/23/25 was provided to the surveyor by Admissions Director (AD) #52. The letter verified that a quarterly statement was provided for the quarter ending June 2025. No additional statements could be provided. b) Resident #24 During an interview with Resident #24 on 03/23/26 at 11:15 AM the resident stated she had not received a quarterly statement to show the amount of money in her account. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and staff interview, the facility failed to ensure a new Pre admission Screening and Resident Review (PASARR) was completed when three (3) of seven (7) residents developed a new mental disorder. Resident identifiers: #7, #22, #53. Facility census: 59.Findings included: a) Resident #53 The most recent PASARR was completed at an acute care facility on 12/17/24. Under Section III, Question 30, Current Diagnosis (Check all that apply). (a) none was checked, and (n) Other related conditions (Specify below) bipolar disorder was typed in. Question 37 is Diagnosis - Other medical conditions requiring services. Included in the typed list are altered mental status, visual hallucinations, bipolar illness, Dementia with behavioral problem. Question 47: The individual has a primary diagnosis of: Dementia was checked. Resident #53 was admiitted to the facility on [DATE]. The resident does not have capacity to make own medical decisions. The resident had the following diagnoses related to 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.

Based on observation, staff interview, resident interview and record review, the facility failed to ensure oxygen therapy was provided at the correct setting per the physician's order and the resident's care plan. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #37. Facility Census: 59. Findings include: a) Resident #37On 03/23/2026, during the initial interview process, Resident #37's oxygen concentrator setting was on two (2) liters. The resident reported she was on four (4) liters of oxygen. Resident #37 reported difficulty breathing. At 11:27 AM, Corporate Registered Nurse #81 reported the oxygen concentrator was set between two (2) and three (3) liters. Corporate Registered Nurse #81 reported the resident's order stated three (3) liters, confirmed the oxygen setting was between two (2) to three (3) liters, and stated they were giving the unit to maintenance to fix. At 11:27 AM, Unit Manager #10 reported the concentrator would not go above two and a half liters so they were replacing it and giving the unit to maintenance 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, record review and staff interview the facility failed to follow the Bed Safety Evaluation and Bed Safety Evaluation Follow-up for bed rails in order to avoid risks including entrapment due to the use of bed rails. This was true for one (1) of two (2) assessments for bed rails. Resident Identifier: #44. Facility Census: #59a) Resident #44 On 03/23/26 at 3:11 PM, Resident #44 was observed with bilateral bed rails in use. A subsequent review of the bed safety evaluation dated 01/25/26 indicated that bed rails should not be used for this resident. According to the evaluation's Step 2 guidance, if a No was recorded for any of the eight mobility questions, staff were instructed to attempt alternatives. The assessment dated [DATE] recorded No for all seven mobility questions. The Bed Safety Evaluation Follow-up dated 01/26/26 noted that alternatives, including elevating the head of the bed and a PT/OT screen, were attempted. The results confirmed these alternatives were successful, concluding that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, hospital staff and facility staff interviews, the facility failed to ensure Resident #63 was permitted to return to the facility following a hospitalization for behavioral evaluation. The facility's refusal to readmit the resident was based on behaviors that occurred prior to the hospitalization. Resident Identifier: #63. Facility Census: 60.a) Resident #63 Record review revealed Resident #63 was transferred to the local emergency room on [DATE] due to aggressive behavior. Progress notes from [DATE] documented the resident exhibited increased agitation and verbal aggression and was sent to the local emergency room for further evaluation per physician order.Interview with Hospital Care Manager (HCM) (#75) on [DATE] revealed the facility refused to take the resident back. HCM #75 was told the resident could not return to the building or to any facility owned/operated by the same company. HCM #75 further stated the facility did not inform the hospital at the time of transfer that 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 record review and interviews, the facility failed to provide required written notice to the resident, resident representative, and the long-term care ombudsman prior to discharging Resident #63 and refusing readmission following hospitalization. The facility's failure to issue appropriate notice deprived the resident and representative of their right to appeal and participate in discharge planning. Resident Identifier: #63 Facility Census: 60Findings included:a) Resident #63Record review showed Resident #63 was transferred to the on 09/04/25 and remained hospitalized beyond the bed-hold period. Despite hospital documentation showing the resident was ready for return, the facility declined readmission.Interview with the Hospital Care Manager confirmed the resident and representative were not notified in writing of the facility's decision to refuse the resident's return. There was no evidence that:A written discharge notice was provided to the resident and representative;The notice contained the reason for discharge, effective date, and appeal rights;The state long-term care…

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

Based on record review, staff interview and resident interview the facility failed to ensure they served food at palatable temperatures. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the complaint survey process. Resident identifiers #2, #44, and #3. Facility census: 59. Findings include: a) A review on 05/27/25 at 1:00 PM, of the recorded food temperatures before meal service from 01/25 to present revealed the following dates with missing food temperatures: -01/18/25: No temperatures taken on the chicken, rice, or mashed potatoes at the lunch meal. -01/24/25: No temperatures taken on the lunch meal. -01/31/25: No temperatures taken on the fish at the supper meal. -02/08/25: No temperatures taken on the chicken, potatoes, or green beans at the lunch meal. -02/27/25: No temperatures taken on the supper meal. -03/02/25: No temperatures taken on the supper meal. -03/09/25: No temperatures taken on the supper meal. -04/23/25: No temperatures taken on the western omelet, and eggs at the breakfast…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure they implemented written policies and procedures that prohibited physical abuse, and investigated allegations of physical abuse. Resident #9 was physically abused by Resident#159. Resident #159 slapped Resident #9in the face. This was determined as Past Non-Compliance. Resident identifiers: #159, #9. Facility census: 60. Findings included: a) Resident #159 During a medical record review on 09/30/24 at approximately 10:30 AM, it was found that Resident #159 was admitted on [DATE]. Admitting diagnoses included encephalopathy, altered mental status, cognitive communication deficit, and Unspecified dementia, unspecified severity with other behavioral disturbance, and anxiety disorder. It was further identified that the resident did not have the capacity to make medical decisions and had a score of six (6) for a Brief Interview for Mental Status (BIMS). 05/22/247:34 PM a behavioral status evaluation revealed the resident had physical aggression…

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 record review, medical record review, staff interview and the facility abuse prohibition policy review, the facility failed to report abuse. Resident #9 was verbally abused and then physically abused. Resident identifiers: 159, #9. Facility Census: 60. Findings Included: a) On 09/30/24 at approximately 12:15 PM during a record review revealed Resident #159 had slapped Resident #9 in the face on 07/11/24 at 4:56 PM. Resident #9 was noted to have redness to the left side of face. During a review of the investigation and the staff interviews obtained at the time of the incident, the staff interview for Nurse Assistant (NA) #20's statement began with After first incident . During an interview with NA #20 at 3:15 PM on 09/30/24. NA #20 stated that Resident #159 was yelling and screaming. NA #20 said, It was the first time I saw him hit someone. NA #20 had seen the resident pushing the victim's wheelchair trying to aggravate her. NA #20 further stated Resident #159 was yelling at the victim (Resident #9) at this time. NA #20 stated, I think there are times he has hit other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure they had evidence that allegations of abuse were thoroughly investigated. Resident #9 was physically and verbally abused by Resident#159. Resident #159 slapped Resident #9in the face. Prior to this Resident #159 threatned harm to Resident #9. The facility did not identify this verbal abuse nor did they investigate it. This was determined as Past Non-Compliance. Resident identifiers: #159, #9. Facility census: 60. Findings included: a) Resident #159 During a medical record review on 09/30/24 at approximately 10:30 AM, it was found that Resident #159 was admitted on [DATE]. Admitting diagnoses included encephalopathy, altered mental status, cognitive communication deficit, and Unspecified dementia, unspecified severity with other behavioral disturbance, and anxiety disorder. It was further identified that the resident did not have the capacity to make medical decisions and had a score of six (6) for 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.

Based on record review and observation, the facility failed to ensure accuracy of assessment for one (1) of two (2) residents reviewed for dental status. Resident identifier: #37. Facility census: 60. Findings included: a) Resident #37 A record review on 10/01/24 at 3:11 PM revealed the last dental assessment from a dentist was greater than one year ago. Visual observation of Resident #37, revealed the resident had two missing teeth. During an interview the Social Worker stated the resident's two front teeth were missing upon admission to the facility. However, MDS completed on 7/20/24 (post admission) had no indications of missing teeth. MDS assessments on 04/14/23, 08/21/24 and 09/14/24 further indicated no dental issues. Registered Nurse (RN) #11 was interviewed and she acknowledged she missed entering missing natural teeth on assessment. Further record review revealed that on 09/25/24 a dentist from 360 Care was set to see the resident, but the resident refused treatment. The resident had an appointment with a dentist from 360 Care on 4/10/24 but was not seen because 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 medical record review and staff interview the facility failed to update Preadmission Screening and Resident Review (PASRR)with new qualifying diagnosis of . This was a random opportunity of discovery during the long-term care survey process. This had the ability to affect a minimum number of residents. Resident identifier: #159. Facility Census: 60. Findings Included: a) Resident #159 During a medical record review on 09/30/24 at approximately 10:30 AM it was identified that Resident #159 admitted on [DATE]. It is further identified that the resident did not have capacity with a Brief Interview for Mental Status (BIMS) of six (6) and was admitted with the following diagnoses dated 02/10/24: * Encephalopathy * Dysphagia, * Gastroesophageal reflux disorder * Hypertension * Unspecified voice and resonance disorder * Atherosclerotic heart disease of native coronary artery without angina pectoris * Hypothyroidism * Other disorders of the pituitary gland, unspecified abnormalities of gait and mobility * Other…

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 medical record review and staff interview the facility failed to update Preadmission Screening and Resident Review (PASRR) after one resident's behaviors intensified. This was a random opportunity of discovery during a long-term care survey process. This had the ability to affect a minimum number of residents. Resident Identifier: Resident #159. Facility Census: 60. Findings Included: a) Resident #159 During a medical record review on 09/30/24 at approximately 10:30 AM it is identified that Resident #159 was admitted on [DATE]. It is further identified that the resident did not have capacity with a Brief Interview for Mental Status (BIMS) of six (6) and was admitted with the diagnosis; During a review of the PASSR completed prior to the resident's admission, the PASSR was completed accurately and did not require Level II. With further medical record review for Resident #159 an exacerbation of behaviors was identified in the following residents progress notes: 03/08/24 at 10:14 AM Resident does not obey…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure residents were assessed to identify risk factors and provide care and services that are resident centered to prevent falls with injury by failing to develop and implement a resident centered fall risk care plan. This was true for 1 (one) of 6 (six) residents reviewed. Resident identifier: #162. Facility census: 60. Findings include: a) Resident #162 Findings include: a) Resident #162 On 10/01/24 at approximately 03:30 PM, a record review was started for Resident #162 which reveal that Resident #162 was an [AGE] year-old female admitted on [DATE] status post hospitalization for an unwitnessed fall that occurred at home. Resident #162 was admitted with the following past medical history: -Alzheimer's Disease -Hypothyroidism -Essential Hypertension -Repeated Falls -Cognitive Communication Deficit -Parkinson's Disease -Insomnia -Depression -Tremors Resident #162 was receiving the following medications upon admission: -Carbidopa-Levodopa-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide resident centered activities. A resident was not provided individual activities. This is idenified as Past Non Compliance. Resident identifiers: #159, #9. Facility Census: 60. Findings Included: a) Resident #159 On 09/30/24 at approximately 12:15 PM during a record review of a an incident it was identified that Resident #159 had slapped Resident #9 in the face at 07/11/24 at 4:56 PM and Resident #9 face was noted to have redness to the left side. During a review of the investigation the Nurse Assistant (NA) #20's statement began with After first incident . During an interview with NA #20 at 3:15 PM on 09/30/24 NA #20 stated that on 07/11/24 Resident #159 was yelling and screaming but it was the first time she saw him hit someone. NA #20 said she saw Resident #159 pushing Resident #9's wheelchair trying to aggravate her. NA #20 further stated Resident #159 was yelling at the victim (Resident #9) at this time. NA #20 stated, I think there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interview, the facility failed to ensure fall interventions were in place for Resident #27 and to ensure a mechanical lift was used, per company policy, to assist Resident #159 out of the floor following a fall. This was true for two (2) of five (5) residents reviewed for accidents during the survey process. Resident identifiers: #27, 159. Facility census: 60. Findings include: a) Resident #27 Resident #27 was admitted to the facility on [DATE] with the following diagnoses: Dementia, Unspecified severity with psychotic disturbance. Muscle Weakness (generalized) Weakness Unspecified abnormalities of gait and mobility Other specified fracture of right pubis, subsequent encounter for fracture with routine healing. Resident #27 suffered falls at the facility on 05/02/24, 05/07/24, 06/09/24, and 07/03/24. As a result of the fall on 05/07/24, Resident #27 suffered a fractured left hip. This was confirmed by an x-ray on 05/09/24. Resident #27 received the following…

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 record review and resident and staff interview, the facility Medical Director (MD) failed to sign orders in a timely manner to ensure Resident #37 did not miss doses of a controlled pain medication. This was true for one (1) of three (3) residents reviewed for pain management during the survey process. Resident identifier: 37. Facility census: 60. Findings included: A) Resident #37 At approximately 1:40 PM on 09/29/2024 during an interview with Resident #37, she stated she was in constant pain a majority of the time, and had missed her pain medication on occasions because the doctor didn't sign the orders for them so the nurses couldn't get them. Resident #37 was asked how she was aware the missing doses were due to the doctor not signing the orders, she stated, The nurses came to give me my medicines and told me they couldn't give me my pain medication because they were out of it and couldn't get any more of it because the doctor hadn't signed for it. At approximately 9:00 AM on 09/30/2024, an interview was conducted with the Director of Nursing (DON) regarding the pain…

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 staff interview the facility failed to to ensure two (2) residents was supplied with working call light. and/or accessible call lights. Resident #2's call light was not working and#55's call light was not within reach. Facility census: 60. Findings included: a) Resident #2 09/29/24 an observation of Resident #2's call light revealed it was not functioning. On 09/30/24 at 2:56 PM the Director of Nursing (DON) said the facility was not aware the call light was not functioning prior to yesterday upon the surveyor finding it. Per an interview with the resident at this time, she states she does not know if anyone knew it was not working. She did not specifically tell anyone that she could recall. b) Resident #55 During interview and observation on on 09/29/24 it was determined that Resident #55's call light cord was pressed between the bed and the wall and then draped over the overhead lights. The cord would not move due to being stuck between the bed and wall. A Nurse Aide (NA) was summoned to the room and she moved the bed away from the wall, moved the cord and…

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

Based on observation and staff interview the facility failed to keep the kitchen equipment in sanitary conditions. The ice machine in the kitchen contained black substance in the ice bin. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility census: 57 Findings Included: a) The improper sanitization of the Ice Machine During the initial tour of the kitchen on 07/10/23 The Food Service Director (FSD) was not present upon entering the facility. [NAME] #63 was in charge of the building. During an observation of the Ice Machine in the kitchen, it contained a black substance inside the ice bin. [NAME] #63 stated the Maintenance department was in charge of cleaning the cleaning machine monthly. An observation of the ice machine cleaning log on the outside of the ice machine stated inside the ice bin cleaned dated 06/22/23. During an interview on 07/10/22 at 10:22 AM Maintenance Director 49 observed the black substance inside the ice machine ice bin. Maintenance Director #49 took a paper towel and wiped 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 record review and staff interview, the facility failed to maintain an accurate and complete record for . This was true for five (5) residents reviewed. Resident identifiers: #12, #52, #3, #23, #55. Facility Census: 57. Findings included: a) Resident #12 A record review for unnecessary medications revealed Resident #12's Physician orders for medication management: Zyprexa Oral Tablet 7.5 MG (Olanzapine) Give 0.5 tablet by mouth one time a day for Dementia yells out, sexually inappropriate NPI: re-direct, offer food/drink. monitor for side effects: dry mouth, sedation with a start date 07/05/23. Lorazepam Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth one time a day for anxiety document behaviors: yells out, sexually inappropriate NPI: re-direct, offer food/drink. monitor for side effects: dry mouth, sedation with a start date 03/03/23. A continued review of Resident #12 medical record revealed a diagnosis: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY During an…

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

Based on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The ice machine in the kitchen did not have a one inch air gap for drainage. This failed practice had the potential to affect all residents currently receiving nutrition from the facility kitchen. Facility census: 57 Findings included: a) Ice Machine drain During the initial tour of the kitchen on 07/10/23 The Food Service Director (FSD) was not present upon entering the facility. [NAME] #63 was in charge of the building. During an observation of the Ice Machine in the kitchen the ice machine water drain was touching the floor drain without a one (1) inch gap allowing for the potential for contaminants to enter the line and travel to the ice machine. During an interview on 07/10/22 at 10:22 AM the Maintenance #49 acknowledged there was not a one (1) inch air gap and the drain was touching the floor.

Based on record review and staff interview the facility failed to ensure one (1) resident had the right to participate in the development of their care plan. Resident identifier: #52. Facility census: 57. Findings included: a) Resident #52 During an interview, on 07/10/23 at 10:47 AM, Resident # 52 stated, I have never been invited to attend a care plan meeting. During a record review on 07/11/23 at 1:43 PM Resident # 52 medical record revealed a care plan note dated Type as written 5/23/2023 10:00 Care Plan Meeting 1. Attendance (list all in attendance): (Social Services #35 name), (Registered Nurse #40 name)CRC/Nursing, (Account Manager #55 name)-Dietary, (Activities #12 name) -Activities, (Therapist #65 name )-Therapy. 2. Family/resident in attendance (Yes/No, who): Daughter in law-(name) attended. 3. Summary of meeting (Brief summary. Details are on care plan): Nursing-began Buspar 05-16-2023 for anxiety, and on 05-19-2023 levothyroxine for thyroid. No weights. No wounds. Awaiting new eye glasses. Appt August 2023 (a local physician name). Social Services-Post Form on file and…

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

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The walls in Resident #52's room were not in good repair. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents that currently reside in the facility. Resident Identifier: #52. Facility Census: 57. Findings Included: a) Resident #52 During the initial tour, on 07/10/23 at 10:47 AM, an observation of Resident #52's room walls revealed several screw holes, and several places with missing paint around the television area. There were also several scuff marks and missing paint on the walls near the floor and near the bathroom door. There was a doorknob-size hole in the wall behind the room door. During an interview, on 07/11/23 at 2:46 PM, the Administrator acknowledged the holes in the wall, the missing paint and the scuff marks. The Administrator stated this room definitely needed painting. .

Based on record review, and staff interview, the facility failed to ensure a resident had a person-centered comprehensive care plan developed and implemented to meet his/her other preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of (16) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the resident at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #42. Facility census: 56. Findings included: a) Resident #42 Review of unnecessary medications for Resident #42 revealed: --Vistaril Capsule 25 MG (hydroxyzine pamoate) Give 1 capsule by mouth at bedtime for anxiety document behaviors: withdrawn, anxious, restlessness. NPI: attempt to calm, listen, re-direct. monitor for side effects: sedation, dry mouth with start date 02/04/23. --Buspirone HCl Tablet 15 MG Give 1 tablet by mouth…

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 medical record review, resident interview and staff interview the facility failed to ensure they revised a care plan after fall occurred. This was true for one (1) out of 15 reviewed for care plans. Resident identifier: #1. Facility Census: 57 Findings included: a) Resident #1 A review of the medical record found Resident #1 had a fall with a major injury on 06/16/23. The nursing note stated Resident #1 was ambulating per usual routine when she stumbled and fell against the back exit door on unit one (1). Resident #1 was unable to bear weight on her left leg. Upon further evaluation, the resident was guarding and striking out with left hip manipulation. Resident #1 pointed to left hip and states that's where its hurt. Resident #1 was transferred to a local hospital for further Evaluation. Tylenol 650 mg was given for pain. Upon further research it was revealed that Resident #1 did not have a history of falling. An interview with administrator on 07/11/23 at 11:45 AM, also revealed Resident #1 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure medications were dated upon opening and disposed of when expired in accordance with accepted standards of care. This was a random opportunity for discovery. Facility Census: 57. Findings included: a) Medication cart On [DATE] at 8:35 AM, the medication cart was reviewed. The review found a Toujeo Kwik pen not dated upon the initial administration for Resident #35. Manufacturers instructions recommend discarding pen 56 days after first use even if the pen still containts insulin. A Humulin R Kwik pen for Resident #35 was found dated [DATE] upon the initial administration. The Humulin R Kwik pen was noted to be expired after 28 days. On [DATE] at 8:38 AM, Licensed Practical Nurse (LPN) #10 verified the Toujeo Kwik pen was not dated upon the initial administration and the Humulin R Kwik pen expired 28 days after the day of the initial administration. On [DATE] at 8:40 AM, the Director of Nursing (DON) #44 was notified. DON #44…

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 staff interviews the facility failed to ensure all handrails were securely affixed to the walls. This was a random opportunity for discovery and the potential to affect more than a limited number of residents who currently reside in the facility. Facility census 57. Findings included: a) 100 hundred hall During the first phase of the survey process, it was discovered that multiple handrails on both sides of the hallway were very loose. This was verified with Nurse Aide #21 on 07/10/23 at 10:31 AM. On 07/10/23 at 10:43 AM Director of Maintenance (DM) #49. was shown the loose handrails. DM # 49 said he would check them all and fix them.