Dunbar Center

Based on record review and staff interview, the facility failed to ensure pressure ulcer prevention was in place. This was true for one (1) of two (2) residents reviewed under the care area of pressure ulcers. Resident Identfier: #69. Facility Census: 110.a) Resident #69 On 06/01/26 at 12:15 PM, a record review was completed for Resident #69. The care plan was reviewed and found an intervention, under the focus area of risk for skin breakdown, were not being implemented. The interventions states, Assist resident in turning and repositioning every 2-3 hrs. (Typed as written.) Therefore, the pressure ulcer prevention was not in place. At this time, a review under the tasks tab was completed. The following dates did not include documentation regarding turning and repositioning each shift: --04/18/26 night shift--04/20/26 night shift--05/01/26 evening shift--05/01/26 night shift--05/05/26 night shift --05/11/26 night shiftOn 06/01/26 at 3:25 PM, the DON confirmed the care plan intervention was not implemented, which did not put pressure ulcer prevention in place. The Corporate Nurse…

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 ensure an accurate and complete medical record for Resident #111. This was true for one (1) of two (2) residents reviewed under the care area of falls. Resident Identifier: #111. Facility Census: 110. Findings Include: a) Resident #11 On 06/01/26 at 2:00 PM, a record review was completed for Resident #111. The review found the fall risk evaluation dated 03/31/26 was not complete. The following sections were left blank: Section Gait/balance Gait/balance: Observe the Resident's gait/balance, have them/they stand on both feet without holding onto anything, if safe to do so. If assistive devices are required, provide the device and then proceed. Walk straight forward, walk through a doorway; and make a turn. Check the response below that best describes the resident abilities. --Gait/balance Normal --Balance problem while standing--Balance problem while walking--Decreased muscular coordination--Change in gait pattern when walking through doorway--Jerking or unstable when making turns--Requires use of assistance devices…

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 maintain an infection control program regarding disposal of a soiled brief and linen. This was a random opportunity for discovery. Resident Identifier: #69. Facility Census: 110. Findings Include: a) Resident #69 On 06/02/26 at 4:23 AM, an observation was made of a soiled brief and soiled wash cloth laying on the floor at the foot of Resident #69's bed. On 06/02/26 at 4:25 AM, Nurse Aide (NA) #160 approached the resident's room and removed the soiled brief and wash cloth. NA #160 stated, let me take care of this. At this time, Licensed Practical Nurse (LPN) #18 observed the NA picking up the items and confirmed the soiled brief and wash cloth should have been disposed of correctly. On 06/02/26 at approximately 5:00 AM, the Director of Nursing (DON) was notified and confirmed the items should have been disposed of properly.

Based on observation and staff interview, the facility failed to ensure confidentiality of medical records. This was a random opportunity for discovery. Facility census: 116.Findings included:a) 300 hallway medication screenOn 01/28/26 at 11:13 AM, the computer screen on the medication cart in the 300 hallway was noted to be displaying resident information. A resident's list of medications to be administered was visible. The cart was located midway down the hallway, and no staff was in attendance.On 01/28/26 at 11:16 AM, Licensed Practical Nurse (LPN) #41 confirmed the computer screen was displaying resident medication and locked the screen so it was no longer visible.No further information was provided through the completion of the investigation.

Based on record review and staff interview the facility failed to ensure medications were administered in a timely manner as ordered. This was true for 1 (one) of 6 (six) residents reviewed for medication administration. Resident identifier: #84. Facility census: 116. Findings included: a) Resident #84 During an investigation for a complaint that the facility failed to ensure residents with elevated blood sugars received adequate care and the facility failed to ensure the residents receive their medications on time a physicians order was found for Fingerstick blood glucose Notify MD if blood sugar greater than 400, if blood glucose is below 70 initiate hypoglycemic protocol two times a day for DM - start date- 02/17/2025. The resident did not receive these Finger sticks on 12/25/25. This is evidenced by no blood sugar being charted in the vitals section (blood sugar summary) of his medical record, the medication administration record (MAR) or in the progress notes for the date noted. This has potential to harm the resident due to not knowing if his blood sugar levels are within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to store clorox wipes in an area to maintain a safe environment in room [ROOM NUMBER]. This was a random opportunity for discovery. Facility Census: 116.Findings Include:a) room [ROOM NUMBER]Upon the initial tour of the facility on 01/28/26 at 11:55 AM, a container of clorox wipes was observed sitting on the bathroom sink in room [ROOM NUMBER]. On 01/28/26 at 11:58 AM, Licensed Practical Nurse (LPN) #21 confirmed the container of clorox wipes should not be in the resident's bathroom. LPN #21 stated, Let me get these out of here.On 01/28/26 at 12:20 PM, the Administrator was notified and confirmed the clorox wipes should not be in a resident's bathroom.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain infection control standards for storage of a bed pan in room [ROOM NUMBER]. This was a random opportunity for discovery. Faciltiy Census: 116.Findings Include:a) room [ROOM NUMBER]Upon the initial tour of the facility on 01/28/26 at 11:55 AM, a bed pan was observed laying on top of trash can in the bathroom, which was not bagged or labeled in room [ROOM NUMBER]. On 01/28/26 at 11:58 AM, Licensed Practical Nurse (LPN) #21 confirmed the bed pan was not labeled or stored in a storage bag. On 01/28/26 at 12:20 PM, the Administrator was notified and confirmed the bed pan should have been labeled and stored in a storage bag.

Based on observation, record review and staff interview the facility failed to ensure all residents were treated with dignity and respect. This was true for five (5) residents and were random opportunities for discovery. Resident Identifiers: #69, #11, #62, #64, and #52. Facility Census: 115. Findings Include: a) Resident #64 Observation of the morning meal on 07/23/25 beginning at 8:08 AM found the resident sitting in her recliner in her room. The nurse aid took her a cup of cranberry juice and told the resident she had brought her a cup of juice. The resident was observed feeling around on her bedside table. She did not find the juice, nor did she take a drink. At about 8:15 AM Registered Nurse (RN) #112 went into the room and asked her how she was doing. The resident stated, I am just hungry. I am starved. The RN asked the resident if she wanted a drink of her juice and she assisted the resident in getting a drink. At 8:28 am the meal cart arrived on the floor from the kitchen. At 8:29 am Resident #64's roommate was served her meal and Resident #64's tray was left on the cart.…

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 keep the resident as free from neglect as possible. This failed practice had the potential to affect more than a limited number of residents. This was a random opportunity of discovery. Resident Identifiers: #11 and #96. Facility Census: 115. Findings include:a) Resident #11On 07/22/25 at 10:45 AM, an observation of room [ROOM NUMBER] was made. The observation found Resident #11 sitting in a geri-chair with dried food and other debris on it. The resident was found facing the wall. There was no television or music playing. The resident appeared disheveled, and the room was noted with a foul odor of urine. The resident's fall mat was observed with a tear on the corner. The floor was sticky and food from breakfast as well as a plastic spoon were in the floor. The resident's clothes were dirty and was noted with a foul body odor. Her hair was disheveled. On 07/22/25 at 10:46 AM, Licensed Practical Nurse (LPN) #54 was asked, Who is caring…

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, record review and staff interview, the facility failed to develop and/or implement the care plan regarding Resident #11's need for meal assistance and cueing for meals, Resident #117's negative pressure wound therapy (wound vac) and turning and repositioning for Resident #122, #21, #63, #7, and #104. This was true for seven (7) of 16 residents reviewed during the survey process. Resident Identifiers: #11, #117, #122, #21, #63, #7 and #104. Facility Census: 115.a) Resident #7 On 07/22/25 at 9:00 AM, a record review found that Resident #7 has multiple pressure ulcers, including his glutes and thighs. He had a Braden Scale for Predicting Pressure Score Risk dated 07/08/25 with a score of fifteen (15) which indicated he was at risk for pressure ulcers. He had an order to cleanse the stage 2 to left and right glutes with IHWC (wound cleanser), apply sure prep to peri wound, apply zinc oxide and leave open to air. Review of his care plan states under the focus of skin breakdown that he is to be turned and repositioned every 1-2 hours. Review of his task sheet for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to provide ADLs to dependent residents. This was true for five (5) of seven (7) residents reviewed for the care area of ADL care during the complaint survey. Resident Identifiers: #11, #96, #21, #119, and #16. Facility Census: 115.Findings Included: a) Resident #21 On 07/23/25 9:00 AM record review of showers for this dependent resident were reviewed. Review of the shower schedule indicates that Resident #21 is scheduled for showers Tuesday and Friday evenings. He was scheduled for a shower but did not receive one on the following dates (six (6) days) 06/24/25, 07/04/25, 07/11/25, 07/15/25, 07/15/25 and 07/18/25. This was confirmed with the Corporate Resource Nurse #106 on 07/23/25 at 2:00 PM at which time she agreed the resident missed several of his showers. b) Resident #119 On 07/23/25 9:30 AM record review of showers for this dependent resident were reviewed. Review of the shower schedule indicates that Resident #119 was scheduled…

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 perform wound treatments as ordered by the physician. This was true for three (3) of five (5) residents reviewed for wound treatments. Resident Identifiers: #21, #63 and #117. Facility Census: 115Findings include:a) Resident #21On 07/21/25 at 1:03 PM a record review of the Treatment Administration Record (TAR) for July, 2025 shows that Resident #21 did not have wound treatments as ordered by the physician.On 07/04/25 a wound care order was not complete for Skin tear right elbow cleanse with hydrating form cleanser Sure prep wound cover with adhesive foam dressing every day shift for wound care. On 07/20/25 a wound care order was not complete for Sure prep left elbow cover adhesive foam dressing for comfort per resident request every day shift.On 07/20/25 a wound care order was not completed on day shift for Apply skin prep to right heel and ensure that heels are offloaded. Monitor skin for any changes to skin integrity every day and night shift for wound. On 07/20/25 a wound care order was not complete for Cleanse…

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 ensure residents received treatment or services to prevent or heal pressure ulcers. This was true for four (4) of five (5) residents reviewed for turning and repositioning. Resident Identifiers: #7, #104, #117 and #122. Facility Census: 115.Findings Included:a) Resident #7On 07/22/25 at 9:00 AM record review found that Resident #7 has multiple pressure ulcers, including his glutes and thighs. He has a Braden Scale for Predicting Pressure Score Risk dated 07/08/25 with a score of fifteen (15) which indicates he is at risk for pressure ulcers.Review of his care plan states under the focus of skin breakdown that he is to be turned and repositioned every 1-2 hours. Review of his task sheet for the last thirty (30) days for GG bed mobility indicates he is back and forth from substantial/maximal assistance to dependent for bed mobility. Review of his task sheet for the last thirty (30) days for turning and repositioning every 1-2 hours indicates he is not turned or repositioned as required.The facility does not document…

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 ensure all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This was true for two (2) of five (5) personnel records reviewed during the extended survey. Employee Identifiers: Nurse Aide (NA) #86 and NA #13. Facility Census: 115. Findings Include: a) Nurse Aide #13 A review of NA#13's competency check offs for the calendar year of 2024 found she had only completed two (2). One (1) for hand hygiene and one (1) for Putting on and taking of personal protective equipment. During an interview with the Nursing Home Administrator (NHA) at 3:12 PM on 07/28/25 confirmed NA #13 only had these two (2) check offs completed. b) Nurse Aide #86 A review of NA#86's competency check offs for the calendar year of 2024 found she had only completed two (2). One (1) for hand hygiene and one (1) for Putting on and taking of personal protective…

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 ensure all nurse aides received an annual performance evaluation. This was true five (5) for five (5) employee personnel records reviewed. This failed practice has the potential to affect more than an isolated number of residents. Employee Identifiers: #86, #13, #21, #5, and #95. Facility Census: 115. Findings Include: a) Performance Reviews On 07/28/25 in the early afternoon the yearly performance evaluations were requested for Nurse Aide (NA) #86, #13, #21, #5 and #95. On 07/28/25 at 2:41 PM during an interviedw with Corporate Resource Nurse (CRN) #106 it was revealed that the facility did not have any of the five (5) performance evaluations requested.

Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to document meal percentages in the Tasks portions of medial records for Resident #121. Facility Census: 115Findings included: a) Resident #121A review of Resident #121's tray cards revealed that the resident was scheduled to receive meal tray on the day of 05/31/25. A review of Resident #121's task documentation for meals had no information for the one day he was present in the facility on 05/31/25. Nurse Aide #43 was interviewed on 07/24/25 at 3:14 PM and reported that Resident #121 was admitted to the facility and left the facility against medical advice the same day as 05/31/25. She stated that he had been arguing with his family because he wanted to go home and they wanted him to stay for treatment. She reported that he was angry when the kitchen did not immediately send out his trays for lunch and breakfast on the food carts, but she had gone to the kitchen to get them for him for both meals, and he refused them both and did not document…

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 provide a safe, clean, homelike environment for Resident #11 and #96. This was a random opportunity for discovery. Resident Identifiers: #11 and #96. Facility Census: 115.Findings Include:a) Resident #11 On 07/22/25 at 10:45 AM, an observation of room [ROOM NUMBER] was made. The observation found Resident #11 sitting in a geri-chair with dried food and other debris on it. The resident was found facing the wall. There was no television or music playing. The resident appeared disheveled, and the room was noted with a foul odor of urine. The resident's fall mat was observed with a tear on the corner. The floor was sticky and food from breakfast as well as a plastic spoon were on the floor. The resident's clothes were dirty and were noted with a foul body odor. Her hair was disheveled. On 07/22/25 at 10:46 AM, Licensed Practical Nurse (LPN) #54 was asked, Who is caring for the residents in room [ROOM NUMBER]? LPN #54 responded, The nurse…

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 family interview, the facility failed to complete a thorough investigation regarding an allegation of neglect for Resident #123. This was true for one (1) of seven (7) residents reviewed under the care area of neglect. This failed practice had the potential to affect more than a few residents. Resident Identfiers: #123 Facility Census: 115. Findings Include:a) Resident #123On 07/23/25 at 11:00 AM, a review of a facility-reported incident regarding Resident #123 was completed. The review found the allegation of waiting over a one (1) hour wait time for the resident to receive assistance. The five (5) day follow-up was reviewed at this time as well. The following was documented: On April 17, 2025 (Name of Resident)'s son reported that his father contacted him the previous eveing stating his call light had been on for 1 hour and 45 minutes and he needed to use the bathroom. The son drove 15 minutes to the facility and when he arrived he saw the call light on. He checked with his dad, who had a bowel movement. He got the attention of staff,…

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

Based on record review and staff interview the facility failed to ensure Resident #59's care plan was revised to reflect the residents history of falls. This was true for one (1) of seven (7) residents reviewed in regards to Facility Reported Incidents during a complaint survey. Resident Identifiers: #59 . Facility Census:115. a) Resident #59A review of a facility reported incident (FRI) found Resident #59 suffered a fall on 08/10/24. A review of the facility's five-day follow-up report found the following, .He does have fall precautions in place, and secondary to this incident, his bed will now be placed against the wall to prevent falling from the bed. A review of the resident's current care plan on 07/22/25 found the resident had no care plan focus statement, goals, or interventions related to being at risk for falls and/or a history of falls. A revision history of the care plan found that on 02/21/25 the following focus statement was resolved Resident is at risk for falls: impaired mobility. This was added to Resident #59's care plan on 08/12/24 two (2) days after his last fall…

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, record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible to prevent injury to the residents. Nurse Aide (NA) #12 transferred Resident #56 from the tilt shower chair to her bed using a stand and pivot method. The residents care plan, Kardex and physician orders all indicated Resident #56 was to be transferred via a total lift with the assistance of two (2) staff members.Resident Identifier: #56. Facility Census: 115. Findings Include: a) Resident #56 On 07/28/25 at 10:48 AM NA #12 was observed transporting Resident #56 back to her room from the shower room. The resident was in a tilt back shower chair at this time. NA #12 was observed taking Resident #56 into her room. No other staff members were observed in the room. At 10:51 AM another NA entered the room. At 10:52 AM the second NA exited the room with the tilt back shower chair. At 10:56 AM NA #12 opened the door to the residents room. Resident #56 was laying on her bed. Under her was a blue lift pad. NA…

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, record review and staff interview the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to weight loss and dehydration. This was true for one (1) of one (1) resident reviewed for the care area of Feeding Tubes during a complaint survey. Resident Identifier: #52. Facility Census:115. Findings Include: a) Resident #52 A review of Resident #52's medical record found a physician's order which read: Enteral feed order one time a day Glucerna:1.5 cal at 70 ML (Milliliters) per hour for 20 hours This order was current at the time of this review and began on 07/15/25. The resident was to be started on the feeding at 2:00 PM and unhooked at 10:00 AM the following day. At 4:15 PM on 07/22/25 an observation of Resident #52 with the Corporate Resource Nurse (CRN) #106 found Resident #52's feeding was running. The rate on the pump was observed to be running at only 60 ML per hour instead of the ordered 70 ML per hour. CRN #106 asked Licensed…

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 resident representative interview, record review, observation, and staff interview, the facility failed to treat each resident with respect and dignity and to care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility failed to ensure Resident #13 was wearing her glasses and also failed to ensure Resident #13's legs were covered when she was in a public area. Additionally, the facility failed to honor Resident #65's right to vote. This failed practice was true for one (1) of three (3) residents reviewed in the area of dignity throughout the complaint process and one (1) of five (5) residents reviewed in the area of activities and voting. Resident identifiers: #13 and #65. Facility census: 109. Findings included: a) Resident #13 During a telephone interview, on 05/05/25, Resident #13's legal representative stated she had discussed with the Administrator the need for Resident #13 to wear glasses for her to be able see. The legal representative stated…

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 secure and keep confidential residents personal and medical information. The facility failed to safeguard private information that was placed in a clear acrylic wall file holders located in the hallway outside of the Medical Records office and the Physician's office. These were random opportunities for discovery. Facility census: 109. Findings included: a) Identifiable Patient Information Visible Outside the Medical Records Office On 05/05/25 at 1:00 PM, a random observation for discovery found an acrylic wall file holder mounted outside of the Medical Records to the left of the door. The file holder pocket had: -- A determination later regarding a resident being cut from skilled care therapy which indicated the resident no longer met the Medicare coverage requirements for skilled nursing services. --A hospital progress note on a resident which outlined the results of an x-ray done to the resident's right foot and the results an MRI of the resident's right foot. -- A hospital discharge summary on a resident which…

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 care and services for skin tears in accordance with professional standards of practice. This deficient practice had the potential to affect four (4) of four (4) residents reviewed for skin tears. Resident identifiers: #110, #26, #58, #90. Facility census: 109. Findings included: a) Policy review Review of the facility's policy and procedure titled, Skin Integrity and Wound Management, with effective date 07/01/01 and revision date 05/01/25 stated wound evaluations would be performed weekly. b) Resident #110 Review of Resident #110's electronic health records showed the resident returned to the facility from the hospital on [DATE]. A nursing note written on 03/18/25 at 11:45 PM documented the resident had the following skin tear wounds: - Front right lateral lower leg. According to the nursing note, Skin issue has been evaluated .Type 1: No skin loss. Wound was present on admission. Wound is new .Staged by: In-house nursing. Measurements…

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 ensure percutaneous endoscopic gastrostomy (PEG) tube care in accordance with professional standards of care for one (1) of three (3) residents reviewed for PEG tube care. Resident identifier: #110. Facility census: 109. Findings included: a) Resident #110 Review of Resident #110's electronic health records showed the resident was receiving enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. A PEG tube is a surgically-placed tube that allows a person to receive nutrition directly through the stomach. Review of Resident #110's Treatment Administration Records (TARs) for February and March 2025 showed no orders for PEG tube treatment. According to Medline Plus, an online health information resource maintained by The National Library of Medicine, PEG tube sites should be cleaned one (1) to three (3) times a day. On 03/25/25, Resident #110 was transferred to the hospital. Hospital records stated upon admission to the hospital, the resident's PEG tube dressing was adhered to the skin by drainage. 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.

Based on resident interviews, anonymous nursing staff interviews, and hours per patient day review, the facility failed to ensure sufficient qualified nursing staff were available to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. The low staffing had the potential to affect all residents in the facility. Facility census: 109. Findings included: a) Anonymous Resident Interviews During an anonymous resident interview the resident reported, There are times when there is only one aide to a hall which means I need to wait a very long time to receive care when I put my call light on. Sometimes, it takes over an hour or more for the aide to get to me. b) Anonymous Nursing Staff Interviews During an anonymous Nurse Aide interview, the aide reported that she frequently rushes through her job in getting residents up and ready for the day stating, It makes me want to not work here. The aide explained that she feels as though it affects her residents because she is unable to…

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

Based on food tray temperatures and staff interview, the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of one (1) hallway tested for food tray temperatures throughout the complaint survey process. This had the potential to affect more than an isolated number of residents. Facility census: 109. Findings included: a) 100 Hall Lunch Time Meal Observation During an observation on 05/05/25 at 1:30 PM, the last meal tray on the 100 Hall was tested by the Director of Operations for the Healthcare Services Group with the following results: -- Ham and Pinto Beans: 140.0 degrees Fahrenheit (F) -- Pan-Fried Potatoes: 112.2 degrees F -- Mixed Vegetables: 123.0 degrees F -- Banana Pudding: 72.1 degrees F The Director of Operations for the Healthcare Services Group agreed the food temperatures obtained for the pan-fried potatoes and the banana pudding were not considered to be the appropriate desired temperature for the point of delivery to the residents. It was discussed that hot foods would typically be served at 120…

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, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Facility staff failed to follow contact precautions and enhanced barrier precautions. Staff also failed to perform appropriate hand hygiene during a dressing change. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #9 and #26. Facility census: 109. Findings included: a) Resident #9 The facility's policy and procedure titled Transmission Based Precautions with effective date 02/15/01 and revision date 05/01/25 stated that healthcare personnel caring for patients on contact precautions would wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. On 05/05/25 at 12:25 PM, Respiratory Therapy Nurse #99 was observed in Resident #9's room, listening to the resident 's lungs with 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.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility failed to keep the 100 Hall hallway at a comfortable temperature level. Additionally, the facility failed to keep the Maple Dining area at a comfortable temperature level. These were random opportunities for discovery. These practices had the potential to affect more than an isolated number of residents. Facility census: 109. Findings included: a) Temperature on 100 Hall and the Maple Dining Room Observation, on 05/06/25 at 8:25 AM, revealed Resident #13 was in the hallway by the nurses' station covered with a blanket. Observation, on 05/06/25 at 10:35 AM, revealed Resident #13 was up in a wheelchair wearing a sweater and was propelling around the Maple Dining Room. The Director of Maintenance took the ambient temperature [the temperature of the surrounding air] in the 100 Hallway on 05/06/25 at approximately 1:50 PM. The temperature was found to be 69.4 degrees Fahrenheit. The Director of Maintenance then took the ambient temperature of 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 ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of pressure ulcers. This was a random opportunity for discovery during the investigation. Resident identifier: #7. Facility census: 109. Findings included: a) Resident #7 Review of Resident #7's electronic health record showed a skilled evaluation was performed on 04/29/25. The skilled evaluation included assessments of pressure ulcers on the sacrum, left heel, and left elbow. Further review of Resident #7's electronic health record showed a quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 04/30/25. Item M0100 stated the resident had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. However, item M0210 answered No to the question, Does this resident have one or more unhealed pressure ulcer/injuries? Because this question was answered no, there was no response for item M0300, the current number of unhealed pressure ulcers/injuries at each stage. On 05/06/25 at 3:00 PM,…

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 send a copy of transfer/discharge notifications to a representative of the Office of the State Long-Term Care Ombudsman. This failed practice was found true for six (6) of seven (7) seven residents reviewed for hospitalizations/discharges during the Long-Term Care Survey Process. Resident identifiers #105, #114, #36, #24,#68, and #5. Facility census: 115. Findings include: a) Resident #105 A record review on 03/31/25 at 3:15 PM, revealed that Resident #105 was transferred to the hospital on [DATE]. A record review on 04/02/25 at 3:12 PM, revealed a transfer/discharge notice was explained to Resident #105's Medical Power of Attorney ([NAME]), via telephone. No transfer/discharge notice was found in the medical record to indicate that the Ombudsman was notified of the transfer. During an interview on 04/02/25 at 3:18 PM, The Administrator stated, We would fax them and all I have is a fax confirmation sheet for each month but nothing to say which…

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 interview, record review, staff interview and observation, the facility failed to ensure dependent residents received showers according to schedule/preference for Resident #14, #111, #62, and #42. Facility census: 115. Findings included: a) Resident #14 During an interview with Resident #14 on 03/31/25 at 02:50 PM, Resident #14 stated she had one shower since admitted to the facility. She stated she is told by staff that she does not get a bed bath often due to the facility being short staffed. Resident #14 reported that would prefer a shower as opposed to bed bath. Resident's hair was unkempt and she reported that it was not clean. On 04/01/25 at 11:24 AM a review of Resident #14's shower log revealed that the resident had zero showers recorded and a bed bath recorded on the following days since her admission on [DATE]: Friday, 03/21/25 at 12:25 AM and 2:22 PM Monday, 03/24/25 at 11:21 PM Tuesday, 03/25/25 at 1:04 PM On 04/01/25 at 11:35 AM a review of resident's Minimum Data Set (MDS)…

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 follow the Physicians order for wound care and providing immunizations as required. This was true for one (1) of five (5) residents' wounds reviewed and three (3) of five (5) immunizations records reviewed. Resident Identifiers: #84, #12, #83, #87. Facility Census: 115. Findings include: a) Resident #84 On 04/03/25 at 09:00 AM record review shows Resident #84 has a Zoster (shingles) vaccination pending. Further review indicated the Medical Power of Attorney was educated and gave consent for the vaccination to be administered on 10/11/24. However, Resident #84 has not received the shingles immunization as of this date (04/03/25). During an interview on 04/03/25 at 09:25 AM with the Infection Preventionist-Registered Nurse #72 it was explained as the facility running behind on all immunizations. It was confirmed at this time that the shingles vaccination should have already been administered. 2) Tuberculosis vaccine On 04/03/25 at 09:00 AM record…

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 with the resident, staff interview and record review, the facility failed to honor resident's choices for food. This was true for 1 (one) of 4 (four) residents reviewed in this annual survey. Resident identifier: #42. Facility census: 115. Findings include: a) Resident #42 On 03/31/25 at12:07 PM, during an interview with Resident, he stated, They give me chicken almost every day and I am not fond of it. For breakfast, I get pancakes or waffles and I don't care for them either. The oatmeal here is bad, too. When asked if he told them he wanted something else, he said he did once. A review of resident's care plan dated 02/25/25 documents: Resident is a nutritional concern r/t (related to) dependent upon hemodialysis, therapeutic diet Under interventions: Honor food preferences within meal plan Monitor for changes in nutritional status and report to food and nutrition/physician as indicated .Food allergies: fish/shellfish/seafood, mushrooms, pineapples, strawberries. Dislikes: chicken, eggs. A review of resident's dietary tray tickets for past two weeks (03/19/25…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and [NAME] interview, the facility failed to provide a written notice of bed hold to the resident or resident representative. This was true for 2 (two) of 7 (seven) residents reviewed during the survey process. Resident identifiers: #36 and #24. Facility census: 115 Findings include: a) Resident #36 Resident was on Hospital leave 12/05/24 - 12/11/24. The Surveyor requested a copy of the bed hold notice and transfer notice from the Nursing Home Administrator (NHA). A review of the bed hold notice, shows it was signed by facility representative on 12/5/24. In the area on the form where the Resident or Resident's representative is suppose to sign, the form was blank, i.e. form was not signed by Resident or Resident representative. In the section for STAFF USE ONLY, at the bottom of the form, staff were to initial and date beside when each copy was sent to Resident or Resident's representative. There was no initials or dates in any of the fields for resident, resident's representative or…

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

Based on record review and staff interview, the facility failed to coordinate the PASARR's diagnosis of dementia, with the MDS assessment. This was found to be true for 1 (one) of 1 resident reviewed during the survey process. Resident Identifier: #42. Facility census: 115. Findings include: A) Record review: Resident's PASARR was updated on 11/19/24, adding dementia as a diagnosis. The Resident's last MDS assessment was 02/10/25. Dementia was not marked in Section I of the MDS, under diagnoses. Resident's BIMS was assessed at 15.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to provide a program of activities to support residents one on one and sensory stimulation needs. This failed practice was found true for (1) one of (2) two residents reviewed for Activities during the Long-Term Care Survey Process. Resident identifier #43. Facility Census 115. Findings Include: a) Resident #43 The initial observation on 03/31/25 at 1:53 PM, found Resident #43 lying in bed, staring at the wall. No television or music was on in the residents room. An observation on 04/01/25, at 9:30 AM, found Resident #43 lying in bed, with her head at the foot of her bed, she was rolling the sheet in her fingers. No television or music was on in the residents room. A record review on 04/01/25 at 1:00 PM, of Resident #43's Activity Participation records for the Months of 01/2025, 02/2025, and 03/2025 revealed that within the (3) three month period, Resident #43 had participated in (6) six out of room activities. She is indicated every 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.

Based on observation and staff interview the facility failed to properly store locked controlled medications and permit only authorized personnel to have access to the keys and medications. This was a random opportunity for discovery. Facility census: 115 Findings Include: a) On 04/02/25 at 03:10 PM it was observed that the medication storage refrigerator had a narcotic medication storage box. The separately locked, permanently affixed box in the facility medication refrigeration was affixed to a removable shelf, however, the shelf was easily slid out of the refrigerator making it easy to remove the shelf and box from the facility. Also, the key to the box was placed (stored) in the lock itself. This was confirmed with Licensed Practical Nurse #56 on 04/02/25 at 3:10 PM and with the Administrator and Corporate Registered Nurse #134 on 04/02/25 at 3:20 PM when they both confirmed the narcotic box must be adhered to the refrigerator itself, not just the shelf.

Based on observation, record review and staff interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat or drink independently, by not ensuring Resident #36 was served lunch on a three (3) compartment plate. Facility census: 115. Findings included: a) Resident #36 On 04/01/25 at 1:12 PM while observing the kitchen plate the lunch meal, kitchen staff were observed serving the tray for Resident #36. It was noticed by staff that they did not have a three (3) compartment plate. District Manager of Dietary inquired as to the whereabouts of the three (3) compartment plates, Kitchen [NAME] #109 reported that they had some this morning but was unaware where they were at that time. Resident #36 was served his meal on a raised lip plate. b)On 04/01/25 at 3:00 PM a review of the care plan for Resident #36 revealed on page #14, Resident is a nutritional concern related to dependent edema, pressure injury, history of peg tube, SCI, aoristic dissection, respiratory failure, Cardiovascular Accident, weakness,…

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 review of documentation, the facility failed to ensure trash was properly contained in the dumpster. Dumpster door broken, another open. Medical Supplies (gloves, wipes, chuck pads) on the ground surrounding area. Facility census: 115. Findings included: a) On 04/01/25 at 10:10 AM, a tour of the outside dumpster area. Three (3) green dumpsters were observed with medical supplies (including numerous latex gloves and chuck pads) on the ground surrounding dumpster. One dumpster did not have a door, and one dumpster did not have a door completely closed. On 04/01/25 at 10:20 AM, looked at the dumpster area with the Administrator who acknowledged that there were chuck pads, wipes and numerous latex gloves on the ground surrounding the dumpster. She reported that the facility had been in contact with the sanitation company on numerous occasions to repair the dumpsters. On 04/01/25 at 3:00 Pm a review of Healthcare Services Group Policy 028, procedure number seven (7) stated All trash will be properly disposed of in external receptacles (dumpsters)…

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 interview, the facility failed to ensure orders were being monitored by having an order for medicine to be taken orally for Resident #64 who is NPO (nothing by mouth). This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the Long-Term Care Facility. Resident identifier: #64 Facility Census: 115 Findings include: a) Resident #64 On 04/01/25 02:58 PM during record review the following orders were found; Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth one time a day for DM, ASCVD Pharmacy Active 3/14/2025 10:00 - 3/18/2025 NPO (nothing by mouth) diet, NPO texture, NPO consistency Diet Active 9/10/2024 17:48 9/11/2024 on 04/01/25 at 3:10 PM LPN #13 states he (resident #64) does not take anything by mouth. i give all his (Resident #64) medications via G-tube. At 3:20 PM Corporate Registered Nurse (RN) #134 stated We will get the clarified and corrected now.

Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program during medication pass and by not properly disposing of urine. These were random opportunities for discovery. Resident Identifier: #63. Facility Census: #115 Findings Include: a) Resident #63 On 04/01/25 at 7:40 AM during medication administration observation with Licensed Practical Nurse (LPN) #69 it was observed that the LPN placed a 50 milligram Tramadol pill in her ungloved hand and then placed it in the medication cup and administered to Resident #63. This was confirmed immediately with the LPN and then with the Administrator and Corporate Registered Nurse #134 on 04/01/25 at 8:45 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to educate, offer and obtain declination or consent for influenza and pneumococcal immunizations. This was true for one (1) of five (5) Residents screened for immunizations. Resident I\identifier: #83 Facility Census: 115 Findings Include: a) Resident #83 (Influenza and Pneumococcal) On 04/03/25 at 09:54 AM during record review of resident immunizations it was found that Resident #83 is a [AGE] year old that was admitted on [DATE]. There is no documentation of any past influenza (flu) or pneumococcal (pneumonia) immunizations education, consents or declinations. The influenza vaccination is marked Not eligible due to being admitted after flu season. The resident was admitted on [DATE]. According to the Centers for Disease Control and Prevention (CDC) guidelines, the flu season runs from October through May. The resident or Medical Power of Attorney (MPOA) should have been educated and offered the influenza vaccine in or near October of 2023 and again…

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 educate, offer and obtain declination or consent for COVID-19 2024-2025 immunizations. This was true for one (1) of five (5) Residents screened for immunizations. Resident Identifier: #83 Facility Census: 115 Findings Include: a) Resident #83 (COVID 19) On 04/03/25 at 09:54 AM during record review of resident immunizations it was found that Resident #83 is [AGE] years old and was admitted on [DATE]. There is documentation that the resident received the following COVID 19 vaccinations prior to admission to the facility: COVID 19 Vaccine dose 1 03/06/21 COVID 19 Vaccine dose 2 04/10/21 Vaccine additional dose 10/27/21 Vaccine additional dose 05/16/22 There is no documentation that Resident #83 or the MPOA was educated or offered a COVID 19 2024-2025 updated vaccination. According to the Centers for Disease Control and Prevention (CDC) guidelines, People ages 65 years and older, vaccinated under the routine schedule, are recommended to receive 2…

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

Based upon record review and staff interview, the facility failed to provide 12 (twelve) hours of education for the past year for nursing aides (NA). This was true for 5 (five) of 5 (five) records reviewed during the annual survey process. Employee iIdentifiers: NA #24, NA #37, NA #48, NA #75, and NA #66. Facility census: 115 Findings include: NA #24's inservices were less than 6 hours. NA #37's inservices were less than 11 hours. NA #48's inservices were less than 11.5 hours. NA #75's inservices were less than 9 hours. NA #66's inservices were less than 10 hours. During an interview, with the Nursing Home Administrator, on 04/03/25 at approximately 12:45 PM, she had nothing to add to about the finding.

Based on record review, staff interview, and resident interview, the facility failed to consider the views of the resident counsel and act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility. This has the potential to affect more than a limited number of residents at the facility. Resident identifiers: #27, #95, #15, #29, #103, #16 and #58. Facility census: 118. Findings included: a) Resident council meeting During the resident council meeting held at 10:00 AM on 03/19/24, numerous residents of the of the seven (7) residents attending ( Residents #27, #95, #15, #29, #103, #16 and #58) either complained of medications being late, waiting for 30 minutes to an hour for call lights to be answered, or cold food. The residents said there was a problem with not having enough staff. They explained staff were scheduled to work but would, call in, leaving the facility short on help. The Residents said staff do the best they can and will apologize when they are late to answer a call light and will even explain what caused…

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, observation and staff interview, the facility failed to develop and/or implement care plans for six (6) of 38 residents reviewed during the long term care survey. Residents #17, #88 and #117 did not receive care and treatment for pressure ulcers as directed by the care plan. Resident #71 was not care planned for advanced directives. Resident #108's care plan was not implemented for the prevention of edema. Resident #63 did not have care plan interventions in place for the prevention of falls. Resident identifiers: #17, #63, #117, #108, #88, and #71. Facility census: 118. Findings included: a) Resident #17 Review of the current care plan found the following: Focus: (Revised 03/03/14) Resident at risk for skin breakdown related to decreased mobility and has actual skin breakdown unstageable to right buttock, skin tear to right knee. The goal associated with the focus: The resident's wound/skin impairment will show signs of healing as evidenced by decrease in size, absence of erythema 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 record review and staff interview the facility failed to revise comprehensive care plans as needed. This was true for three (3) of thirty-eight (38) care plans reviewed during the Long Term Care Process. Resident Identifiers: #93, #77 and #51. Facility Census: #118 Findings include: a-1) Resident #93 On 03/20/24 at 11:15 AM record review of Resident #93's care plan shows she is permitted to smoke with supervision per the smoking assessment. The care plan was created on 08/29/22. According to the two smoking assessments on file, dated 10/02/23 and 01/03/24 Resident #93 is not allowed to smoke. Confirmation with the Director of Nursing on 03/20/24 at 11:30 AM confirms that Resident #93 does not smoke. a-2) Resident #93 On 03/20/24 at 11:15 AM record review of Resident #93's care plan shows she is at risk for complications related to the use of psychotropic drugs: anti-psychotic, anti-depressant, anti-manic and anti anxiety medications. The care plan was created on 04/05/22 and revised on 06/13/23. Review of current medications ordered for Resident #93 shows she is not on ant…

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, resident interview and staff interview, the facility failed to follow or obtain physician's orders regarding medication administration, obtain a weight and a physician's order for advance directives. This is true for seven (7) of 38 residents reviewed during the survey process. Resident identifiers: #88, #9, #108, #112, #103 and #71. Facility Census: 118. Findings Included: a) Resident #88 On 03/17/24 at 11:40 AM, a physician's order was found stating, Extremity Protectors to be in place to bilateral arms. Remove every shift and prn (as needed) for bathing/skin inspections. (Typed as written. On the following dates and times, observations were made to show the extremity protectors were not in place: --03/17/24 at 11:40 AM --03/18/24 at 12:40 PM --03/18/24 at 4:00 PM --03/19/24 at 8:20 AM On 03/19/24 at 8:25 AM, the resident was interviewed and asked do you wear the extremity protectors on your arms? The resident stated, I haven't worn them for a couple of weeks .I don't know when the last time was. On 03/19/24 at 9:25 AM, the Director of Nursing (DON) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview and staff interview, the facility failed to ensure three (3) of four (4) residents reviewed for the care area of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Resident identifiers: #17, #117, and #33. Facility census: 118. a-1) Resident #17 - Treatments During an interview with the resident on 03/17/24 at 12:07 PM, the resident stated she developed a pressure ulcer on her backside while at the hospital, she still has it, but believes the area is getting better. Record review found the resident was admitted to the facility on [DATE] with an unstageable pressure ulcer to the right gluteus. Review of the treatment administration record (TAR) for February and March 2024 found the following orders for treatment to the pressure ulcer: -On 02/06/24 an as needed (PRN) order was written to, cleanse the unstageable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure all medical supplies stored in the medication storage room were stored in accordance with currently accepted professional principles. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: #118 Findings include: a) Medication Storage Room on 200 hall On [DATE] at 10:42 AM observation of the medication storage room on the 200 hall found the following supplies to be expired: Expired supplies as listed: Fifty two (52) Female Luer Lock Caps expired 1- expired on 03-23-21. 18 - expired on 01-03-22 13 - expired on 09-02-22 3 - expired on 11-01-22 14 - expired on 01-11-23 3 expired on 02-19-24 Eleven (11) Magellan 1 milliliter Tuberculin Safety Syringes expired on 08-31-23. The above information was confirmed with the Director of Nursing on [DATE] at 10:50 AM.

Based on observation and staff interviews, the facility failed to post accurate menus prior to meal times. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 118. Findings included: a) Observation At approximately 10:40 AM, on 03/17/24, the facility was observed having old menus hanging on the 300 and 400 hallways. The following menus were posted: Thursday's Breakfast Specials Cereal and Juice Oatmeal Scrambled Eggs Eggs prepared to order Choice of Bakery Breads Friday's Lunch Specials Tossed Salad with Signature Dressing Chicken Pot Pie Dinner Roll with Margarine or, Spinach Frittata Hash Browns Dinner Roll with Margarine Seasonal Fresh Fruit Saturday's Dinner Specials Baked Ham Seasoned [NAME] Beans Sweet Potato Casserole Dinner Roll with Margarine or, Roasted Chicken Season [NAME] Beans Sweet Potato Casserole Dinner Roll with Margarine Scalloped Apples At approximately 10:50 AM, the Record Management Manager (RMM) acknowledged the incorrect menus posted in the hallways. At approximately 11:00 AM…

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, record review, and resident interview, the facility failed to serve food at palatable temperatures for resident consumption. There were a total of 18 complaints of cold food during the survey process. This had the potential to affect more than a limited number of residents. Resident identifiers: #224, #223, #117, #33, #12, #51, #82, #59, #103, #73, #71 #55, #27, #95, #15, #29, #16 and #58 complained of cold food during the long term care survey. Facility census: 118. Findings included: a) Resident interviews Residents #224, #223, #117, #33, #12, #51, #82, #59, #103, #73, #71, #55 #27, #95, #15, #29, #103, #16 and #58 complained of cold food during the long term care survey on 03/17/24. In addition Residents #27, #95, #15, #29, #103, #16 and #58 complained of cold food during the resident council meeting held on 03/19/24 at 10:00 PM. b) Food temperatures At approximately 01:26 PM on 03/18/24, temperatures were taken by the Registered Dietitian (RD), along with the District Manager of Dietary Services (DMDS) and the Dietary Account Manager (DAM), from a test tray…

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 establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections due to not wearing protective protection equipment (PPE) in an enhanced barrier room and touching the surroundings with soiled glove for Resident #88, for proper storage of a nebulizer mask for Resident #62, no hand hygiene completed before meals for room [ROOM NUMBER], 408 and 411 and by placing a dirty meal tray on a clean dining cart. These were random opportunities for discovery. Resident Identifiers: #88 and #62 . Facility Census: 118. Findings Included: a1) Resident #88 On 03/18/24 at 12:40 PM, Nurse Aide (NA) #107 was observed completing incontinence care for Resident #88 without wearing proper PPE (gown). The door was noted with signage stating, Enhanced Barrier Precautions .during high-contact resident care activities .changing briefs and assisting with toileting…

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 dignified and respectful existence for Resident #88 and #104. These were random opportunities of discovery. Facility Census: 118. Findings included: a) Resident #88 On 03/18/24 at 12:40 PM, an observation was made during preparation for wound care. Registered Nurse (RN) #102 was performing hand hygiene and Nurse Aide #107 was gathering supplies for incontinence care. After the incontinence care was complete, the resident remained uncovered from 12:42 PM through 12:52 PM. Resident #88 was lying in bed with her brief unfastened and folded down. On 03/18/24 at 12:52 PM, NA #107 obtained a blanket from the resident's closet and covered the resident after wound care was completed. On 03/18/24 at 12:58 PM, RN #102 was notified of the time frame the resident was exposed. RN #102 stated, oh, okay. On 03/18/24 at 1:05 PM, the Director of Nursing (DON) was notified about the resident being exposed while awaiting wound care. The DON stated, thank you for letting me know. b) Resident #104 At approximately 2:02 PM 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 observation, record review, and resident and staff interview, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure water temperatures in the shower room were comfortable for Resident #73. This was a random opportunity for discovery. Resident identifiers: #73. Facility census: 118. Findings included: a) Resident #73 At approximately 12:24 PM on 03/17/24, an interview was conducted with Resident #73 concerning the care they received while residing in the facility. Resident #73 stated their showers are frequently cold when they receive them. An interview was conducted with RN #41, in which it was confirmed Resident #73 received their showers in the 100 Hall Shower Room. At approximately 02:25 PM on 03/18/24, temperatures were taken in the shower rooms with the Maintenance Director (MD) and Maintenance Helper (MH) #99. The water temperature of the shower room on the 100 hall, where Resident #73 received showers, was taken twice. The first temperature taken by the MD was 86.9 degrees fahrenheit. The MD stated, This doesn't feel right,…

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 resident and staff interview, the facility failed to provide activities of daily living (ADL) care to a dependent resident by not providing proper nail care to Resident #104. This was true for one (1) of two (2) residents reviewed for ADL care. Resident identifier: 104. Facility census: 118. Findings included: A) Resident #104 At approximately 01:55 PM on 03/17/24, while conducting an interview with Resident #104, their toenails were observed as being long. Resident #104 was asked if they preferred having long toenails, to which they stated, Not really, I would like to have them trimmed, but they haven't been touched in a long time. At approximately 2:57 PM on 03/17/24, an interview was conducted with Nurse Aide (NA) #132, who was providing care for Resident #104. NA #132 stated they knew Resident #104 would like to have their toenails trimmed and that it had not been done yet. NA #132 stated, I know they're long and they need trimmed but we just haven't had a chance to get to it yet. At approximately 09:45 AM on 03/19/24, Resident #104's toenails were…

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, resident interview and staff interview, the facility failed to maintain a safe and accident-free environment as possible. These were a random opportunities for discovery. Resident identifiers: #87 and #73. Facility Census: 118. Findings Included: a) Resident #87 On 03/17/24 at 11:47 AM, an interview with Resident #87 was held. During the interview, an observation of two (2) medication cups with a clear cream inside was found sitting on the over-the-bed table by the bed. The resident was asked, do you know what is in the medication cups? The resident responded, I think they use that for my wound on my leg. On 03/17/24 at 11:50 AM, Licensed Practical Nurse (LPN) #135 was notified regarding the two medication cups with a clear cream inside. LPN #135 stated, let me get rid of that .I'm not sure what it is .it looks like Aquaphor. On 03/17/24 at 12:30 PM, the Director of Nursing (DON) was notified and confirmed no medication should be kept at bedside. b) Resident #73 At approximately 12:27 PM on 03/17/24, an observation was conducted in the bathroom of Resident…

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

Based on observation and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of one (1) residents reviewed under the care area of dialysis. Resident Identifier: #51. Facility Census: 118. Findings Included: a) Resident #51 On 03/19/24 at 10:36 AM, a record review was completed for Resident #51. The review found the dialysis communication book was incomplete. On the following dates the hemodialysis communication book was missing information: --03/01/24 pre-dialysis facility nurse signature and date --03/01/24 post dialysis no assessment of the arteriovenous (AV) shunt and no indication of new orders from the dialysis center --03/04/24 dialysis center AV assessment was incomplete and the nurse signature and date were missing --03/04/24 post dialysis vital signs were not completed by the facility nurse --03/08/24 dialysis center section was incomplete in all fields including pre-and post weights --03/11/24 dialysis center section was incomplete in all fields including pre-and post weights --03/13/24…

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.

Based on record review and staff interview, the facility failed to complete performance reviews for Nurse Aides at least once every twelve months. This was true for one (1) of five (5) employees reviewed for performance reviews during the long term care survey process. Facility census: 118. Findings included: a) Nurse Aide #34 At approximately 01:39 PM on 03/19/24, record review was conducted for the facility's staffing. The Director of Nursing (DON) produced the yearly performance reviews for the requested employees, and stated We are missing the one for Nurse Aide (NA) #34. Upon further record review, it was confirmed the yearly performance review for NA #34 was missing.

Based on record review and staff interview the facility failed to identify a diagnoses for psychotropic medications. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident Identifier: #93 Facility Census: #118 Findings include: a) Resident #93 On 03/20/24 at 08:36 AM record review shows Resident #93 is on three (3) antidepressants. There is an active medical diagnosis listed for Resident #93 of depression and anxiety disease. Behavior documentation was reviewed. The Physician orders are written as: Escitalopram Oxalate Tablet 20 milligrams (MG) give one (1) table by mouth one time a day for targeted behavior(s) potential to demonstrate verbal behaviors related to: ineffective coping skills, related to not wanting a roommate, blasting volume on TV to bother roommates, making false allegations against staff members, can be become angry and yell at staff. Trazodone CL Tablet 50 MG Give 1 tablet by mouth at bedtime for targeted behavior(s) potential to demonstrate verbal behaviors related to: ineffective coping skills, related to not wanting 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.

Based on record review and staff interview the facility failed to maintain complete and accurate medical records. This was true for one (1) of three (3) resident records reviewed for discharge during the Long-Term Care Survey Process. Resident #120 was discharged and the physician did not complete the recapitulation of the resident's stay. Resident identifier: #120. Facility census: 118 Findings included: a) Resident #120 A medical record review on 03/19/24 for Resident #120 revealed the resident was discharged on 12/20/23, with no anticipation to return to the facility. The physician failed to complete a recapitulation of the resident's stay. In an interview with the Nursing Home Administrator (NHA) on 03/19/24 at 10:52 AM, reported he was unable to locate the physician's recapitulation of Resident #120's stay while in the facility.

Based on observation and staff interview, the facility failed to ensure a resident's call light was accessible. These were random opportunities for discovery and affected only a limited number of residents. Resident identifiers: #4 and #63. Facility census: 118. Findings included, a) Resident #4 At approximately 02:18 PM on 03/17/24, the call device for Resident #4 was observed lying on the floor beside the resident's bed and the resident was not able to reach from the bed to retrieve it. At approximately 02:33 PM on 03/17/24, the call device for Resident #4 was observed still on the floor, with the resident still unable to reach it. At approximately 02:35 on 03/17/24, Registered Nurse (RN) #41 entered Resident #4's room to provide assistance to their roommate. Upon entering, Resident #4 asked RN #41 for assistance. RN #41 acknowledged Resident #4, stepped over the call device, and moved the bedside table closer to Resident #4's bed. RN #41 then stepped over the call device again to go to Resident #4's roommate. As RN #41 turned around to leave the room, they walked past the call…

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.

c) Resident #24 During the initial tour on 02/13/23 at 11:33 AM Resident #24 laying in bed, and was easily aroused. The room was dark with no stimulation provided. During an observation on 2/13/23 at 2:18 PM, the Resident was laying in bed. The room continued to be dark with no sensory stimulation. During a review on 02/13/23 at 3:24 PM Resident #24's medical record revealed a care plan with an initiation date of 08/19/22. The care plan contained the following. Focus Statement: While in the facility, resident/patient states that it is important that she/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. The goal associated with this focus was: Resident/Patient will express satisfaction that her/his daily routines and preferences are accommodated by staff. The interventions included: -I enjoy listening to music and prefer classical and country. -I like to participate in special events and music activities with group of people. -I enjoy watching/listening TV. During an observation on 02/14/23 at 8:12 AM Resident #24 lying in bed 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 record review, and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician's Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This was true for four (4) of 23 reviewed for the Long-Term Care Survey Process. Resident Identifiers: #2, #9, #105 and #43. Facility Census: 115. Findings Included: a) Resident #2 On 02/13/23 at 2:00 PM, the Physician's Orders for Scope of Treatment (POST) was reviewed. On 03/11/21 a verbal consent was obtained by two (2) staff members from the Medical Power of Attorney (MPOA). A review of the [NAME] Virginia End-of-Life Center instructions for completing a POST form was reviewed. The review found the following: If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from…

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, facility documentation, and staff interview the facility failed to implement an infection control intervention designed to reduce transmission of resistant organism (Multidrug-resistant organism (MDRO) transmission. This failed practice had potential to affect a more than a limited number of residents who currently reside at the facility. Resident identifiers: #38, #63, #26, #25 and #166. Facility census 115. Findings included: a) Resident #38 A review of the line listing for infections in the month of 01/23 found the following resident had an MDRO and was not placed in Contact Precautions. Resident #38 was positive for ESBL (extended spectrum beta-lactamase) in the urine on 01/27/23. The resident was treated with Fosfomycin Tromethamine (an antibiotic), and placed on standard precautions. The lab results were from an outside facility and were dated 01/27/23. The final results on the report were: Escherichia coli ESBL (extended spectrum betalactamase) Attention: ESBL!!! FOLLOW CONTACT PRECAUTIONS!!! On 02/15/23 at 8:55 AM, the Infection Preventionist (IP) 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 record review, and staff interview the facility failed to ensure (1) of five (5) Residents reviewed for antibiotic use received the appropriate antibiotic for treatment of an infection. Resident identifier: #63. Facility census 115. Findings included: a) Resident #63 Review of the medical record found a note from the facility provider, dated 12/09/22: Resident #63 was reported to have had a fever. It was documented that Resident #63 had a Urinary tract infection on 11/17/22 and was admitted in an intensive care unit due to septic shock. On this day the provided ordered lab work, CBC, BMP, UA, and culture, however, with the contractures it is difficult to catheterize. Noted Resident #63 also had suprapubic tenderness with palpation. Medications ordered: Ceftriaxone (Rocephin) 1 gram intramuscularly (IM) every 24 hours for fever, likely UTI for three (3) days. Nursing note dated and timed 12/09/22 at 10:21 AM, read: Female nurse attempted to obtain urine for specimen, UTO (unable to obtain). Care provider notified. (This is the only nursing note found about attempting to get…

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 medical record review and staff interview the facility failed to provide a notice of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 form to beneficiaries and/or representatives for one (1) out of three (3) residents reviewed for the care area of beneficiary notices during the Long-Term Care Survey. Resident Identifier: Resident #10. Facility Census: 115. Findings included: a) Resident #10 Record review found CMS form 10123 issued to residents' representative on 12/01/22 . The resident was discharged from skilled care due to reaching the maximum potential in therapy. The last day of covered services was 12/03/22. The resident was discharged from skilled care but continued to reside at the facility with Medicare benefit days remaining. During an interview on 02/14/23 at 2:14 the Business Office Manager (BOM) #140 stated she was unable to find evidence the resident #10's family representative receive an SNF ABN -CMS-10055 . .

Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all residents currently residing in the facility. This had the potential to affect an unlimited amount of residents living in the facility. Facility Census: 115 Findings Included: a) Grievance Forms A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 read as follows. .Process . 2.1 The right to file grievances orally (meaning spoken) or in writing, the right to file grievances anonymously; . During Initial Tour of facility on 02/13/23, observed that the Grievance forms were on the outside of the conference room door not at wheelchair level for resident accessibility. During an interview on 02/14/23 at 12:56 PM, Licensed Practical Nurse (LPN) #37 stated I am not sure about the grievance forms and where to find them, let me go find out. During an interview on 02/14/23 at 12:57 PM, LPN #37 stated the Social Worker is here Monday thru Friday and we send the resident to them. When the SW is not here there is 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 medical record review and staff interview the facility failed to accurately complete a Minimum Data Set (MDS) assessments for two (2) of 23 residents reviewed during the Long-Term Care Survey (LTCSP). Resident #22's MDS was not coded to indicate the Resident's current dental status. Resident #2's MDS was not coded to indicate the resident was receiving dialysis. Resident identifiers: #22 and #2. Facility census: 115. Findings included: a) Resident #22 Observation of the resident on 02/13/23 at 10:19 AM, found she had several decayed teeth on the lower gum. Several teeth were missing and it was unclear if the teeth were broken. Two teeth were black in color. Record review found the resident was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/15/22 found the MDS did not indicate the resident had likely broken teeth or cavities. On 02/14/23 03:30 PM, the Director of Nursing was asked about the residents oral status. The DON…

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 revise a care plan for fall interventions and dialysis. This was true for two (2) of 23 residents reviewed for the care area of care plans. Resident Identifiers: #266 and #2. Facility Census: 115. Findings Included: a) Resident #266 On 02/15/23 at 12:30 PM, the care plan was reviewed for Resident #266. The focus area entitled resident is at risk for falls and lists one (1) intervention. The intervention is keep personal items in reach. The resident was admitted on [DATE] with multiple diagnoses indicating the resident was a high risk for falls. The following diagnoses were listed upon admission: --unspecified lack of coordination --other abnormalities of gait and mobility --disorientation, unspecified --unsteadiness on feet --history of falling --muscle wasting and atrophy, not elsewhere classified, multiple sites --muscle weakness (generalized) The resident was noted with a fall with major injury on 12/24/22. The major injuries listed…

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, staff interview and resident interview, the facility failed to ensure Resident #68 received showers as scheduled. This was true for one (1) of two (2) Residents reviewed for the care area of activities of daily living (ADL) care. Resident #68. Facility census: 115. Findings included: a) Resident #68 On 02/13/23 at 10:42 AM, the Resident said, I can only get 2 showers a week, I was told that's how it is. Other people here need to have showers to. I don't always get the 2 showers a week. The resident was alert and oriented and had capacity to make her own medical decisions. Record review found the resident was admitted to the facility on [DATE]. An interview on 2/14/23 at 2:35 PM, with Licensed Practical Nurse (LPN) #37 found when the resident was admitted on [DATE] she was in room [ROOM NUMBER]. Her shower days were Wednesday and Saturday. When the Resident moved to her current room, 410 on 02/06/23, she was showered on Wednesdays and Sundays LPN #37 confirmed the Resident would have…

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 follow a physician order to administrator an antibiotic as ordered for Resident #63. This failed practice had the potential to affect a limited number of residents that currently reside at the facility. Resident identifier: #63. Facility census 115. Findings included: a) Resident #63 A record review found on 12/24/22 an order was given to administrator Ceftriaxone Sodium Solution Reconstituted 1 gram. (antibiotic given for a urinary tract infection) Use 1 gram intravenously every 24 hours for UTI for three (3) days. Review of the MAR (medication administration record) found Resident #63 only received two (2) doses for two days instead of three (3) as prescribed by the physician. During an interview on 02/15/23 at 1:20 PM, the Director of Nursing (DON) stated the staff did not give the total number of doses ordered. The DON said staff have been re-educated about checking and completing all orders. .

Based on observation, resident interview, staff interview, and record review, the facility failed to ensure that the foot care was provided, consistent with professional standards of practice. Resident #44's toe nail were long and jagged. This was a random opportunity for discovery. Resident identifier: Resident #44. Facility Census: 115 Findings Included: a) Resident #44 During the initial interview process on 02/13/23 at 10:58 AM, observation found Resident #44's , toe nails were long and jagged with chipped red nail polish. Resident # 44's feet were very dry and cracking. During an interview on 02/13/23 at 10:58, Resident # 44 stated they never put lotion on my feet. I have not had my nails trimmed since I have been here. During an interview on 02/13/23 at 2:13 PM Registered Nurse (RN) #122 acknowledge Resident #44 long toenails and dry feet. RN #122 stated (name of company) sees her for her toe nails, there is no physician's orders for foot lotion but I will get one. During an interview on 02/13/23 at 2:52 PM, the Director of Nursing (DON) stated Resident # 44 was was receiving…

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, record review and staff interview, the facility failed to ensure the residents' environment was free from accidents and hazards as is possible. This true for one (1) of six (6) reviewed for the care area of accidents. Resident Identifier: #7. Facility Census: 115. Findings Included: a) Resident #7 On 02/13/23 at 10:31 AM, a medicine cup with white powder inside was found at the bedside of Resident #7 with no label or name listed. On 02/13/23 at 10:33 AM, Licensed Practical Nurse (LPN) #33 was notified. LPN #33 stated, it looks like nystatin powder and it shouldn't be sitting at the bedside. On 02/13/23 at 10:45 AM, the Director of Nursing (DON) was notified and stated it should not be at bedside .I will get an education out right now. No further information was obtained during the long-term survey process. .

Based on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This was true for one (1) of two (2) residents reviewed for respiratory care area. It was observed Resident #67 was not receiving the oxygen therapy at the prescribed rate. Resident identifier: Resident #67. Facility census: 115. Findings Included: a) Resident #67 During an observation on 02/12/23 at 10:52 AM Resident #67's oxygen flow rate was at five (5) liter/minute (l/m) via nasal cannula. On 02/13/23 at 1:25 PM Licensed Practical Nurse LPN #37 acknowledged Resident #67 was receiving her oxygen at five (5) l/m. After review of Resident #67's orders, the physician orders for oxygen was three (3) l/m. During a record review on 02/13/23 at 2:02 PM, Resident #67's medical record revealed a physician order dated 02/17/22: Oxygen via nasal cannula at three (3) liters for Shortness of Breath. .

Based on record review and staff interview, the facility failed to ensure the physician documented a rationale in the medical record when the physician disagreed with a recommendation from the pharmacist to attempt a gradual dose reduction (GDR) of an antipsychotic medication for Resident #13. This was found for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #13. Facility census: 115. Findings included: a) Resident #13 Record review the resident was receiving the antipsychotic medication Olanzapine (Zyprexa) for a diagnosis of Schizoaffective disorder with hallucinations. A new order written on 02/07/23, found Olanzapine (Zyprexa) 1 tablet by mouth at bedtime. (The order failed to include the dose of the medication.) Prior to this order, the Resident was receiving Olanzapine (Zyprexa) 2.5 mg at bedtime for psychosis/hallucinations/confusion. This medication had a start date of 08/02/22 and was discontinued on 02/07/23. Record review found a pharmacist consultation report, dated 02/02/23. Under the comment section 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 ensure an antipsychotic (Xanax) medication prescribed on an as needed basis (PRN) had non-pharmacological interventions implemented/attempted before administration. In addition, the targeted behaviors that would warrant the administration of the PRN medication were not specific. The Resident also received the antipsychotic medication (Zyprexa) even though a gradual dose reduction was indicated by the physician. The Zyprexa was also administered in absence of the dose indicated for use. The medical record did not include the side effects of the medication for nursing staff to monitor. This was true for one (1) of five residents reviewed for the care area of unnecessary medications. Resident identifier: #13. Facility census: 115. Findings included a) Resident #13 I. Alprazolan (Xanax) On 12/16/22 an order was written for Alprazolam tablet 0.25 mg, give 1 tablet by mouth every 12 hours as needed for Anxiety for 7 days. The medication was administered on 12/18/22 at 7:29 PM, 12/18/22 at 7:29 AM and 7:50 PM, and 12/22/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on policy review, observation and staff interview, the facility failed to ensure safe and sanitary use of resident owned refrigerators. This is true for two (2) refrigerators identified by a random opportunity for discovery. Resident rooms: room [ROOM NUMBER] and room [ROOM NUMBER]. Facility census: 115. Findings include: a) room [ROOM NUMBER] A review of the facility policy titled Refrigerators: Patient In-Room with a revision date of 09/01/22 read as follows. .Practice Standards . .4.1 A Refrigerator/Freezer Temperature Log will be maintained for every patient refrigerator. 4.2 Nursing will observe and record temperatures of the refrigerator on a daily basis using the Refrigerator/freezer Temperature Log. During the initial tour on 02/13/23 at 10:38 AM an observation reveled the resident room refrigerator temperature log was incomplete. Evidence revealed the temperature log was missing documented temperatures for the following days: -02/04/23 void temperature and initials -02/05/23 void temperature 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.