Autumn Lake Healthcare At Crystal Springs

Based on observation and interviews, the facility failed to display notices regarding the availability of survey results, and the related plans of correction, in areas that are prominent and easily accessible to residents and their representatives. Facility census: 77. Findings include: a) Observation on 03/04/25 at approximately 10:55 AM, revealed there was no signage posted indicating the availability of the survey results for residents to review. After being notified of this lapse, on 03/04/25 at approximately 11:30 AM, the Administrator indicated that the survey results were available for review in a binder located on the table near the entrance of the facility. During a resident council meeting on 03/05/25, at approximately 2:05 PM, when resident council members were asked, Do you know where the facility survey results are? Resident #5 stated, That's not our business; that's for the staff! The Assistant Director of Nursing (ADON) confirmed on 03/05/25 at approximately 2:30 PM that there was no posted notice identifying where residents or their representatives could review 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 provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one (1) of three (3) residents reviewed during the annual survey process. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #333, #334, and #335. Facility census: 77. Findings Included: a) Resident #333 On 02/19/25 at 2:15 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following resident: Resident #333 began Medicare Part A skilled services on 01/07/25. The last covered day of Part A service was 02/08/25. There was no evidence that a NOMNC form was provided. Review of the social worker's social service notes to Resident # 333's daughter, dated 02/06/25, verified a planned discharge. The note stated, This worker updated (Resident #333) on upcoming discharge that PT/OTwill be put in the home and Lincare is dropping resident off an oxygen tank to have on Saturday after discharge. In an…

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

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Resident #34's bathroom wall was not in good repair. This was a random opportunity for discovery. Resident identifier: #34. Facility census: 77. Findings included: a) Resident #34 Upon entering Resident #34's bathroom on 03/06/25 at approximately 9:20 AM, an immediate observation found one (1) rectangle shaped tear approximately 11 inches wide by 8 inches long in the dry wall on the left wall area, to the left side above the sink. On 03/06/25 at 9:25 AM, during an interview with Registered Nurse (RN) #5 she acknowledged there was a tear in the drywall on the bathroom wall left of the sink. She said she would notify maintenance for repair schedule.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) was updated after a new diagnosis. This was true for two (2) out of three (3) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifiers: #23, #28 and #27. Facility census: 77. Findings included: a) Resident #28 - A PAS, completed on 01/04/18, marked Mental Retardation under Section III Question 30 entitled, Current Diagnosis . Additionally, Section IV Question 37 entitled, Diagnosis included the following: Spontaneous rupture of flexor tendons, right lower leg. Fracture of unspecified part of scapula, left shoulder, initial encounter for closed fracture. essential (primary) hypertension. Mild intellectual disabilities Anxiety disorder, unspecified. A medical record review, completed on 03/04/25 at 9:18 AM, revealed Resident #28 had a diagnosis of: Unspecified Psychosis Not due to due to a substance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and record review the facility failed to provide evidence that residents were invited to care plan meetings in order to participate in planning for her their own care. This was true for Resident #15. Facility census: 77. Findings included: a) On 03/03/25 at 3:41 PM during an interview with Resident #15, she reported that she had never been asked to attend her care planning meetings. She reported that she did not feel she was a part of the decision making process for her care. On 03/05/25 at 3:14 PM an interview was conducted with Facility Administrator who reported that they do not have documentation to support that Resident #15 had been invited to care plan meetings. She stated that the facility, was cited for this last time and they were doing what they were supposed to but do not have current documentation that they have been doing this. A review of Minimum Data Set MDS assessment dated [DATE] Section Q, Participation in Assessment and Goal Setting, question 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 observations, staff interviews, and record review, The facility failed to ensure two (2) of two (2) resident environments were free from accident hazards for which it had control. Resident identifiers: #23 and #34. Facility census: 77. Findings included: a) Resident #23 On 03/03/25 at 02:46 PM It was observed there were no fall mats at Resident #23 bedside per physician orders. 03/03/25 at 2:48 Nurse Aide (NA) #85 acknowledged there were no fall mats on the floor at resident #23's bedside. Physician Order dated 11/27/25 indicated: Fall Mats were to be located at bedside while Resident #23 was in bed. A Care Plan review revealed: Risk for fall R/T (related to) S/P (status post) CVA. Contractures right knee and left hip. Unable to ambulate on own or transfer self in/out of bed. · b) Resident #34 During an observation in Resident # 34's room, on 03/06/2025 at 9:20 AM, a 6 fluid ounce bottle of Derma-[NAME] containing Hydro-Cortisone Cream was found in Resident 34's bathroom. A subsequent record review…

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 ensure the updated staffing information was posted. Facility census: 77. Findings included: a)The facility failed to post an updated staffing report sheet for 03/03/2025. On 03/03/25 at 11:35 AM, Upon entrance to the facility the posted daily staffing report sheet had not been updated for 5 days. The daily staffing report sheet was dated 02/26/2025 actual date of entry was 03/03/2025. 03/05/25 at10:54 AM In an interview with the DON, she acknowledged that on Monday 03/03/25, the Daily Staffing report sheet was dated 02/26/25. The Facility failed to post the census on the nurse staffing data at the beginning of each shift for eight (8) of eight (8) sampled days. Not listed for the 7:00 PM - 7:00 AM shift: -Sunday, 07/07/24 -Sunday, 07/21/24 -Sunday, 08/04/24 -Sunday, 08/18/24 -Saturday, 09/14/54 -Sunday, 09/15/24 -Saturday, 09/28/24 -Sunday 09/29/24 In an interview 03/05/2025 at 10:45AM, the DON confirmed census was not listed.

Based on observation and staff interview it was determined that the facility failed to ensure they disposed of garbage and refuge properly. The facility failed to ensure garbage and refuse containers were in good condition and waste was properly contained in dumpsters or compactors with lids or otherwise covered. This practice had the potential to affect more than an isolated number of residents. Facility census: 77. Findings included: a) On 03/03/25 at 1:35PM during the tour of the facility, the dumpster was observed with one lid open and one lid that was broken and did not fit properly. On 03/03/25 at 1:40PM during an interview with Kitchen Account Manager #44 who acknowledged the dumpster lids should be closed and properly fitting. On 03/06/25 at 1:05 AM, a review of document title HCSG Policy 030, Policy Statement All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures # two (2), The Dining Services Director will ensure that appropriate lids are provided for all containers.

Based on record review and staff interview, the facility failed to implement the care plan intervention of weekly skin evaluations for Resident #30, #76, #18 and #75. This was true for four (4) of five (5) residents reviewed during the survey process. Resident Identifiers: #30, #76, #18 and #75. Facility Census: 82. Findings Include: a) Resident #30 On 11/26/24 at 10:00 AM, a record review was completed for Resident #30. The review found the care plan had not been implemented regarding weekly skin evaluations. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations: --02/19/24-02/27/24 8 days --03/04/24-03/19/24 15 days --04/15/24-04/23/24 8 days --05/14/24-05/28/24 14 days --06/04/24-06/18/24 14 days --07/16/24-08/01/24 16 days --08/06/24-08/20/24 14 days --08/20/24-09/02/24 13 days --09/02/24-09/17/24 15 days --09/30/24-10/14/24 15 days On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly. b) Resident #76 On 11/26/24 at 10:30 AM, a 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 record review and staff interview, the facility failed to follow physician's orders regarding weekly skin evaluations for four (4) of five (5) residents reviewed for quality of care. Resident #30, #76, #18 and #75 were affected by this. Resident identifiers: #30, #76, #18, and #75. Facility Census: 82. Findings Included: a) Resident #30 On 11/26/24 at 10:00 AM, a record review was completed for Resident #30. The review found the physician's order regarding weekly skin evaluations had not been followed. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations: --02/19/24-02/27/24 8 days --03/04/24-03/19/24 15 days --04/15/24-04/23/24 8 days --05/14/24-05/28/24 14 days --06/04/24-06/18/24 14 days --07/16/24-08/01/24 16 days --08/06/24-08/20/24 14 days --08/20/24-09/02/24 13 days --09/02/24-09/17/24 15 days --09/30/24-10/14/24 15 days On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly. b) Resident #76 On 11/26/24 at 10:30 AM, 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 provide an accurate and complete medical record for Resident #75, #30 and #18. This was true for three (3) of five (5) residents reviewed during the survey process. Resident Identifiers: #30, #75 and #18. Facility Census: 82. Findings Included: a) Resident #75 On 11/25/24 at 1:00 PM, a record review was completed for Resident #75. The review found the Physician Orders for Scope of Treatment (POST) form was incomplete. The preparer's signature and date were left blank. On 11/25/24 at 3:30 PM, Social Worker (SW) #48 confirmed the POST form was incomplete. b) Resident #30 On 11/25/24 at 1:15 PM, a record review was completed for Resident #30. The review found white correction fluid on the area of the physician's signature and the preparer's signature and date were left blank on the POST form. On 11/25/24 at 3:30 PM, Social Worker (SW) #48 confirmed the POST form was incomplete and white correction fluid was used on the area of the physician's signature. c) Resident #18 On 11/25/24 at 1:30 PM, a record review 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 medical record review and staff interview the facility failed to honor code status for one (1) of 23 residents reviewed. This is cited as past non compliance due to the facility's correction of the problem prior to the surveyors arrival at the facility. Resident identifier: #83. Facility census: 82. Findings included: a) Resident #83 At approximately 11:00 AM on [DATE], a review of a facility reported incident was conducted. During the review it was noted Resident #83 had passed away at the facility on [DATE] and the facility failed to administer CPR, despite the resident being a full code status. According to a summary report provided by the Administrator and Director of Nursing (DON), Resident #83 had an order to Do Not Resuscitate (DNR) until [DATE], when the code status was changed on [DATE] at a hospital for a surgical procedure. The resident was admitted to the facility on [DATE] with orders from the hospital as a full code, meaning CPR was to be initiated if needed. However, the hospital sent 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 a complaint investigation conducted from 11/25/24 through 11/26/24. Record review, and interview, revealed that the facility failed to ensure that the physician reviewed and documented a response, to the irregularities noted by the consultant pharmacist. This was true for one (1) of six (6) resident records surveyed. Resident Identifier: #35. Facility census:82 Findings included: a) Resident #35 Record review on 11/25/24 at approximately 12:30 PM revealed that Resident #35 was currently on the following medications: Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth every morning and at bedtime for psychosis Order dated 07/18/24 Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 125 mg by mouth three times a day for psychosis may mix in food such as pudding or ice cream. Order dated 07/16/24. Record review of the consultant pharmacist's recommendations for the period 02/09/24 to 11/11/24 revealed the following: Consultant pharmacist review on 04/09/24: The Consulting pharmacist suggested discontinuing PRN use of Seroquel…

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 have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population. This was true for five (5) of five (5) staff members reviewed for competencies. Facility census: 59. a) Nurse Aide (NA) #100 At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #100 had not completed any competencies. At approximately 11:00 AM on 02/22/24, the Director of Nursing (DON) was notified and acknowledged the missing competencies for NA #100. b) Nurse Aide (NA) #38 At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #38 had not…

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

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide appropriate infection surveillance, hand hygiene and catheter care. This failed practice had the potential to affect every resident currently residing in the facility. Resident Identifiers: #43 and #44. Facility census: 59. Findings included: a) Infection Surveillance Record review of the facility's Infection control practices found the facility was unable to provide the required infection surveillance documentation of communicable illnesses. During an interview, on 02/22/24 at 11:25 PM, the Infection Preventionist stated they were unable to locate the documentation of the infection control surveillance prior to her starting in November 2023. No other information was provided prior to the end of the survey on 02/22/24 at 4:00 PM. b) Resident #43 At approximately 1:56 PM on 02/20/24, an observation was made while conducting an…

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

Based on observation, and staff interview, the facility failed to ensure residents have a right to a dignified existence. The staff failed to knock on the door while Resident #44 was receiving catheter care and failed to ensure a dignifying dining service. These failed practices were random opportunities for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Resident identifiers: #44. Facility census 59. Findings included: a) Resident #44 While observing catheter care on 02/22/24 at 8:52 AM on Resident #44, a Housekeeper #21 walked into the room without knocking. On 02/22/24 at 9:14 AM, Housekeeper #21 was asked if she always walks in resident rooms without knocking first. Housekeeper #21 said she knocks but she does it very lightly in case someone is sleeping. b) Dining At approximately 12:58 PM on 02/19/24, an observation was made during lunch service in the North Dining Room of residents at the same table not being served at the same time. Meals were being served to residents in random order at different tables. An…

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

Based on observation and resident and staff interview, the facility failed to ensure that each resident had reasonable and ready access to their personal funds held by the facility. This had the potential to affect more than a limited number of residents. Resident identifier: #43. Facility census: 59. Findings included: a) Resident #43 At approximately 1:56 PM on 02/19/24, an interview was conducted with Resident #43. When asked about the facility holding personal funds and the access they were given to those funds, Resident #43 stated the facility has what is called bank hours, which was designated times residents were allowed to access their funds throughout the day. Resident #43 stated, There have been times that I have not been able to get any money because the bank is not open. If there is a time where the bank is not open and you need money, you just must wait for it to open. If the bank is closed for the day and you need money, you just have to wait for it to open the next day. At approximately 9:40 AM on 02/21/24, an interview with the Administrator revealed the Activities…

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 interview and staff interview, the facility failed to review resident rights during the residents stay. This was a random opportunity for discovery during the Resident Council meeting and had the potential to affect all residents in the facility. Resident identifiers: #12, #22, #51, #169, #19, #41, #29, #46, #7, and #21. Facility census: 59. Findings included: On 02/20/24 at 11:05 AM during the Resident Council meeting Residents #12, #22, #51, #169, #19, #41, #29, #46, #7, and #21 stated that the facility did not go over resident rights during their stay at facility. On 02/21/24 at 10:33 AM the Activity Director (AD) stated that she can't provide evidence of resident rights being reviewed in Resident Council because she had not reviewed resident rights for some time. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, and staff interviews, the facility failed to ensure the facility had a clean comfortable homelike environment for all residents. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Facility census 59. Findings included: a) Shower Room North Short Hall On 02/20/24 at 10:24 AM an observation of shower room number N130 on North Short Hall found towels, blue pleated pants, and a white T-shirt on the floor. In addition, a soiled washcloth with brown matter on it, a shower chair had brown matter on the seat and under the seat, chunks of brown matter were on the floor by the shower chair. The door to the shower room was open. On 02/20/24 at 10:32 AM the Director of Nursing (DON) was shown the shower room and asked Nurse Aide #75 to clean the shower room. b) Bathroom Temperatures On 02/21/24 at 11:05 AM, an overheard conversation between Maintenance #96 and a nurse revealed they were saying that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation, staff interviews and written statements, the facility failed to complete a thorough investigation of an allegation of neglect. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident identifiers: #21. Findings included: a) Resident #21 A review of the timecard punches for the day of 11/24/23 found the following Nurse Aides (NA) worked the following times on the south side of the facility. NA #92 worked 7 AM to 11 AM. NA#67 worked from 7 AM to 7 PM. NA# 110 worked 7 PM to 3 AM NA #30 worked 3 PM to 7 AM NA # 23 worked 3 PM to 11 PM This left two (2) NA's from 7 AM to 11 AM, and one (1) from 11 AM to 3 PM. At 3 PM NA #23 worked until 11 PM and NA #30 worked until 7 AM. NA #110 worked 7 PM to 3 AM. A review of the complaint filed named Resident #21, and a review of the reportable was conducted. A report was filed on 11/24/23 at 8:30 PM for Resident #21. The allegation was that Resident #21 was left on 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 staff interview and record review, the facility failed to develop and/or implement a personalized comprehensive care plan for each resident. This included the care areas of implementing monitoring use of phsychotropic medications, oxygen care and indwelling Foley catheters. This was true for three (3) out of 17 residents reviewed for care plans and affected a limited number of residents Resident identifiers: #44, #43, and #13. Facility census 56. Findings included: a) Resident #44 During a review of the care plan for Resident #44 it revealed the interventions for receiving antipsychotics were: --Assess for changes in mood, behaviors, depression, vital signs, a decline in cognitive and slurred speech. -- In the event of sleeplessness/abnormal behavior provide food, fluids, pain assessment, quiet/dark room, massage/aroma therapy. After a review of the medical chart for Resident #44 found no evidence of behavior monitoring. On 02/21/24 at 1:19 PM the Director of Nursing (DON) was asked for the Mood/Behavior monitoring forms. At 3:39 PM on 02/21/24, the DON stated that there…

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

Based on observation, Facility policy, and staff interview, the facility failed to provide indwelling Foley catheter care at the current professional standard of practice. This is true for one (1) out of three (3) residents who had indwelling Foley catheters. Resident identifiers: #44, #43, and #13. Facility census 56. Findings included: a) Resident #44 On 02/20/24 at 10:06 AM, it was discovered the indwelling Foley catheter collection bag was laying on the floor beside the bed. Also, the Foley catheter collection bag did not have a privacy bag cover. The collection bag contained dark amber urine in color. On 02/20/24 at 10:08 AM, Activities #85 verified the catheter collection bag was on the floor. On 02/20/24 at 10:09 AM Nurse Aide (NA) #38 also verified there was not a privacy cover on the bag, and it was on the floor. At 8:30 AM on 02/22/24 NA #28 was pushing Resident #44 in a wheelchair back to her room. The Foley catheter collection bag was under the wheelchair and the tubing was being dragged on the ground from the dining area to her room. Approximately four (4) inches for…

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

Based on record review and staff interview, the facility failed to complete a performance review of every Nurse Aides at least once every 12 months, and provide regular in-service education based on the outcome of those reviews. This was true for three (3) out of (5) staff members reviewed for performance reviews during the long-term care survey process. Facility census: 59. Findings included: a) Nurse Aide (NA) #100 At approximately 5:00 PM on 02/21/24, during record review for facility staffing, NA #100 was found to be missing a yearly performance evaluation. At approximately11:00 AM on 02/22/24, an interview was conducted with Human Resources (HR) #52, in which they acknowledged and confirmed that NA #100 was missing their annual performance evaluation. HR #52 stated that they were unable to locate the evaluations and were unsure as to whether they were missing or just not done. b) NA #72 At approximately 5:00 PM on 02/21/24, during record review for facility staffing, NA #72 was found to be missing a yearly performance evaluation. At approximately 11:00 AM on 02/22/24, an…

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

Based on record review and staff interview, the facility failed to ensure all posted nurse staffing information was up-to-date and accurate. This was true for four (4) out of five (5) days reviewed for posted nurse staffing information during the long-term care survey process. Facility census: 59. Findings included: a) At approximately 5:00 PM on 02/21/24, during record review for facility staffing, it was determined that the facility failed to update their daily nurse staff postings to accurately reflect the number of staff and hours for the days reviewed. The following days for daily nurse staff postings were reviewed: 08/12/23- The daily nurse staff posting for the day stated there were a total of 264 hours worked with a total census of 59 residents, resulting in an average of 4.47 hours per patient day. The facility hours per patient day (HPPD) report lists the average hours per patient day as 3.59. 08/13/23- The daily nurse staff posting for the day stated there were a total of 248 hours worked with a total census of 58 residents, resulting in an average of 4.28 hours per…

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 failed to have a pharmacist review each resident's medication regimen monthly in order to identify irregularities and maintain record of the identified irregularities and did not follow through with a regimen reccomendation. This was true for five (5) residents reviewed for unecessary medications. Resident identifiers: #24, #61 #44, #28 and #13. Facility census: 59. Findings included: a) Resident #24 A review for Unnecessary Medication for Resident #24 on 02/21/23 found the record did not contain medication regimen reviews or gradual dose reductions for April 2023, June 2023, August 2023, September 2023, October 2023 or December 2023. During an interview on 02/21/23, at 11:10 AM, the Director of Nursing (DON) verified that the facility was unable to find documentation that pharmacy reviews were completed. b) Resident #61 A review for Unnecessary Medication for Resident #61 on 02/21/23 found the record did contain a medication regimen review completed on 02/09/24. The Recommendation for an Abnormal Involuntary Movement Scale (AIMS) 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 observation and resident and staff interview, the facility failed to follow menus for meals and post accurate menus prior to mealtimes. This had the ability to affect more than a limited number of residents. Resident identifier: #16. Facility census: 59. Findings included: a) Resident #16 At approximately 12:47 PM on 02/19/24, an observation was conducted during lunch service in the North Dining Room of menus being hung up late and for the wrong day. Lunch service was scheduled to begin at 12:00 PM, at approximately 12:47 PM, menus were being placed in the hallway on the North wing of the facility. Menus were hung with the meal served that day listed, however, a mark was made through the main course, which was kielbasa, and a new one was handwritten in, pork chops. Tuesday was written at the top of the menu, despite them being for Monday's meal. Nurse Aide (NA) #38 confirmed menus were hung late and listed the wrong day. At approximately 2:19 PM on 02/19/24, an interview was conducted with Resident #16. Resident #16 stated, We never know what we are having for any meal. 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 observation and staff interview, the facility failed to serve milk at appetizing temperature. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility census: 59 Findings included: a) On 02/19/24 at 1:00 PM holding and serving temps were checked with Dietary Manager (DM). The milk temperature was 47.3 degrees Fahrenheit (F). On 02/19/23 at 1:04 PM the DM confirmed the milk should be served no more than 41.0 degrees F. .

Based on record review and staff interview, the facility failed to maintain complete, accurate, and readily accessible medical records for each resident, by failing to include care plan meeting notes in the resident medical records. This was true for three (3) of three (3) residents reviewed for care plan meetings during the long-term care survey process. Resident identifiers: #57, #28,and #43. Facility census: 59. Findings include: a) Resident #57 At approximately 10:00 AM on 02/20/24, a record review was conducted for Resident #57. During record review, no care plan meeting notes were found in the resident's medical record. At approximately 12:00 PM on 02/20/24, care plan meeting notes were requested from the Administrator. At approximately 1:15 PM on 02/20/24, the Administrator was able to produce social services notes, but no notes pertaining to care plan meetings. The Administrator stated the care plan meetings were being done, but no documentation had been put into the electronic health record of the resident. At approximately 11:45 AM on 02/22/24, an interview was conducted…

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 report accurate payroll-based journal information. This was true for five (5) of five (5) days reviewed during the long-term care survey process. This has the potential to affect more than a limited number of residents. Facility census: 59. Findings included: a) During record review of facility staffing, it was determined the facility failed to have at least 8 hours of RN coverage and 24 hours of licensed nursing coverage on 08/12/23, 08/13/23, 08/20/23, 09/03/23, and 09/09/23. According to the facilities punch in and out reports, there was no RN coverage or 24-hour licensed nurse coverage on those days. At approximately 11:00 AM on 02/22/24, an interview was conducted with Human Resources (HR) #52, in which they stated the facility was using multiple staffing agencies at that time, and the process for reporting was to make an excel spreadsheet of agency employees' time worked and send it to corporate for reporting purposes. HR #52 stated it appeared that had not been done, but they would be able to pull reports 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 and staff interview, the facility failed to ensure Nurse Aides (NA) received the required 12 hours of training each year. These training's needed to include dementia training, abuse prevention training, areas of weakness as determined in performance reviews, facility assessment, special needs of residents determined by facility staff, and care of the cognitively impaired resident for those NA's providing care for individuals with cognitive impairments. This was true for three (3) of five (5) NA's reviewed for yearly in-services. Facility census: 59. Findings included: a) Nurse Aide (NA) #100 At approximately 5:00 PM on 02/21/24, a record review was conducted. During that review, it was determined NA #100 had not completed at least 12 hours of annual in-services. NA #100 had not completed the following in-services: Dementia training, infection prevention and control, wandering management and elopement prevention, and hand hygiene. At approximately 11:00 AM on 02/22/24, the Director of Nursing (DON) was notified and acknowledged the missing yearly in-services…

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 interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for two (2) of two (2) residents reviewed for the category of Pre-admission Screening and Resident Review (PASARR), during the long-term care survey. Resident identifiers: #31 and #28. Facility Census 59. Findings Included: a) Resident #31 On 02/20/24, a record review of the resident's electronic medical record (EMR) revealed the resident's most recent PAS, dated 11/03/23, indicated no level II not required. The record also revealed the resident had a developmental disability diagnosis of Moderate Intellectual Disabilities on admission [DATE]. The resident did not receive a new PAS to address whether specialized services were needed. On 02/22/24 at 11:33 AM, the Director of Nursing (DON) and Administrator verified, Resident #31's PAS did not reveal his diagnosis of Moderate Intellectual Disabilities. The DON confirmed a new PAS was not completed. b)…

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 interview, the facility failed to revise a person-centered comprehensive care plan. The facility failed to revise care plans for ambulation. This practice affected one (1) of seventeen (17) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifier #61. Facility census: 59. Findings included: a) Resident #61 On 02/19/24 an observation of Resident (R#61's) found him walking around in his room and the hallway independently without an assistive device. Staff passing and communication with Resident #61. A review of R#61's medical record revealed a Physicians order: --Patient to ambulate with staff assist x1 person using front wheeled walker and gait belt to decrease fall risk. Staff encourage out of bedtime daily to prevent functional decline every shift. Start…

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 Resident #44 received the necessary services to maintain good grooming and personal hygiene. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside in the facility. Facility census 56. Findings included: a) Resident #44 On 02/20/24 at 10:03 AM an observation of Resident #44 found she was unable to wake by calling out name and was wearing blue leopard print top and bottom. hair appears oily and standing up on it own. In general, she appeared disheveled. On 02/21/24 at 11:32 AM Resident #44 was in her bed wearing different clothes. It was a red shirt and tan pants. Her hair appeared to be very wet. One could see a comb was used on her hair as it was pressed against her scalp. On 02/21/24 at 2:52 PM, Resident #44 was in her bed with eyes closed. The comb marks were still visible and her hair was unmoved and still plastered to her scalp. On 02/22/24 at 8:30 AM Resident #44 hair appeared to be stuck to her scalp and had no…

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, policy review, and staff interview, the facility failed to complete neurological assessments after an unwitnessed fall. This was true for one (1) of one (1) residents reviewed for neurological (neuro) assessments during the long-term care survey process. Resident identifier: #57. Facility census: 59. Findings included: Upon review of the facility's policy as it pertains to neurological assessments, residents are to be assessed following a known, suspected (unwitnessed) if the resident is unable to verbalize or has a BIMS score under 9, or a verbalized head injury. Per the facility's policy, neurological assessments are to be completed every 15 minutes x 3, every 30 minutes x 2, 1 hour x 4, and q shift x 6. a) Resident #57 At approximately 10:00 AM on 02/20/24, a record review was conducted for Resident #57. During the record review, it was discovered that Resident #57 sustained an unwitnessed fall with major injury on 08/30/23. According to the incident report, Resident #57 fell face first out of their geri chair and was found on the floor by staff. 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, record review, and resident and staff interview, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan, and the resident's choice, by failing to change the O2 tubing and humidifier for Resident #43 per orders. Resident Identifier: #43. Facility census: 59. Findings included: a) Resident #43 At approximately 1:56 PM on 02/19/24, an observation of Resident #43's oxygen concentrator was made while conducting an interview for the long-term care survey process. The humidifier and tubing were dated for 02/11/24. Upon review of Resident #43's orders, it was determined there were orders for the oxygen tubing and humidifier to be changed once a week. At approximately 1:56 PM on 02/20/24, an interview was conducted with Resident #43 in which they stated, This oxygen is putting water into my nose. An observation of the tubing and humidifier was made and it was determined it had not been changed and was still dated for 02/11/24. At approximately 2:09 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 record review and staff interview, the facility failed to adequately document mood and behaviors for the use of psychotropic medications and failed to attempt a gradual dose reduction. This failed practice was true for two (2) out of five (5) reviewed in the care area of unnecessary medications. Resident identifier: #44, and #28. Facility census: 56. Findings included: a) Resident #44 A review of records revealed Resident #44 was diagnosed with schizophrenia and paranoid disorder. Records showed Resident #44 was receiving the following medications: Risperdal IM 37.5 mg every Friday morning for schizophrenia and paranoia. Risperdal 3 mg every morning. Lorazepam every night. After a review of the medical chart for Resident #44 found there was no evidence of behavior monitoring. On 02/21/24 at 1:19 PM the Director of Nursing (DON) was asked for the Mood/Behavior monitoring forms. At 3:39 PM on 02/21/24 the DON stated that there were no Mood/Behavior monitoring forms for Resident #44, however, she was going to correct that. The DON agreed it was unclear if Resident #44 was…

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

Based on observation and staff interview, the facility failed to ensure there were no expired medications in the medication refrigerator on the South Hall. This failed practice had the potential to affect a limited number of residents. Facility census: 59. Findings included: On 02/21/24 at 12:05 PM in the Medication room on the South Hall, an open multidose vial of Purified Protein Derivative (PPD) was found dated 12/01/23 as the opened date. The vial had been punctured. According to the manufacturer's directions the PPD is only available for use for 30 days after the vial is punctured. Licensed Practical Nurse (LPN) #15 confirmed the PPD was expired and immediately removed the vial.

Based on record review and staff interview, the facility failed to ensure two (2) of 22 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly. Additionally, the facility failed to ensure three (3) of 22 residents or their legal representative were informed of his or her right to develop an advance directive. Resident identifiers: #1, #25, #30, #37, and #44. Facility census: 65. Findings included: a) Resident #1 A medical record review, completed on 07/06/22 at 3:33 PM, found the following: --Health Care Surrogate paperwork indicated a Department of Health and Human Resources (DHHR) employee was Resident #1's legal decision-maker. --POST form, dated 06/27/22, 2016 edition. The POST form was not signed or dated by the physician. The Using the POST Guidance for Healthcare Professionals, 2016 Edition, stated a physician's signature is mandatory. A form lacking a physician's signature is not valid. During an interview on 07/07/22 at 10:51 AM, the Administrator acknowledged the POST form was lacking 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 interview, the facility failed to ensure a resident fall resulting in serious bodily injury and two (2) resident-to-resident physical altercations were reported in a timely manner to the appropriate state agencies. Resident identifiers: #266 and #1. Facility census: 65. Findings included: a) The Federal regulation 483.12(c)(1) directs incidents involving serious bodily injury must be reported to the state survey agency within two (2) hours after the injury is noted. b) The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive the serious bodily injury report within two (2) hours. c) Resident #266 fall resulting in serious bodily injury A review of facility reportables revealed Resident #266 experienced a fall on 12/23/21 at 6:00 AM and was sent to the hospital for evaluation. A subsequent nursing note, on 12/23/21 at 10:50 PM, revealed resident's x-ray showed a displaced intertrochanteric fracture of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and interview, the facility failed to develop person-centered comprehensive care plans. The facility failed to develop care plans for dialysis care, a skin condition, loss of dentures, meal supervision, safety alarms, and an indwelling urinary catheter. This practice affected five (5) of (22) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #19, #6, #28, #37, and #18. Facility census: 55. Findings included: a) Resident #19 On 07/06/22 a review of Resident (R#19's) medical records revealed, a physician's order: Dialysis three (3) times a week with the order date 04/07/22. A review of the current care plan with the initiated date of 05/03/22 showed there was no care plan addressing dialysis…

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 interviews, the facility failed to revise care plans for a resident with weight loss, a resident with a fall and effectiveness of staff interventions with a resident with behaviors. This was true for three (3) of 22 sample residents reviewed for care plans. Resident identifiers: #28, #11, #1. Facility census: 65. Findings included: a) Resident #28 Resident #28 was observed at 07/06/22 at 7:31 AM during breakfast. The Resident's tray had been set up and was feeding himself. Nurses Aide (NA) #60 stated that his wife brings him in things to eat. A review of the care plan on 07/07/22 at 9:48 AM found the following: Focus .Refuses to be fed by staff, refuses supplements at times and refuses other foods offered. Initiated 05/17/22. Goal Will be clean, dry and free from odors and will participate in AM care as evidenced by wash face, hands and upper body every AM after supplies are set up and placed within reach by next review. Revised on 07/02/22. Interventions .Explain…

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, observation and interview, the facility failed to have accurate or follow orders for residents with wander guard, special diet orders, contact precautions, oxygen saturation monitoring and weekly weights. These failed practices had the potential to affect more than a limited number of residents reviewed in survey sample. Resident identifiers #54, #50, #37, #48, #25,#51, #15, #31, #18 #26. Facility Census 65 Findings included; a) Resident #15 On 07/11/22 at 2:56 PM, review of Resident #15's electronic medical record found an order for weekly weights starting 02/23/22 . Review of weights documented by the facility since weekly weights ordered on 02/23/22 revealed: --02/23/22 - 265.6 punds (lbs) --03/04/22 - 268.6 lbs --03/21/22 - 284 lbs --03/24/22 - 277.4 lbs --03/25/22 - 273 lbs --04/07/22 - 255.6 lbs --04/13/22 - 254.4 lbs --04/22/22 - 251.4 lbs --04/28/22 - 252 lbs --05/13/22 - 259.4 lbs --06/20/22 - 247.6 lbs On 7/11/22 at 1:45 PM, interview with Director of Nursing (DON) regarding weekly weights missing. DON stated, Resident #15 does have weekly weights…

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 label and store all medications according to acceptable standards of practice. Three (3) of four (4) residents receiving insulin did not have the insulin dated as to when the insulin was opened. Medication refrigerators failed to have evidence of refrigerator temperatures being monitored daily. Resident identifiers: #35 #62, # 50 and #3. Facility census: 65. Findings included: a) Resident #35 On 07/06/22 at 7:41 AM observed with Licensed Practical Nurse (LPN) #68, Resident #35's Ozempic (non-insulin used to treat Type 2 Diabetes) pen with no date on the pen to verify the date when opened. LPN #68 confirmed the pen should be dated when opened. b) Resident #62 On 07/06/22 at 7:41 AM observed with Licensed Practical Nurse (LPN) #68, Resident #62 Basaglar (insulin) pen with no date on the pen to verify the date the insulin was opened. LPN #68 confirmed the pen should be dated when opened. c) Resident #50 On 07/06/22 at 7:41 AM observed with Licensed Practical Nurse (LPN) #68, Resident #50's Ozempic pen dated 04/04/22.…

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.

Based on record review and interview, the facility failed to have complete, accurate, and readily accessible medical record, including documentation related to legal representation, and advanced directives (Physician Orders of Scope of Treatment or POST form) were not part of the resident's charts or readily accessible for all shifts. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers #17, #51, #15, #43, #50, #48, #30, #1, and #25. Facility Census 65. Findings included: a) Location of POST forms (advance directives) and Staff Interviews During an interview on 07/05/22 at 1:45 PM, with Minimum Data Set Coordinator (MDS) regarding POST forms and where they are located. The MDS coordinator stated, they are kept in a binder in my office for all residents. When asked if that was the only location for resident POST forms in the facility, the MDS coordinator verified that was correct. During an interview with the Director of Nursing (DON) on 07/05/22 at 3:15 PM, she verified that nursing staff would have to access to the 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.

Based on observation and interview, the facility failed to ensure a Resident's catheter bag was covered with a privacy bag. This was a random opportunity for discovery. Resident identifier #45. Facility census: 55. Findings included: Observation on 07/05/22 at 12:19 PM of Resident #45 found her catheter bag hanging on her bed in view of other residents, and visitors. During an interview with Resident # 45 on 07/05/22 at 12:19 PM, she stated that she would prefer the catheter bag be covered. Resident #45's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 05/32/22 noted the resident had a score of 15 on the Brief Interview for Mental Status (BIMS). A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A BIMS score of 15 is the highest score on the scale. During an interview nn 07/05/22 at 12:34 PM, the Licensed Practical Nurse (LPN) #86, verified the catheter bag was not covered. She stated that it should be covered when in view. LPN #86 replaced the privacy bag. .

Based on interview and record review, the facility failed to ensure each resident was provided a verbal and written description of the State Long-Term Care Ombudsman program, the name of the Ombudsman, and contact information in a manner they understood. This had the potential to affect more than a limited number of residents. Resident identifiers: #33, #39, #316, #8, #49, and #16. Facility census: 65. a) Resident Council Meeting - Residents #33, #39, #316, #8, #49, and #16 During a resident council meeting, on 07/06/22 at 1:40 PM, six (6) out of six (6) residents were unable to report where (or if) the Ombudsman's contact information was posted within the facility. No one recognized the Ombudsman by name or by job description. Resident #11 stated, I didn't know someone like that existed or we could speak to someone else about the care we receive. How do we reach her? The other five (5) residents agreed they were unaware of the right to let someone like the Ombudsman know about their care if they ever had a concern. A subsequent review of resident council minutes from July 2021 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 record review and interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form to three (3) of three (3) residents reviewed for the facility's beneficiary protection notification. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #35, #63, and #65. Facility census: 65. Findings included: a) Skilled Nursing Facility Advanced Beneficiary Notice on Non-Coverage Form Instructions Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-Coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires skilled nursing facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary; or considered custodial. b) Residents #35, 63, and 65 On 07/07/22 at 9:15 AM, a review was completed regarding the beneficiary protection notification liability notices…

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

Based on observation and interview, the facility failed to protect resident right to privacy and confidentiality for all aspects of care and services. Signs posted in resident rooms and visible to others included clinical and personal care information. Resident identifiers: #50 and #37. Facility census: 65. Findings included: a) Resident #50 Observation on 07/05/22 at 2:07 PM, found signs posted in Resident #50's room directing staff on the correct way to transfer resident. A second observation, on 07/06/22 at 12:27 PM, revealed three (3) signs with the following wording, [Resident #50's Name] is now transferring using a sliding board for increased safety. Please see therapy if any concerns with this change. Thank you. Slide board is in bathroom. The first sign was on the wall by Resident #50's television and clock. The second sign was to the right side of the resident's bed. The third sign was positioned on the right of the headboard. A fourth sign with the wording, Use Slide board only for transfers. Hoyer lift has been discontinued was also found to the right side 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 interview and record review, the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for two (2) of two (2) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #45 and #28. Facility census: 55. Findings Included: a) Resident #45 On 07/05/22 at 12:23 PM during an interview, Resident #45 stated that she doesn't sleep well, due to the Resident next-door yelling, all the time. She stated that she has talked to the social worker about the issue of the other Residents yelling. A record review on 07/06/22 of grievances, revealed no grievance form was filled out for this issue. Resident #45's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 05/32/22 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15 the highest score obtainable. During an interview with the Social Services Director (SSD) on 07/12/22 at 9:52 AM, she stated she was aware of the complaint about the noise of the other resident but had…

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 the direct monitoring and supervision provided during the use of physical restraint for a resident including documentation of the monitoring. This was true for one (1) of three (3) residents reviewed for physical restraint. Resident identifier: #43. Facility census: 65. Findings included: a) Resident #43 Observation, on 07/05/22 at 12:57 PM, found Resident #43 wore a safety belt when up in wheelchair. An electronic health record review was completed on 07/11/22 at 11:39 AM. There was a physician order, dated 01/28/22, directing: Restraint: seat belt while in w/c (wheelchair). Release seat belt every two (2) hours and prn (as needed) for repositioning visual check every 30 minutes on every shift. The facility's Use of Restraints Policy, dated July 2019, directed: The following safety guidelines shall be implemented and documented while a resident is in restraints . - A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition…

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 thorough investigations of two (2) resident-to-resident physical altercations, maintain documentation that the incidents were thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incidents in accordance with State law. Resident identifier: #1. Facility census: 65 Findings included: a) Resident #1 Resident-to-Resident Physical Altercation on 04/16/22 at 8:00 AM An electronic medical record review was completed on 07/11/22 at 11:00 AM. A general nurses' note, on 04/16/22 at 8:00 AM, revealed, Resident yelling and agitated. Shoved [another female resident] 's wheelchair. [The other female resident] was heading for breakfast cart, but nurse ran over and stopped the wheelchair. A subsequent review of the facility's reportable log revealed the incident was not reported to designated state agencies. During an interview, on 07/11/22 at 3:45 PM, the DON reported the facility did not have an incident report 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.

Based on record review and interview, the facility failed to provide wound care treatment order by the physician for Resident #18. This was true for one (1) of four (4) residents reviewed for pressure ulcers. Resident identifier: #18. Facility census: 65. Findings included: a) Resident #18 A review of Resident #18's medical record showed a physician order dated 06/07/22 stated, weekly wound assessments and documentation on Tuesday. A review of the June 2022 Medication Administration Review (MAR) showed that there was no assessment or wound care provided for the date of 06/14/22. There was no evidence of a progress note that revealed wound care documentation for 06/14/22. During an interview on 07/06/22 at 2:02 PM, Director of Nursing (DON) stated that the wound care for 06/14/22 was not available for that day as the Assistant Director of Nursing (ADON) who provided wound care for the facility right now may be have been pulled to work the med cart that day. .

Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not properly stored. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #46, and #25. Facility census: 55. Findings included: a) Resident #46 An observation on 07/05/22 at 12:05 PM found, Resident #46's's nasal cannula and tubing (an oxygen delivery device) from an oxygen concentrator laying on concentrator without being placed in a protective bag. An interview on 07/05/22 at 12:36 PM with License Practical Nurse (LPN) #86 confirmed that Resident #46's nasal cannula should be placed in a protective bag when not in use. b) Resident #25 Observation, on 07/05/22 at 2:10 PM, found Resident #25's O2 nasal canula stored on top of the oxygen concentrator, not in a sterile bag. Additionally, the resident's nebulizer mask was not bagged and was resting on top of nebulizer machine. During an interview on, 07/05/22 at 2:20 PM, Nurse Aide #8 confirmed 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 provide the necessary behavioral health care services to attain or maintain the highest practicable mental and psychosocial well-being. Resident identifier: #1. Facility census: 65. Findings included: a) Resident #1 An electronic medical record review, completed on 07/06/22 at 1:33 PM, revealed the following documented behaviors: 04/09/22 22:10 General Nurses' Note making rude comments to residents and staff. Calling people fat, and ugly, and stupid and talking very loudly to other residents when they were trying to speak to her or others. Resident noted to be agitated, pacing back and forth, and talking very loudly while pointing her finger at staff / residents. 04/16/22 08:00 General Nurses' Note Resident yelling and agitated. Shoved [another female resident's] wheelchair. Wheelchair was heading for breakfast cart, but nurse ran over and stopped the wheelchair. 04/16/22 11:15 General Nurses' Note Resident loud and arguing with [a male] resident. Resident grabbed [the male resident's] arm and shook vigorously.…

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 interview, the facility failed to ensure narcotics were reconciled per shift. This failed practice had the potential to affect a limited number of residents. Facility census: 65. Findings included: a) Narcotic Count A review of the narcotic count on the North Hall was conducted on 07/06/22 at 7:48 AM with Licensed Practical Nurse (LPN) #68. The narcotic count sheets were found in a spiral notebook. The narcotic note book had no information regarding a card count of the narcotics. The Director of Nursing (DON) confirmed there was no narcotic card count for July 2022 for the North Hall on 07/06/22 at 8:26 AM. LPN #68 stated that she used to count cards but there was no way with the current system to tell if a narcotic sheet and/or medications were missing she understood this could be a problem. On 07/06/22 at 2:34 PM in an interview with the Director of Nursing (DON) regarding narcotic counts agreed there was no way to tell if the narcotic count was correct with the documentation system. The DON confirmed this presented an opportunity for…

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

Based on record review and interview, the facility failed to ensure Resident #54 was free from unnecessary medications. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #54. Facility census: 55. Finding included: A review for unnecessary medication for Resident #54 on 07/06/22 found the record did not contain Physicians responses to the Pharmacist recommendations in March 2022, May 2022, and June 2022. During an interview on 07/07/22 at 10:57 AM the Director of Nursing (DON) stated that there is no documentation for Physician responses from pharmacy reviews on 03/28/22, 5/25/22 or 06/27/22. .

Based on resident interview, staff interview, and medical record review, the facility failed to obtain needed dental services when Resident #28 had missing dentures. This failed practice had the potential to affect a limited number of residents. Resident identifier: #28. Facility census: 65. Findings included: a) Resident #28 On 07/05/22 at 12:25 PM an interview with spouse stated that he (Resident #28) had both lower and upper dentures when admitted to the facility. Further stated that staff think he threw them away. Resident #28 tells spouse he wants his dentures. Spouse stated that she had talked to staff about replacing the dentures but she had not heard back from staff and this had been over a month ago. Licensed Practical Nurse (LPN) #68 on 07/06/22 at 10:45 AM confirmed R #28 had no dentures in place. On 07/06/22 at 11:05 AM in an interview with LPN #68 stated that Resident #28 flushed both upper and lower dentures down the toilet. The Director of Nursing (DON) entered the conference room on 07/06/22 at 2:43 PM and stated the dentures were lost and replaced once and now they…

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 interview, record review, and staff interview, the facility failed to provide a resident with a peanut allergy an alternative nourishing snack when other residents were receiving peanut butter cookies for the bedtime snack. This practice had the potential to affect a limited number of residents. Resident identifier #33. Facility census: 65. Findings included: a) Resident #33 During a resident council meeting, on 07/06/22 at 1:40 PM, Resident #33 stated there are times when the only evening / bedtime snack offered is peanut butter cookies. Resident #33 reported she is allergic to peanuts and cannot eat the cookies. The resident went on to report the staff have replied they do not have an alternative to offer resident and she has gone without an evening / bedtime snack at those times. A brief medical record review, completed on 07/06/22 at 1:35 PM, revealed a nutrition evaluation noting resident was allergic to peanuts and peanut butter. The nutritional evaluation was dated 11/20/21. During an interview on 07/07/22 at 10:00 AM, the Administrator acknowledged the need…

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

Based on observation and interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently. This failed practice had the potential to affect a limited number of residents. Resident #46. Facility census: 55. Findings included: a) Resident #46 An observation on 07/05/22 of the noon meal, found Resident #46 had issues holding the silverware to eat. A record review on 07/06/22 at 9:12 AM revealed a physician order: --Large-handled utensils with all meals, assistive device. Order date on 04/24/22. A second observation on 07/06/22 at the noon meal, found Resident #46 had issues holding the silverware to eat, even dropping the spoon. During an interview on 07/06/22 at 12:29 PM, Resident #46 stated that he was having a little problem with eating because his hands were cold, and he could not grip the utensils. An interview on 07/06/22 at 12:35 PM with Licensed Practical Nurse (LPN) #6 verified Resident #64 had a physician's order for assistive devices for meals. LPN #6 confirmed Resident #46 did not…

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

Based on observation and interview, the facility failed to keep soiled cloths in sanitized bucket and failed to label and date food upon opening or use. This failed practice had the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census 65 Findings included: a) Soiled cloths On 07/05/22 at 11:45 AM, on the initial tour with the Dietary Manager revealed two (2) soiled cloths laying on the counter and on the tray line belt and not in a sanitized bucket. During the initial tour the Dietary Manager agreed soiled cloths should not be laying around and should be in sanitized bucket. The Dietary Manager immediately removed the soiled cloths. b) Unlabeled and dated food item During the same initial tour, revealed two (2) undated or labeled bowls of coleslaw in the reach in refrigerator. The Dietary Manager verified the bowls of coleslaw should not be in reach in refrigerator without being label and dated as to when they were first opened or used. The Dietary Manager immediately removed the bowls of coleslaw. .

Based on facility documentation and interview, the facility failed to ensure current staff were fully COVID-19 vaccinated. This was true for one (1) of eight (8) staff members reviewed for compliance with COVID-19 vaccinations. Facility Census: 65. Findings Included: a) Staff Covid-19 Vaccinations A review of the facility's Infection Control practices found the facility was unable to provide the required evidence of staff Covid-19 completed vaccination in a two-dose series for Nurse Aide (NA) #9. Continued review of facility documentation found NA #9's first vaccine was administered on 05/27/22. There was no evidence the second dose was administered. During an interview on 07/12/22 at 11:36 AM, the Assistant Director of Nursing (ADON) stated that NA #9 was only partial vaccinated. The ADON stated they missed the second dose of the two-dose series. The ADON verified NA #9 was still working in the facility and should have had the second vaccine within 30 days after the first dose. .