Pierpont Center At Fairmont Campus

Based on record review and staff interview the facility failed to provide bed hold notification for residents being discharged /transferred. This is true for two (2) of two (2) resident's reviewed for discharge/transfer. Resident identifiers, Resident #117 and Resident #115. Facility Census 111. Findings included: b) Resident #115 Medical chart was reviewed for a hospitalization. The facility did not provide a bed hold notification for the resident being discharged to the hospital. On 01/07/26 at 01:00PM, Social Worker #56 confirmed there was no bed hold notification and reported that the resident was going to discharge anyway to another facility. Social Worker #56 reported the resident went to the hospital and discharged from the hospital to another skilled nursing facility. The social worker stated, Nurses aren't so good here about the bed hold policy. b) Resident #117 On 1/06/26 at 02:36 PM this surveyor was reviewing documentation of transfer of resident to hospital from this facility and asked for the following documents: Behold Notice, Transfer Notice and Ombudsman…

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 new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for one (1) out of three (3) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifier: #1. Facility census: 111 Findings included: a) Resident #1 Record review revealed the most recent PASARR was completed 07/28/25. Resident #1 was given new diagnoses of Bipolar disorder, depression, anxiety on 08/06/25. During staff interview on 01/06/26 at approximately 1:00 PM, the director of Social service reported, We use meditelecare for psych services, once they update a diagnosis I am informed to update the PASSARR. At end of the week they send us a report of who was seen and any change given. Review of facility policy revealed, Social services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1:1 it is learned after admission that the Pre- admission…

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 baseline care plan was developed and implemented with instructions needed to provide effective and person-centered quality care. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #126. Facility Census: 111 Findings included: Resident #126 On 01/05/26, the resident's care plan was initially reviewed for diet and nutritional information due to no diet order found on Resident #126's medical record. On the resident's Care Plan Report, the only focus documented was for resident assistance for mobility related to recent hospitalization. Upon further review, no care plan focus, goals or interventions were listed for behavior/emotions, dementia care, nutrition or psychotropic medications were found on the resident's initial care plan. The resident's care plan was updated on 01/05/26 following surveyor intervention. On 01/05/26 at 1:55 PM, the Corporate Compliance Officer confirmed the care plan had only one focus for mobility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation the facility failed to ensure a resident's care plan was revised in the areas of dialysis catheter and activities. Resident identifiers: #15 and #51. Facility Census: 111Findings included:a) Resident #15 On 01/07/26 a review of Resident #15's care plan revealed the following: Resident is scheduled for outpatient surgery on 10/21/25 to get dialysis catheter removed. Date initiated and created 10/19/25. Goals and interventions were also listed for time of procedure. On 01/07/26 2:38 PM, Resident #15 reported he had a dialysis catheter removed from his chest a few moths ago, around October and now has a fistula in his arm. He pulled down his shirt without being prompted and exposed the cite where his catheter once was and stated it had healed and that there were no issues. On 01/07/26 3:00 PM, Corporate Nurse #129 acknowledged that resident's care plan needed to be revised. b) Resident #51 The initial observation on 01/05/26 at 1:59 PM, revealed Resident #51 lying…

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 program of activities to meet the interest of and support the physical, mental, and psychosocial well-being of each residents. This failed practice was found true for (2) two of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #51, and #52. Facility Census 111. Findings Include: a) Resident #51 The initial observation on 01/05/26 at 1:59 PM, revealed Resident #51 lying in her bed, saying repeatedly, I hurt, I hurt. There was no stimulation in the room. Further observation on 01/06/26 at 2:00 PM, revealed Resident #51 lying in her bed, turned toward the separation curtain. No stimulation on in the room. A review on 01/07/26 at 9:30 AM, of Resident #51's Activity participation for the months of 11/2025, 12/2025, and 01/2026 to date, revealed that the resident has had a significant decrease in her activity participation. During the month of 11/2025 Resident #51 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, record review, and staff interview the facility failed to ensure the environment in which it had control of to be as free from accident hazards as possible, by not ensuring fall prevention interventions were being followed. This failed practice was found true for (1) one of (3) three residents reviewed for falls during the Long-Term Care Survey Process. Resident identifier: #5. Facility census: 111.Findings Include: a) Resident #5 A record review, on 01/07/26 at 5:30 PM, revealed that from 10/01/25 to present, Resident #5 has had (6) six falls. One (1) fall with serious injury, and two (2) of the falls were from bed one causing a skin tear to her right eye. Further record review revealed a falls care plan that read as follows:Focus: Resident is at risk for falls: Impaired mobility.Fall on 08/30/25 no injuries.Fall on 09/15/25 no injuries notedFall on 10/31/25 no injuries notedFall on 11/12/25 no injuriesFall on 11/13/25 no injuriesFall on 12/8/25 no injuriesFall on 12/10/25 skin tear above R eye One of the interventions for falls initiated on 12/11/25 for 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, staff interview and resident interview, the facility failed to ensure staff supports the nutritional well-being of the residents while respecting the individual's right to make choices about their diet and taking the resident's preference into consideration. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #24 and #97. Facility Census: 111. Findings included: a) The facility's policy and procedure for Dining and Food Preferences stated the resident's Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. b) Resident #24 On 01/05/26 at 12:40 PM, Resident #24's tray card was reviewed. Apple Juice 8 oz was printed on the tray card. The resident did not have apple juice on her tray. The resident stated, I've never gotten apple juice. When I first came in they asked my preference, but did not get it. Administration Staff #120 confirmed the resident did not get apple juice ,but reported 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 the facility assessment identified the staffing levels and training requirements needed to provide the necessary care and services for their residents. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 106. Findings included: a) Facility Assessment A review of the Facility Assessment was completed on 03/11/24 at 9:27 PM. On page 20, Section II. Staffing, Training, Services & Personnel A.1. Function - Sufficiency Analysis Summary had the following guidance: Considerations: Use and/or refer to: 1. Staffing and scheduling systems 2. Staff training and competency program 3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. Please document the total #/average/range of staff required to ensure a sufficient number of qualified staff are available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation…

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 and staff interviews, the facility failed to ensure each resident had reasonable and ready access to their personal funds held by the facility. This was true for four (4) out of 11 residents that were interviewed during the resident council meeting. This had the potential to affect more than a limited number of residents. Facility census: 106. Findings included: a) Resident Council At approximately 3:00 PM on 03/12/24, a resident council meeting was held at the facility. During that meeting, four (4) residents in attendance expressed concerns about personal funds held by the facility. Residents stated that obtaining money on the evenings and weekends was difficult, with one resident stating I'm not even sure we can get the money after they leave the offices for the day, so the weekend wouldn't be possible. Another resident stated outings had to be canceled the day of the event, on more than one occasion, because the facility did not have money for the residents to take. At approximately 12:50 PM on 03/13/24, an interview was conducted with Receptionist #107…

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, resident interview and staff interview, the facility failed to ensure the living areas for residents were clean, safe, and sanitary; failed to ensure furniture was in good repair; failed to clean and/or change the P-Tac (packaged terminal air conditioner) vents (filters on the heat and air conditioners that are in each room.); and leaving a large amount of transparent type on a resident wheelchair. Resident identifiers: #35, #90. The facility census 106. Findings included: a) P-Tac vents During a tour on 03/12/24 at 2:34 PM of Rooms #301, #302, #303, #304, and #305 it was discovered the P-Tac vents were heavily soiled with a thick layer of debris. The above findings were verified on 03/12/24 at 2:54 PM with Maintenance Helper (MH) #43. MH #43 said the P-Tacs should be cleaned or replaced monthly. He went on to say it should be documentation of when it was last done on a form, he referred to Direct Supplies Tell MH #43 did not provide this documentation at the close of the survey. According…

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 ensure all residents were free from unnecessary medication psychotropic medications used for refusal of care. This was true for two (2) out of five (5) reviewed for unnecessary medication. Resident identifiers: #5. and #91. Facility census 106. Findings included: a) Resident #5 While reviewing orders for an antipsychotic named Abilify. It was discovered that Abilify was ordered on 01/07/2024. The order was written as typed below: Abilify Oral Tablet 5 MG (Aripiprazole) Give 5 mg (milligram) by mouth one time a day for antipsychotic Target behavior: refusal of care, combative, aggression. On 03/13/24 at 11:24 AM Director of Nursing (DON) was shown the above order. DON stated, We do not give medications for refusal of care. b) Resident #91 During record review for Resident #91 on 03/11/24 at approximately 12:15 PM, it was discovered the resident had the following order beginning on 01/25/24. Abilify Oral Tablet 10 MG (Aripiprazole) Give one tablet by mouth at bedtime for mood target behavior: refusal of care. At…

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 update the Pre admission Screening and Resident Review (PASRR) for a resident that was diagnosed with a serious mental disorder upon admission to the facility. This was true for nine (9) of ten (10) residents reviewed for Preadmission Screening and Resident Review (PASARRs) during the long-term care survey process. Resident Identifiers: #82, #38, #6, #32, #29, #37, #102, #77. Facility census:106. Findings included: a) Resident #82 At approximately 9:00 AM on 03/12/24, a record review was conducted for Resident #82. It was revealed that Resident #82 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. According to the PASRR for Resident #82, major depressive disorder was not marked. At approximately 12:00 PM on 03/13/24, the Director of Nursing (DON) was notified and acknowledged the missing diagnosis from Resident #82's PASRR. b) Resident #38 At approximately 9:00 AM on 03/12/24, a record review 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 provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner and failed to follow a physician's order regarding Insulin. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Facility census 106. Findings included: a) RSV immunization During a review of the facility documents regarding immunization it was determined that zero (0) out of 106 residents had been provided educational information about the risk and benefits of receiving the RSV vaccination. On 03/13/24 at 1:25 PM, the Infection Preventionist (IP) stated she had not offered the RSV vaccine. She stated that the facility did not offer the RSV vaccine. b) The Centers for Disease Control and Prevention (CDC) Respiratory Syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more…

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 all vials of multi-use insulin were labeled with the initial date it was opened. This was true for three (3) out of three (3) vials found in the medication cart. Resident identifiers: #32, #72, and #71. Facility census 106. Findings included: a) Medication cart On 03/13/24 at 9:06 AM Registered Nurse (RN) #28 verified the following insulin vials for the following residents did not have a date to indicate what day it was initially opened. The facility staff should date the label of any multi-use vial when the vial is first accessed and access the vial. A multi-use vial of Lispro belonging to Resident # 32 did not have a date on the vial. A multi-use vial of Lantus belonging to Resident # 71 did not have a date on the vial. A multi-use vial of Levemir belonging to Resident # 72 did not have a date on the vial. A multi-use vial once punctured is not to be used longer than 30 days per the CDC. On 03/13/24 at 11:30 AM the Director of Nursing (DON) was informed of the issues above.

Based on observations and staff interview, the facility failed to store food in accordance with professional standards for food service safety. It was discovered food was not stored properly in the freezer, a trash can was situated near the beverage dispensers, a broken floor tile and a dirty floor in the walk-in freezer. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 106. Findings included: a) Kitchen tour During a kitchen tour, on 03/11/24 at 11:30 AM, it was discovered that a box of breaded fish filets were not sealed properly exposing the filets to the elements in the walk-in freezer. A trash can was stored in front of the beverage dispensers, causing the staff to lean over the trash can in order to fill the beverage pitchers, beside the ice machine there was a large section of a floor tile missing. Also the floor of the walk-in freezer had debris and food particles under the shelving unit. In an observation and interview with the Dietary Manager (DM), on 03/11/24 at 11:45 AM, the DM verified the breaded fish filets were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations and staff interviews, the facility failed to ensure the Quality Assessment and Assurance committee made good faith attempts to correct quality deficiencies of which it did have or should have had knowledge. The discovery was made during the facility tasks area for a Safe/Clean/Comfortable and Homelike environment for leaks in the ceiling, damaged furniture, a resident's wheelchair had damage to the armrest and the heating, ventilation and air conditioning (HVAC) units had an excessive amount of dust buildup. These deficient practices did not allow for a safe, clean, comfortable and homelike environment for residents. Facility census: 106. Findings included: Based on observation, resident interview and staff interview, the facility failed to ensure the living areas for residents were clean, safe, and sanitary; failed to ensure furniture was in good repair; failed to clean and/or change the Packaged Terminal Air Conditioner (P-Tac) vents (filters on the heat and air conditioners that are in…

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 observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent cross-contamination and the development and transmission of communicable diseases and infections with regards to laundry services, bed pan storage and the community ice machine. This practice had the potential to affect all resident's resident in the Facility. Resident Identifiers: #16, #256, #257, and #59. Facility census: 106. Findings included: a) Bedpan Storage An observation of Resident's #16, #256, and #257's adjoining restroom found their used bed pans stored together without covers in the bathtub. During an interview and observation on 03/11/24 at 2:05 PM Nurse Aide (NA) #92 stated they should be stored in bags. When asked how to tell them apart she stated that they should have names on them. She proceeded to put the used bed pans in bags and place them back in the bathtub. b) Laundry Services An observation during the laundry tour on 03/13/24 at 3:20 PM found,…

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, record review and staff interview, the facility failed to ensure the residents choices were honored in regard to diet. This was true for one (1) of one (1) residents reviewed for choices. Resident identifier: #9. Facility census: 106. Findings included: a) Resident #9 On 03/11/24 at 1:39 PM Resident #9 said she is lactose intolerant and today they gave her cheese on her sandwich again. She stated that she picked the cheese off of the grilled ham and cheese sandwich and ate the ham and one slide of the bread. Resident #9 stated she did not want anything else to eat. Care Plan Review Revealed: The resident is at risk for dehydration as evidenced by medications (diuretic, laxatives). H Encourage residents to consume fluids during & between meals. Offer 1 cup Lactaid milk & 1 cup Cranberry juice at breakfast. Monitor weight per protocol and report as indicated Resident is at nutritional risk r/t (related to) dx (diagnosis) of Type 2 Diabetes Mellitus (T2DM), adult failure to thrive (FTT), hypothyroidism, major depressive disorder, Chronic Kidney…

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 notify the resident's representative in a timely fashion when care was altered. An antibiotic, Amoxicillin, was ordered for Resident #54 on 03/08/24 but the Resident Representative was not informed of the new medication order. The facility's failure to notify the resident's representative of a change in condition was true for one (1) of 29 residents sampled in the Long-Term Care Survey Process. Resident Identifier: #54. Facility Census: 106. Findings included: a) Resident #54 A record review, completed on 03/11/24 at 9:11 PM, revealed: -A 03/08/25 at 00:00 Encounter note which stated, Patient requested to be seen by staff for right sided facial swelling. The patient is unable to provide information, family is not available, and prior charts do not include family history. Diagnosis and Assessment: Sialectasia of parotid gland (a condition resulting from duct obstruction of the parotid or submandibular glands associated with pain and swelling) and Abscess (abscesses occur when an area of tissue becomes infected and 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 ensure a resident's right for privacy and confidentiality. Resident #95 had three (3) signs regarding personal care information posted throughout her room. Resident identifier: #95. Facility census: 106. Findings included: a) Resident #95 During a visit on 03/11/24 at 1:15 PM, the following three (3) typed signs were on display in Resident #95's room: -I do not get up alone. -I get help for the bathroom. -No straws. A subsequent record review, on 03/11/24 at 3:02 PM, revealed Resident #95 lacked decision-making capacity and had a family member serving as her Medical Power of Attorney (MPOA). During a telephone interview on 03/11/24 at 7:59 PM, Resident #95's MPOA stated, The nursing staff must've done that. It wasn't a request from the family. On 03/12/24 at 10:55 AM, the Social Worker #145 confirmed the signs in the resident's room were visible to others and included clinical and/or personal information on how to provide appropriate care to the resident. The Social Worker also confirmed the need for the signage to be…

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

Based on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury was reported in a timely manner to the appropriate state agencies. This failed practice was true for one (1) of two (2) residents reviewed for falls during the Long-Term Care Survey Process. Resident identifier: #29. Facility Census: 106. Findings included: a) Resident #29 A record review, completed on 03/11/24 at 8:36 PM, revealed the following: A General Note, dated 11/22/2023 at 8:56 PM, indicated a resident had fallen in her bathroom. The resident was alert and verbal. The resident complained of right arm pain and left hip pain. Resident's physician was notified, and the resident was sent to the hospital for further evaluation. Another General Note, dated 11/23/2023 at 2:19 AM, documented, Resident returned from ER (emergency room) with diagnosis of facial contusion, cervical sprain, contusion of left hip, skin tear of right top hand, and nasal bone fracture. Review of the facility's reportable log, completed on 03/12/24 at 1:25 PM, revealed the fall 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.

Based on medical record review and staff interview, the facility failed to provide the Notice of Transfer to the State Ombudsman. This was discovered for one (1) of one (1) residents reviewed for a transfer/discharge during the Long-term Care Survey Process. Resident #105 was transferred to another long-term care facility and no notice of transfer was sent to the State Ombudsman. Resident identifier #105. Facility census: 106. Findings included: a) Resident #105 A medical record review on 03/13/24 revealed the notice of transfer was not sent to the State Ombudsman for Resident #105 when transferred to another facility on 12/12/23. In an interview with the Licensed Social Worker (LSW) on 03/13/24 at 9:45 AM, verified the Notice of Transfer was not sent to the State Ombudsman regarding the transfer for Resident #105, who was transferred to another long-term care facility. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to update the PASARR for a resident that had a diagnosis of a serious mental disorder after admission to the facility. This was true for one (1) of ten (10) residents reviewed for Pre admission Screening and Resident Review (PASARRs) during the long-term care survey process. Resident Identifier: #6. Facility census: 106. Findings included: a) Resident #6 At approximately 9:00 AM on 03/12/24, a record review was conducted for Resident #6. It revealed that Resident #6 was admitted to the facility on [DATE] and was diagnosed with schizophrenia on 09/07/19 and the resident's PASARR was not updated to reflect the diagnosis. According to the PASARR for Resident #6, seizure disorder is marked as a current diagnosis, however, schizophrenia is not. At approximately 12:00 PM on 03/13/24, the Director of Nursing was notified and acknowledged the missing diagnosis from Resident #6's PASARR. .

Based on record review and staff interview, the failed to develop a comprehensive person-centered care plan for the area of discharge planning. This was true for one (1) of one (1) resident care plans reviewed for discharge planning during the Long-Term Care Survey Process. The care plan for Resident #105 was not developed for discharge planning. Resident identifier: #105. Facility census: 106. Findings included: a) Resident #105 A medical record review on 03/13/24, revealed Resident #105 was discharged on 12/12/23. The comprehensive person-centered care plan had not been developed for any discharge planning for Resident #105. In an interview with the Licensed Social Worker (LSW) on 03/13/24 at 9:20 AM, verified the care plan had not been developed for discharge planning for Resident #105.

Based on record review and staff interview, the facility failed to revise a person-centered comprehensive care plan. This was true for one (1) of four (4) resident care plans reviewed for urinary catheter care during the Long-Term Care Survey Process (LTCSP). The care plan for Resident #84 had not been revised when the urinary catheter was removed. Resident identifier: #84 Facility census: 106. Findings included: a) Resident #84 A medical record review on 03/13/24 indicated Resident #84 had an indwelling urinary catheter removed on 02/05/24. The care plan had not been revised to indicate the urinary catheter had been removed for Resident #84. During an interview with the Director of Nursing (DON) on 03/13/24 at 11:54 AM, verified the care plan had not been revised when the urinary catheter had been removed on 02/05/24 for Resident #84. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and resident and staff interview, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for one (1) of one (1) residents reviewed for ADL care during the long-term care survey process. Resident Identifier: #38. Facility census: 106. Findings included: a) Resident #38 At approximately 1:41 PM on 03/11/24, an interview was conducted with Resident #38. During the interview, the resident stated they had been at the facility for a couple of weeks and had only received bed baths. The resident said, I would really like to get in the shower to get my hair washed. At approximately 1:30 PM on 03/12/24, records were obtained from the Director of Nursing (DON) pertaining to Resident #38's showers. The DON stated Resident #38 was to receive baths on Wednesdays and Saturdays. Upon review of the records obtained from the DON, it was revealed…

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 resident environment remained free of accident hazards over which it had control. A prescribed medication was found on the floor in Resident #43's room. This was a random opportunity for discovery. Resident Identifier: #43. Facility census: 106. Findings included: a) Resident #43 During an in-room visit on 03/11/24 at 12:14 PM, an unidentified white, round, scored (having a line down the middle to make it easier to split) pill was found on the floor in front of Resident #43's bed. On 03/11/24 at 12:17 PM, Social Worker #145 confirmed the pill was on the floor During an interview, on 03/11/24 at 12:20 PM, LPN #16 identified the pill as Amiodarone and stated resident received the medication for AFib (atrial fibrillation, which is a type of arrhythmia, or abnormal heartbeat.) According to Healthline, (https://www.healthline.com/health/amiodarone-oral-tablet), the medication Amiodarone has boxed warnings. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). It alerts doctors…

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 ensure all residents were free from unnecessary psychotropic medications used for refusal of care, no rationale provided for continuing to use a psychotropic PRN (take as needed) medication used longer than 14 days. This was true for two (2) out of five (5) reviewed for unnecessary medication. Resident identifiers: #5. and #91. Facility census 106. Findings included: a) Resident #5 While reviewing orders for an antipsychotic medication Abilify it was discovered that Abilify was ordered on 01/07/2024. The order was written as typed below: Abilify Oral Tablet 5 MG (Aripiprazole) Give 5 mg by mouth one time a day for antipsychotic Target behavior: refusal of care, combative, aggression. On 03/13/24 at 11:24 AM the Director of Nursing (DON) was shown the above order. DON stated, We do not give medications for refusal of care. Medical records show Resident #5 was ordered Xanax 0.25 mg 1 tablet Q12 hours as needed for anxiety on 01/07/24. On 03/13/24 at 11:24 AM, the DON could not provide a rationale for having an order…

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 appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently. This was a random opportunity for discovery. Resident identifier: #37. Facility census: 106. Findings Included: a) Resident #37 An observation on 03/11/24 at 12:36 PM, noon meal, found Resident #37 having issues drinking her milk. Review on 03/11/24 of Resident #37's tray card revealed regular water in a spout cup. During an interview on 03/11/24 at 12:40 PM, Nurse Aide #67 stated that Resident #37 doesn't like the spout cup, so they don't provide it to her. A record review on 03/12/24 at 9:12 AM revealed a care plan: Focus: - Resident was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Paralysis affecting left extremities. Goals: Residents ADL care needs will be anticipated and met throughout the next review period. Intervention: The resident must use a proval cup (blue handles) for all liquids. Continued…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and resident and staff interview, the facility failed to maintain accurate and complete medical records by failing to accurately record side effects of psychotropic medications, and not accurately documenting the type of ADL care provided to dependent residents. This was true for two (2) of two (2) residents reviewed for documentation during the long-term care survey process. Resident identifiers: #38, #91. Facility census: 106. Findings included: a) Resident #38 At approximately 1:41 PM on 03/11/24, an interview was conducted with Resident #38. During the interview, the resident stated they had been at the facility for a couple of weeks and only received bed baths. The resident said, I would really like to get in the shower to get my hair washed. At approximately 1:30 PM on 03/12/24, records were obtained from the Director of Nursing (DON) pertaining to Resident #38's showers. The DON stated Resident #38 was to receive baths on Wednesdays and Saturdays. Upon review of the records…

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 observations, family interview, and staff interviews the facility failed to provide a homelike environment by not having adequate bed linens. This had the potential to affect all residents residing on the A hallway. Resident identifier: Resident #3. Facility Census: 108. Findings included: a) Resident #3 09/05/23 at 11:00 AM, Resident #3 and #39's family was standing in hallway. They said that staff was cleaning Resident #3. She had a bowel movement and was all over her and the bed. They were told that they would clean her up but would not be able to change the sheets as none were available. 09/05/23 at 11:10 AM asked Employee #147 if Resident #3's bed had been changed. She said she had cleaned the resident but there were no sheets available to make the bed. 9/05/23 at 11:17 AM, the surveyor asked the Administrator why there were no sheets for bed changes. He said they were on the way. The Laundry had been notified. When asked if they routinely ran out of linen, he said not usually but occasionally they were late coming from the laundry. On 09/05/23 at 11:19 AM, 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 post up-to-date data for nurse staffing. During the tour for a complaint investigation, it was discovered the Daily Nurse Staffing Form had not been updated since 09/01/23. The deficient practice had the potential to affect more than a limited number residents and visitors. Facility census: 108. Findings included: a) During an observation on 09/05/23 at 4:45 AM, it was discovered the staff posting, for public view had not been updated over the holiday weekend. The Daily Nurse Staffing Form had a date of 09/01/23. In an interview with the Nursing Home Administrator on 09/05/23 at 9:00 AM, verified the Daily Nurse Staff Posting had not been updated since 09/01/23.

, Based on observation and staff interview, the facility failed to provide a dignified dining experience. This was true for six (6) out of 12 residents dining in the Vintage dining room. Facility census 112. Findings included: a) Vintage Dining Room During an observation on 11/28/22 at 12:35 PM, Nurse Aide (NA) #37 served a tray to one resident that was seated with a table mate. NA #37 continued to serve two other tables, doing the same leaving the other resident at the table without their meal, before moving on to other tables. It was approximately seven (7) to 10 minutes before serving the other table mate. On 11/28/22 at 12:52 PM, NA #37 said he has never heard of having to serve both residents at the same table before moving on to serve other residents seated at other tables. During a brief interview on 11/28/22 at 1:10 PM, the Director on Nursing (DON) stated she will have to address that issue and she knows she has work to do. The DON went on to say she has only been in the facility for six (6) weeks. .

Based on observation, resident council minutes, resident interview, and staff interview the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances concerning issues of resident care. This had the potential to affect more than a limited number of residents living in the facility. Facility census: 112. Findings Included: A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Policy .Center leadership will investigate, document and follow up on all concerns and grievances registered by any patient or patient representative a) Resident Council Meeting held on 05/30/22 Record review on 11/29/22 revealed a Resident Council meeting held on 05/30/22. The following concerns were voiced: -There are issues with the lack of variety of the food -The food has been cold. -Complaints on cleanliness of rooms -Wait times regards to call lights. b) Resident Council Meeting held on 06/27/22 Record review on 11/29/22, revealed a 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 record review, staff interview, and resident interviews, the facility failed to notify a resident and/or resident's responsible party of a significant change in the resident's condition. Resident's #64 and #42 was not informed of physician appointments and Resident #105's representative was not notified when a change occurred in the medication regimen. This deficient practice was found for three (3) of 17 sampled residents. Resident identifiers: #64, #42 and #105. Facility census: 112. Findings included: a) Resident #64 During an interview, with Resident #64, on 11/28/22 at 4:15 am, he voiced the concern about not being notified of his appointments prior to the ambulance and/or facility van arriving at his door. It is hard to be ready for an appointment when I am not informed about them. Review of Resident 64's medical records found the resident has capacity to make his own medical decisions. The following appointments found no documentation the resident was notified, and no physician order's for: --10/26/21- Cardiologist --05/03/22- CT scan --01/04/22- Heart stress test 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, resident interview, and staff interview, the facility failed to have adequate clean bed and bath linens in good condition. This had the potential to affect more than a limited number of residents at the facility. Facility census: 112. Findings include: a) Confidential interviews: Confidential interviews found residents do not have linen available at all times - especially the fitted sheets, wash clothes, and towels in late evening hours through the night shift. b) Laundry Supervisor Interview and tour of laundry facilities: On 11/30/22 at 11:45 am, a tour of the building found the laundry facilities are located in a separate facility. The facility's laundry aide takes the dirty linen to another facility and picks up clean linens at 8:00 am, 11:00 am, 1:30 PM and 3:00 PM. The facility has no new linen available at the present time. c) Linen storage closet inventory: Inventory of the linen closets with the Laundry Supervisor on 11/30/22 at 1:10 PM. found: Unit A- Sixteen (16) flat sheets, twenty (20) fitted sheets, five (5) wash cloths, twenty (20) towels 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was developed for smoking, an indwelling urinary catheter and dialysis. This was true for three (3) of 27 residents reviewed for the care area of developing and implementing a comprehensive care plan during the long term care survey process. Resident Identifiers: Resident #99, #102 and #105 . Facility Census: 112. Findings Included: a) Resident #99 On 11/28/22 at 2:53 PM, a list of smokers was provided by the facility. Resident #99's name was on the list. On 11/29/22 at 1:25 PM, a record review was completed for Resident #99. Upon completion of the review, the care plan did not list the smoking status as a focus area. On 11/30/22 at 8:15 AM, the Director of Nursing (DON) confirmed the smoking status was not listed on the care plan. No further information was obtained during the long-term survey process. b) Resident #102 On 11/28/22 a record review was completed for Resident #102. Upon completion 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.

Based on resident interview, record review, and staff interview, the facility failed to ensure three (3) of four (4) resident's dependent upon staff for bathing activities, received the necessary care and services to maintain good grooming, and personal hygiene. Resident identifiers: #24, #19, and #14. Facility census: 112. Findings included: a) Resident #24 On 11/28/22 at 2:14 PM, the resident was observed to be disheveled. His hair was unclean, with the roots of the hair stuck to his head, and his hair was not combed. When asked if he was allowed to choose his bathing activity, the resident said he didn't think he had a bath for a while. He said he would like to have a shower every now and again. Review of the most recent Minimum Data Set (MDS), a quarterly with an assessment reference date (ARD) of 11/11/22, found the resident was coded as requiring the extensive assistance of 1 staff person for bathing activities. Review of the medical record on 11/29/22 found the resident's shower days are Monday and Thursday. During the month of November 2022, the resident should have received…

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 interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. This failed practice had the potential to affect four (4) of seventeen (17) residents sampled. Resident identifiers: #79, #69 and 115. Facility census: 112. Findings include: a) Resident #79 Review of Resident #79's medical records, found he was admitted to the facility on [DATE] from an acute care facility. Admitting diagnosis included myelofibrosis, candidemia, bacteremia, urinary tract infection, diabetes mellitus, hypertension, and coronary heart disease. Resident had capacity to make medical decisions. On 10/23/22 the Nurse Practitioner (NP) saw the resident and he was asked about his advance directives. The resident stated he has been on mechanical ventilation twice and does not ever want that again. He stated he would like selective treatments including hospitalization if needed and is willing to have artificial feeding (which he currently does…

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 council, staff interview, resident interview, record review and sampling of test tray, the facility failed to follow the dietary recipe to meet nutritional value and palatability. This was a random opportunity for discovery and had a potential to affect more than a limited amount of residents receiving nutrition from the facility kitchen. Facility census: 112 Findings Included: a) Chicken Vegetable Soup During the interview process of the Long Term Care Survey Process on 11/28/22 several residents had food concerns about taste and temperature. On 11/29/22 four (4) state surveyors tasted the noon time meal for palatability. The chicken vegetable soup was tasteless and not palatable. On 11/30/22 the Certified Dietary Manager(CDM) #148 provided the recipe for the Chicken Vegetable Soup, -Carrots: eight (8) pounds (lb) -Celery: four (4) lbs -Garlic Cloves: two (2) two/three (2/3) ounces (oz) -Yellow Onions: four (4) three/four 3/4 lbs -Squash, Zucchini: five (5) three/eight (3/8) lbs -Margarine: 21 five/eight 5/8 oz -Chicken: four (4) lbs -Water: five (5)…

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, resident interviews, staff interviews, Resident Council meeting interviews, tray temperatures at time of service and a sampled meal, the facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature. This had the potential to [NAME] than a limited number of residents at the facility. Facility census:112. Findings include: a) Confidential Interviews --Food is always cold --Food is cold when we get it. -- They run out of the alternative food cold I lost weight because I can't eat this food. -- I just got beans and they know I don't eat that. I have ordered a chief salad. -- Food is bad. I only eat breakfast the food does not have any seasoning at all. -- Food is horrible. -- Food is cold, bad, and given food I should not have. No salad on weekend due to no lettuce, the menus posted are not followed. -- The food is awful -- The food is horrible, the substitution meal is worse b) Temperature checks -- Food temperatures of lunch meal on 11/29/22 at…

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 meal temperature of each meal prior to serving and staff interview, the facility failed to ensure monitoring records, of temperature logs from the tray line, were completed with each meal. This had the potential to affect more than a limited number of residents. Facility census: 112. Findings include: a) Temperature logs from the tray line: Review of the last week of temperatures from the tray line taken for each meal found no temperatures documented for breakfast on 11/25/22 and 11/27/22. On 11/28/22 at 5:00 PM, the Certified Dietary Manager (CDM) confirmed he could not find the temperatures for 11/25/22 and 11/27/22. No further information was provided. .

Based on staff interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement Committee members attended the meetings. This failed practice had the potential to affect more than a limited number of Residents residing at the facility. Facility census: 112. Findings included: Record review of the facility's sign in sheets for the Quality Assurance Performance Improvement (QAPI) meetings showed the Infection Preventionist had only attended one meeting (on 11/30/21) since September of 2021. On 11/30/22 at 1:00 PM, the Administrator verified the Infection Preventionist was not attending the QAPI meetings. The Administrator stated, We [the facility] did not have one [Infection Preventionist] for a while, that position was vacant. [Current IP name] just started here on July 11th, 2022. During an interview on 11/30/22 at 1:20 PM, the facility's Infection Preventionist (Registered Nurse #117) was asked if she had attended any QAPI meetings? The IP stated, No I have not. I was part of the newest group that just came here in July and needed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. PPE (Personal Protection Equipment) was not readily available for resident care. Hand hygiene for residents was not provided prior to being served a meal. Staff failed to use hand hygiene between residents being served meals and used unsanitized hands to pick up and butter slices of bread. Respiratory equipment was not stored in a sanitary manner. Resident Identifiers: Resident #5, and #83. Facility census 112. Findings included: a) Resident #5 Resident #5 is a totally dependent upon staff for care and has MDROs (Multidrug-Resistant Organisms) which can be easy spread from one resident to another without proper use of PPE. The current MDROs: --Methicillin Resistant Staphylococcus Aureus (MRSA), Carbapenem-Resistant Enterobacter…

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 designate a qualified individual(s) as the infection preventionist(s) (IP)(s) responsible for the facility's IPCP. This had the potential to affect more than a limited number of residents at the facility. Facility census: 112. Findings include: Review of Employee #117, Registered Nurse (RN), Infection Preventionist (IP) records found her hire date was 07/11/22. She stated she is enrolled in a program to be certified but has not completed the program. Per the IP, I have been pulled to give medications frequently. Employee #27, an RN, Market Resource Nurse, provided a certificate of training. E #27 said she was at the facility at least part time and she assisted with infection control program. Review of Employee #27's timecard for November 2022, found she was at other facilities from 11/01/22 through 11/29/22. No further information was provided. .

Based on medical record review and staff interview, the facility failed to ensure residents were offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the residents have already been immunized. This was true for 43 of 112 residents residing in the facility. Resident identifiers: #38, #26, #105, #108, #107, #46, #89, #54, #365, #17, #104, #10, #8, #33, #48, #84, #5, #110, #27, #100, #39, #11, #4, #32, #36, #69, #47, #82, #86, #13, #109, #1, #19, #44, #95, #63, #103, #52, #90, #61, #58, #74, and 29. Facility Census: 112. Findings include: a. Covid-19 vaccinations: Review of the Center for Disease Control and Prevention (CDC) indications for Covid-19 vaccinations as follows: 1st dose, 2nd dose 3 weeks after 1st dose, 3rd- booster- 4 weeks after the 2nd dose and 4th- booster- 2 months after 3rd dose. The following residents were not offered Covid-19 boosters as follows: 1. Resident 38- Received three (3) vaccines- last given 11/10/21. Was eligible for 4th dose on 01/10/22. 2. Resident #26- Received three (3) vaccines- last given 11/08/21. Was eligible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of dialysis during the long-term care survey received hemodialysis care consistent with professional standards of practice including ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring the resident's condition during treatments, monitoring for complications, and implementing appropriate interventions. Resident identifier: #105. Facility census: 112. Findings included: a) Resident #105 Record review found the resident is receiving hemodialysis at an outpatient dialysis center. An order, written at the time of admission on [DATE]: Dialysis center phone number is: (telephone number) Dialysis days: Tuesday, Thursday, and Saturday. Time for Pick up: 0630 Transport to: (name of facility) - order date 10/22/22. The facility uses a communication form, Hemodialysis Communication Record, sent with the resident to each 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.

Based on resident interview, record review and staff interview, the facility failed to ensure the facility physician made all required visits to meet the requirements in frequency/ timeliness. This was true for one (1) out of two (2) residents reviewed for choices. Resident identifier: Resident #23. Facility census 112. Findings included: a) Resident #23 During an interview on 11/28/22 at 2:57 PM, Resident # 23 said she has not seen a doctor in long time. Review of medical records revealed there were no visits from 12/24/21 thru 04/06/22. On 11/29/22 at 9:30 AM Director of Nursing (DON) was asked if there were any documentation of a physician and/or provider visit during the time frame of 12/24/21 to 04/06/22. A year look back on Physician visits revealed -11/30/21 APRN (Advanced Practice Registered Nurse) -12/24/21 visit by DO (Doctor of Osteopathic Medicine) -04/6/22 APRN -05/1/22 MD (Doctor of Medicine) -06/3/22 APRN -08/9/22 MD -09/12/22 APRN -10/7/22 MD -11/21/22 APRN During an interview on 11/30/22 at 8:19 AM, DON was asked if any information was located regarding the three…

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 medications were kept in proper temperature controls in accordance with the accepted professional standards of practice. This was a random opportunity for discovery. Facility Census: 112. Findings Included: a) Medication Refrigerator On 11/29/22 at 8:55 AM, a tour of the medication room on B wing was completed. There was one incomplete temperature log hanging on the medication refrigerator. The November temperature log was entitled Temperature Log For Medication/Vaccine Refrigerator. The Temperature Log for Medication/Vaccine Refrigerators states record temps (temperatures) twice daily. (Typed as written.) On 11/29/22 at 9:03 AM, Registered Nurse (RN) #135 confirmed the log was incomplete in recording the temperatures for the days in the month of November, 2022. RN #135 stated Those days are missing. The following dates are missing temperature checks for the medication refrigerator: --11/01/22 evening --11/03/22 day --11/03/22 evening --11/06/22 evening --11/08/22 day --11/10/22 evening --11/11/22 evening…

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 administer a pneumococcal vaccine after Resident #86 signed a consent on 07/06/21. This was true for one (1) of five (5) residents reviewed for pneumococcal vaccines. Resident identifiers: 86. Facility census: 112. Findings include: a) Resident #86: Review of Resident #86's medical records found on 07/06/21, the resident and/or representative signed a consent for the pneumococcal vaccine. Review of the medical record found no documentation the resident received the pneumococcal vaccine. On 11/39/22 at 9:30 AM the Director of Nursing (DON) reviewed Resident #86's immunization record. She confirmed Resident # 86 had not received the pneumococcal vaccine. No further information was provided. .