Pocahontas Center

Based on record review and staff interview, the facility failed to ensure an incident was reported for a resident who obtained a hematoma to the head following a transfer with a lift requiring staff education. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #37. Facility Census: 59. Findings included: a) The facility's policy and procedure for Abuse Prohibition stated, Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. b) During a Facility Reported Incident investigation, Resident #37's care plan was reviewed. The care plan stated, Resident sustained a hematoma to head (left near top) during transfer using the full body mechanical lift (the bar hit her head). Policy being followed with two-person assist. c) A Facility Reported Incident was not completed, however staff education was completed for a transfer involving 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 record review and staff interview, the facility failed to ensure an investigation was completed accurately and thoroughly for a Facility Reported Incident (FRI) for an allegation of abuse. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #29. Facility Census: 59. Findings included: The FRI summary stated Resident #29 was referred to as [NAME] (not the resident's real name) and was capacitated. The resident was deemed incapacitated by the facility's physician on 12/22/24. The resident's most recent Brief Interview for Mental Status (BIMS) score was a three (3) on 08/01/2025. The resident's BIMS was completed on 08/03/2025 per documentation on the resident's medical record. On 09/30/2025 at 10:45 AM , Corporate Registered Nurse #72 stated that it was an error and that they (the facility) had complete multiple FRI's. The incorrect BIMS date, capacity statement discrepancies and documentation on the reportable with incorrect name were confirmed by 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 record review and staff interview, the facility failed ensure Resident #71 was permitted to return to the facility after hospitalization. This was true for one (1) of one (1) residents reviewed under the care area of Discharges. Resident Identifier: #71. Facility Census: 59.Findings Include:a) Resident #71On 11/03/25 at approximately 9:15 AM, a complaint was reviewed regarding Resident #71 being denied readmission after a hospitalization due to behaviors, a urinary tract infection and severe dehydration. The resident was sent to an acute care facility on 09/12/25. Based on the hospital history and physicaldated 09/18/25 at 10:27 AM, the resident was admitted to a medical unit until a bed became available on the psychiatric unit. The resident continued to have behaviors after intravenous fluids (IVFs) and an antibiotic had been administered. The resident was then admitted to the psychiatric unit on 09/18/25 for further stabilization. Following admission to Psychiatry, the resident expressed concern that…

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

Based on record review and staff interview, the facility failed to ensure an accurate Minimum Data Set (MDS) for Resident #9 regarding hospice care. This was true for one (1) of one (1) residents reviewed under the care area of hospice. Resident Identifier: #9. Facility Census: 59.Findings Include: a) Resident #9 On 09/24/25 at 11:00 AM, a record review was completed for Resident #9. The review found the MDS with an assessment reference date (ARD) of 07/30/25. The resident was placed under hospice care on 07/23/25. However, the MDS section O K1., hospice care was marked no for receiving hospice care. On 09/24/25 at 11:06 AM, the Corporate Registered Nurse (RN) #72 confirmed the MDS was incorrect.

Based on record review and staff interview, the facility failed to develop a complete and accurate care plan for Resident #9. This was true for one (1) of one (1) residents reviewed under the care area of hospice care. Resident Identifier: #9. Facility Census: 59.Findings Include:a) Resident #9On 09/24/25 at 8:55 AM, a record review was completed for Resident #9. The review found the care plan had not been developed completely under multiple focus areas, goals and interventions. The following areas of the care plan were left blank:--Under the focus area of resistive to care related to cognitive loss/dementia, the intervention observe for pain. Attempt non-pharmacologic interventions to alleviate pain (blank) and document effectiveness. Administer pain medications as ordered and document effectiveness/side effects.--Under the focus area of at risk for decreased abilit to per ADLs (activities of daily living( (blank) related to (blank) chronic disease/condition: (specify disease or condition: (blank) Other: (blank).--Under the focus area of hospice, the goal states, Pt/Resident will…

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 input a physician's order for Resident #9 regarding hospice services and follow physician's orders for Resident #26 and #27 regarding late medication. This was true for three (3) of 20 residents reviewed during the survey process. Resident Identifiers: #9, #26 and #27. Facility Census: 59.Findings Include:a) Resident #9On 09/24/25 at approximately 1:00 PM, a record review was completed for Resident #9. The review found the resident was placed under hospice services on 07/31/25. However, a physician's order was not input until 09/24/25. On 09/24/25 at 1:30 PM, Corporate Registered Nurse (RN) #72 confirmed the resident was under hospice services as of 07/31/25 and the physician's order was input on 09/24/25.

Based on record review and staff interview, the facility failed to ensure nurse aide performance reviews were completed annually. This was true for three (3) of five (5) nurse aides' annual performance reviews during the survey process. Facility Census: 59.Findings Include: a) Performance Review On 09/30/25 at 3:45 PM, a review of the five (5) nurse aides (Nas) performance reviews was completed. The review found three (3) of the five (5) performance reviews were not completed. The following were incomplete: --NA #50 due 09/18/25--NA #46 due 06/27/25--NA #38 due 07/25/25 On 09/30/25 at 4:40 PM, the Administrator and the Regulatory Compliance Advisor #73 confirmed the performance reviews were not completed.

Based on observation and staff interview, the facility failed to serve food at an appetizing and palatable temperature for Resident #46. This was a random opportunity for discovery and was true for Resident #46. Resident Identifier: 46. Facility Census: 59. On 11/03/25 at 12:44 PM an observation of Resident #46 found the resident was in her bed with her head at the foot of the bed and the bed wedge was kicked out to the side of her bed. Nurse Aide #35 was asked how much the resident had eaten she stated, I dont know I was not the one who feed her. She said, let me see. She then was asked if her dirty tray was on the cart on the hall, she said no we do not put the dirty ones back on that cart we put them somewhere different. She then opened the cart and stated, Oh she hasn't been feed yet and neither has her roommate. She stated, I will feed her now. The surveyor then asked her to get the dietary manager to test the temperature of the tray and to request a new tray for the resident from the kitchen. A quick tour of the hallway found no other residents were being assisted with their…

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 maintain an infection control program during medication administration for Resident #19. This was true for one (1) of five (5) residents reviewed under the care area of medication administration. Facility Census: 59.Findings Include: a) Resident #19 On 11/04/25 at 8:24 AM, medication administration completed by Graduate Practical Nurse (GPN) #14 for Resident #19. While preparing the medication for administration, GPN #14 touched the medication cart trash can lid two times. GPN #14 did not complete hand hygiene after touching the medication cart trash can lid two times. On 11/04/25 at 9:10 AM, GPN #14 confirmed hand hygiene should have been completed after touching the trash can lid. On 11/04/25 at 9:20 AM, the Director of Nursing (DON) was notified. The DON confirmed hand hygiene should have been completed after touching the trash can lid.

Based on observation and staff interview the facility failed to ensure the resident environment of which it had control was as free from accident hazards as possible. The facility failed to maintain the dryer in a safe manner. This failed practice has the potential to affect all residents currently residing in the facility. Facility census: 67. Findings include: a) Facility On 08/01/24 at 9:40 AM, an observation of the laundry room was conducted. While observing the lint traps in the facility dryers they were noted to full and had overflowed with lint into the floor. On 08/01/24 at approximately 9:50 AM, a review of the facility Environmental Services Operations Manual section Laundry Operations was performed. During this review the section of the manual entitled Lint Screens stated lint screens must be brushed and cleaned after every load or every hour. In addition the section, Lint Screens states that if these lint screens are not brushed and cleaned as stated above the screen will become packed with lint and that when this occurs, the warm air moving through the system is…

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 facility record review and staff interview the facility failed to have Registered Nurse coverage for eight (8) consecutive hours daily. This was discovered through the long term care survey process and has the potentios to affect all residents currently resding in the facility. Facility Census: 67. Findings Include: a) No RN coverage. During a review of the staffing posting forms on 07/29/24 at approximately 6:30 PM the following staffing form for 03/18/23 did not have an RN on staff for the day. It was further observed that 04/09/23 had only 7.83 of the required eight (8) hours of RN coverage. During an interview with the Scheduler #88 on 07/30/24 at approximately 8:55 AM she agreed, there was no RN coverage for 03/18/23 and only 7.83 of the required eight (8) hours for 04/09/24.

Based on facility record review and staff interview the facility failed to complete staff evaluations. This was true for one (1) of five (5) staff evaluations reviewed during the long term care process. Identifier: Certified Nursing Assistant (CNA) # 61. Facility Census: 67. Findings Included: a) CNA #61 During a record review of the CNA's evaluation it is identified that CNA #61 was hired on 05/09/24 and the evaluation was completed by the DON on 06/27/24. However a small yellow post-it note was identified to be covering the signature line for CNA #61 and it stated (typed as written) employee missed to go over review with the [DON name] During an interview with the Scheduler #88, she agreed that the evaluation was incomplete and should have been completed with the staff member when she had returned to the facility.

Based on facility record review and staff interview the facility failed identify the required Certified Nurse Aide (CNA)/nursing competencies to meet the resident populations care needs. This was a random opportunity for discovery during the CNA/nursing competency review of the long term care survey process. This had the ability to affect more than a limited number of residents. Facility Census: 67. Findings Include: a) Facility assessment During a review of the facility assessment on 08/31/24 at approximately 10:30 AM it was identified the facility centered care areas of the resident population is outlined. It is further identified on page 20 of 43 of the facility assessment, under II. Staffing, Training, Services and Personnel that the required nursing competencies to meet the resident population care needs is outlined and under this header (typed as written) Staff Training/Competencies/Skill Sets each category/subcategory listed is marked as sufficient. During an interview with the Person in Charge (PIC) and an assisting Administrator #89 on 07/31/24 at approximately 8:36 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to implement the policy and procedure entitled, Abuse Prohibition. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: Resident #20, Resident #22, Resident #62. Facility census: 67. Findings include: a) Resident #20 On 07/29/24 at approximately 3:15 PM, a review of the facility reported incidents (FRI), it was discovered a FRI had been submitted for Resident #22. During the review of this FRI, it was noted on 07/02/24 at 6:15 PM, Resident #20 was witnessed grabbing Resident #22's breast. Nurse Aide (NA) #62 and NA #40 witnessed the incident, separated and redirected the residents, and immediately reported the incident to Licensed Practical Nurse (LPN) #20. A review of the FRI revealed the following 5 (five) day was submitted as a summary of the incident and read as follows: On July 2, 2024 at approximately 6:15 PM, Resident #20 was witnessed grabbing Resident #22's breast. NA #62 and NA #40…

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 report to the appropriate state agencies as listed in the policy and procedure entitled, Abuse Prohibition. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: Resident #20, Resident #22, Resident #62. Facility census: 67. Findings include: a) Resident #20 On 07/29/24 at approximately 3:15 PM, a review of the facility reported incidents (FRI), it was discovered a FRI had been submitted for Resident #22. During the review of this FRI, it was noted on 07/02/24 at 6:15 PM, Resident #20 was witnessed grabbing Resident #22's breast. Nurse Aide (NA) #62 and NA #40 witnessed the incident, separated and redirected the residents, and immediately reported the incident to Licensed Practical Nurse (LPN) #20. A review of the FRI revealed the following 5 (five) day was submitted as a summary of the incident and read as follows: On July 2, 2024 at approximately 6:15 PM, Resident #20 was witnessed…

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 imvestigate allegations of abuse as listed in the policy and procedure entitled, Abuse Prohibition. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: Resident #20, Resident #22, Resident #62. Facility census: 67. Findings include: a) Resident #20 On 07/29/24 at approximately 3:15 PM, a review of the facility reported incidents (FRI), it was discovered a FRI had been submitted for Resident #22. During the review of this FRI, it was noted on 07/02/24 at 6:15 PM, Resident #20 was witnessed grabbing Resident #22's breast. Nurse Aide (NA) #62 and NA #40 witnessed the incident, separated and redirected the residents, and immediately reported the incident to Licensed Practical Nurse (LPN) #20. A review of the FRI revealed the following 5 (five) day was submitted as a summary of the incident and read as follows: On July 2, 2024 at approximately 6:15 PM, Resident #20 was witnessed grabbing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview the facility failed to act in accordance with currently accepted professional principles in accordance with expired medical supplies. This failed practice has the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 67 Findings include: a) On [DATE] at 8:46 AM observation of the medication/supply storage room found two (2) boxes of [NAME] (BD) Blood Transfer Devices (50 in each box) with an expiration date of 2011-04. b) On [DATE] at 8:46 AM observation of the medication/supply room found twenty (20) urinary catheters which have a past expiration date. Expired urinary catheters (20) 20 French 30 milliliter expired [DATE] 16 French 30 milliliter expired [DATE] X 2 20 French 30 milliliter expired [DATE] 20 French 30 milliliter expired [DATE] 22 French 30 milliliter expired [DATE] X 2 22 French 20 milliliter expired [DATE] 16 French 10 milliliter expired [DATE] X 10 22 French 5 milliliter 2 way expired [DATE] 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 observation and staff interview the facility failed to prevent infections through indirect contact transmission by storing clean resident clothing in the chemical closet of the laundry room. This failed practice has the potential to affect more than a limited number of residents. Facility census: 67. Findings include: a) Facility On 08/01/24 at 9:40 AM, an observation of the laundry room was conducted which revealed several items of personal resident clothing to be hanging in the chemical closet, which was located on the dirty side of the laundry room where soiled linen is brought to for laundering. These personal resident clothing items were in direct contact with the Rapid Multi-Surface Cleaner, this cleaner was confirmed to be used for the mops in the facility by Employee #72. In addition, this cleaning solution was noted to be stored on the floor. At this time, an interview was conducted with Employee #72 who stated she hangs personal resident clothing in this closet after the clothing is laundered and is is not labeled and not able to be directly delivered to 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 provide a dignified dining experience for a resident while assisting them to eat. This was a random opportunity of discovery during the long term care survey process and was true for Resident #7. Resident Identifier: #7. Facility Census: 67. Findings include: a) Resident #7 On 07/29/24 at 1:56 PM, Registered Nurse (RN) #26 was observed standing over Resident #7 on the left side of the resident's bed as she was assisting him to eat. It was observed Resident #7 had a laptop sitting on the over the bed table along with his dinner tray. It was further observed there was an empty chair available to use sitting at the right side of the bed. On 07/29/24 at approximately 1:55 PM, during an interview with Clinical Reimbursement Coordinator Registered Nurse (CRC RN) #32 she stated RN #26 is new and should not be doing that. On 07/29/24 at approximately 1:57 PM, during an interview with RN #26 she agreed she should not be standing over the resident but was concerned with his computer being on the over the bed table with the dinner…

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

Based on record review and staff interview the facility failed to ensure Resident #60 had documentation related to the provision of information provided to Resident #60 and/or Resident #60's representative related to advanced directives. This was true for 1 (one) of 7 (seven) residents reviewed in the Long Term Survey Process. Resident identifier: Resident #60. Facility Census: 67. Findings include: a) Resident #60 On 07/29/24 at 11:47 AM, a record review was conducted for Resident #60 revealing the absence of an Advanced Directive. On 07/31/24 at 4:24 PM, an interview was conducted with Employee #33. At this time, Employee #33 acknowledged no documentation was present to show Resident #60 and/or Resident #60's representative had been provided information related to implementing an Advanced Directive and the facility did not have documentation of an Advanced Directive for Resident #60. Employee #33 stated a call had been placed to Resident #60's representative and Resident #60's representative wanted Resident #60 to remain a Do Not Resuscitate (DNR) at this time. In addition,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview the facility failed to provide the Resident the right to a safe, clean, comfortable and homelike environment. Resident Identifier: Room #A1-1 and B9-1. Facility Census: 67 Findings Include: a) Room A1-1 On 07/29/24 at 9:56 AM, it was observed that room A1-1 had two (2) soiled privacy curtains in the room. One had a brown substance on it and the other had a brown substance and red spots. On 07/30/24 at 10:21 AM, it was observed and noted that the curtains were still in the room. This was confirmed with Registered Nurse #28 and Corporate Clinical Lead on 07/30/24 at 10:03 AM. b) Unit B room [ROOM NUMBER] A During a tour of the facility on 07/29/24 at approximately 9:08 AM of Unit B, the bed side night stand for room [ROOM NUMBER] A was observed to have one third (1/3) of the top surface laminate to be torn off leaving rough edges and the underneath particle board exposed. During an interview with Registered Nurse (RN) #28 on 07/29/24 at approximately 9:30 AM, RN #28…

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 interviews the facility failed to notify to the ombudsman of a resident transfer/discharge to the hospital. This was true for one (1) of three (3) residents reviewed for hospitalizations during the long term care survey process. Resident Identifiers: Resident #68. Facility Census: 67. Findings include: a) Resident #68 During a medical record review for Resident #68 on 07/30/24 at 7:30 AM it was identified the resident had a change in condition for abnormal vital signs and an order was received to transfer the resident out to the hospital on [DATE]. With further review of the medical record a notification to the Ombudsman was not found During an interview with the facility Clinical Reimbursement Coordinator #32 on 07/31/24 at approximately 9:30 AM the CRC stated, the Ombudsman notification was a responsibility of the Social Worker who is out on medical leave. CRC #32 stated, this notification was not completed. She further stated she would reach out to the Ombudsman 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 medical record review and staff interviews the facility failed to notify resident representatives of the bed hold policy at the time of transfer/discharge. This was true for two (2) of two (2) residents reviewed for transfers/discharges during the long term care survey process. Resident Identifiers: Resident #68 and Resident #51. Facility Census: 67. Findings include: a) Resident #68 During a medical record review for Resident #68 on 07/30/24 at 7:30 AM it was identified the resident had a change in condition for abnormal vital signs and an order was received to transfer the resident out to the hospital on [DATE]. Further review of the medical record found the record was void of a bed hold notification to the medical power of attorney (MPOA) for this discharge. During an interview with the facility admission Director (AD) #36 on 07/30/24 at 3:47 PM, the AD stated the bed hold notification had not been completed with this transfer and further stated it should have been but did not know why it wasn't.…

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

Based on record review and staff interview the facility failed to coordinate with the appropriate State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs when completing/revising a Pre-admission Screening and Resident Review (PASSR). This was true for three (3) of three (3) residents who had their PASSR's reviewed during the long term care survey process. Resident Identifiers: 57, 43, 16. Facility Census: 67. Findings Include: a) Resident #57 On 07/30/24 at 11:00 AM record review found Resident #57 had the following medical diagnosis: Schizoeffective Disorder Bipolar Type Onset 06/18/24 Unspecified Dementia Onset 10/06/23 Unspecified Psychosis Onset 10/06/23 Delirium Onset 06/18/24 Major Depressive Disorder Onset 10/06/23 Anxiety Disorder Onset 12/26/23 Review of the PASSR dated 06/13/24 found that the following medical diagnosis were not identified on the PASSR. Schizoeffective Disorder Bipolar Type Onset 06/18/24 Delirium Onset…

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 monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder. This was true for 1 (one) of 1 (one) resident's reviewed for the Long Term Care Survey Process. Resident identifier: Resident #16. Facility census: 67. Findings include: a) Resident #16 On 07/30/24 at approximately 9:00 AM, a review of Resident #16's medical record was conducted. During this review, Resident #16 was noted to have the following diagnoses: 1. Post Traumatic Stress Disorder, Chronic. Dated: 03/20/24. 2. Unspecified Dementia, mild with other behavioral disturbance. Dated: 03/20/24. 3. Schizoaffective Disorder, unspecified. Dated: 03/20/24. 4. Bipolar Disorder, unspecified. Dated: 03/20/24. 5. Major Depressive Disorder, single episode, unspecified. Dated: 03/20/24. In addition, Resident #16 was noted to be receiving the following psychotropic medication: 1. Fluphenazine 2.5 milligrams (MG). Give 1 (one) tablet by mouth three times a day for schizoaffective disorder. 2. Seroquel 200 mg. Give 1 (one) tablet by mouth 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 revise care plan to be resident specific when the residents care needs changed. This was true for two (2) of 23 sampled residents reviewed during the long term care survey process. Resident Identifier: #25 and #44. Facility Census: 67 Findings Include: a) Resident #25 On 07/31/24 at 2:58 PM record review of the comprehensive care plan for Resident #25 found that it had not been revised when they no longer was insulin dependent. The care plan (created on 11/16/23) focus for diabetes states Resident #25 is insulin dependent when in fact her Lantus insulin was discontinued on 07/25/24. This was confirmed with the Corporate Clinical Lead #75 on 07/31/24 at 3:30 PM who agreed the care plan should have been revised accordingly. b) Resident #44 On 07/29/24 at 9:45 AM observation shows Resident #44 is a frail, small resident. She is unable to speak loud enough to be heard. She is laying in a fetal position with contractures observed. On 07/30/24 at 1:55…

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 orders related to reporting elevated blood glucose levels. This was a random oppurtunity for discovery and was true for Resident #25. Resident Identifier: #25 Facility Census: 67 Findings Include: a) Resident #25 On 07/31/24 at 4:16 PM record review found, Resident #25 has the following orders: Monitor blood sugars twice weekly at 6:30 am. Notify Physician if less than (<) 60 or greater than (>)300 one time a day every Wednesday and Sunday for signs and symptoms of hyper or hypo glycemia diaphoresis changes of level of conscience. Documentation shows the following dates the blood glucose was out of range and not reported to the physician as ordered. 04/23/24 309 milligrams per deciliter (mg/dl 04/24/24 345 mg/dl 04/25/24 306 mg/dl 04/26/24 349 mg/dl The above information was confirmed on 08/01/24 at 9:00 AM with Corporate Clinical Lead #75 who agreed all of the elevated blood glucose levels should have been reported to the Physician. .

Based on observation and staff interview the facility failed to ensure a resident who is incontinent of bladder received timely appropriate incontinence care. This was true for 1 (one) of 1 (one) residents reviewed for the Long Term Care Survey Process. Resident identifer: Resident #60. Facility Census: 67. Findings include: a) Resident #60 On 07/29/24 at 9:17 AM, an interview and observation was conducted with Resident #60. At this time Resident #60 indicated he was incontinent, stating Somebody was supposed to come clean me up, but I don't know how long before she gets here. This Surveyor asked Resident #60 if he had used his call bell to alert staff incontinence care was needed. Resident #60 stated he had, and some staff came in an turned it off and told me they would be back after the lunch trays were picked up At this time, this Surveyor walked out of Resident #60's room and spoke with Employee #43 who was outside of Resident #60's room. This Surveyor asked Employee #43 if she was taking care of Resident #60 to which Employee #43 acknowledged she was. This Surveyor informed…

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 monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder. This was true for 1 (one) of 1 (one) resident's reviewed for truama informed care during the Long Term Care Survey Process. Resident identifier: Resident #16. Facility census: 67. Findings include: a) Resident #16 On 07/30/24 at approximately 9:00 AM, a review of Resident #16's medical record was conducted. During this review, Resident #16 was noted to have the following diagnoses: 1. Post Traumatic Stress Disorder, Chronic. Dated: 03/20/24. 2. Unspecified Dementia, mild with other behavioral disturbance. Dated: 03/20/24. 3. Schizoaffective Disorder, unspecified. Dated: 03/20/24. 4. Bipolar Disorder, unspecified. Dated: 03/20/24. 5. Major Depressive Disorder, single episode, unspecified. Dated: 03/20/24. In addition, Resident #16 was noted to be receiving the following psychotropic medication: 1. Fluphenazine 2.5 milligrams (MG). Give 1 (one) tablet by mouth three times a day for schizoaffective disorder. 2. Seroquel 200 mg. Give…

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, resident interview and staff interview, the facility failed to provide medically necessary social services in the area of discharge planning and appointment of a healthcare decision maker. This was a random opportunity for discovery and true for resident #62 and #48. Facility Census: 67. Finding include: a) Resident #62 On 07/29/24 at 10:09 AM, an interview with Resident #62 was conducted. During this interview Resident #62, stated she hoped to go home. She states, she has capacity and is able to care for herself but she needs help finding a place to live. Resident states, the Social Worker has been out for a couple of months. Her last rental home had the heat out, water lines busted and she us unable to go back there. She states, she is [AGE] years old and would like to reside near her family. Resident stated she has been here since February when her ammonia levels where really high and the facility helped to save her life but now she is able to take care of herself, she would like 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 staff interview the facility failed to monitor behaviors for a resident receiving psychotropic medication. This was true for 1 (one) of five (5) resident's reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident identifier: Resident #16. Facility Census: 67. Findings include: a) Resident #16 On 07/30/24 at approximately 9:00 AM, a review of Resident #16's medical record was conducted. During this review, Resident #16 was noted to have the following diagnoses: 1. Post Traumatic Stress Disorder, Chronic. Dated: 03/20/24. 2. Unspecified Dementia, mild with other behavioral disturbance. Dated: 03/20/24. 3. Schizoaffective Disorder, unspecified. Dated: 03/20/24. 4. Bipolar Disorder, unspecified. Dated: 03/20/24. 5. Major Depressive Disorder, single episode, unspecified. Dated: 03/20/24. In addition, Resident #16 was noted to be receiving the following psychotropic medication: 1. Fluphenazine 2.5 milligrams (MG). Give 1 (one) tablet by mouth three times a day for schizoaffective disorder. 2. Seroquel 200 mg. Give…

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

Based on record review and staff interview the facility failed to ensure Resident #16's medical record was complete and accurate. This was true for 1 (one) of 23 sampled residents reviewed during the Long Term Care Survey Process.Resident identifier: Resident #16. Facility Census: 67. Findings include: a) Resident #16 On 07/30/24 at approximately 09:00 AM, a review of Resident #16's medical record was conducted. During this review, Resident #16 was noted to have the following diagnoses: 1. Post Traumatic Stress Disorder, Chronic. Dated: 03/20/24. 2. Unspecified Dementia, mild with other behavioral disturbance. Dated: 03/20/24. 3. Schizoaffective Disorder, unspecified. Dated: 03/20/24. 4. Bipolar Disorder, unspecified. Dated: 03/20/24. 5. Major Depressive Disorder, single episode, unspecified. Dated: 03/20/24. In addition, Resident #16 was noted to be receiving the following psychotropic medication: 1. Fluphenazine 2.5 milligrams (MG). Give 1 (one) tablet by mouth three times a day for schizoaffective disorder. 2. Seroquel 200 mg. Give 1 (one) tablet by mouth at bedtime 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 observation, resident interview, and staff interview, the facility failed to ensure that food was served to residents at a palatable temperature. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 66. Findings included: a.) Resident Interview On 08/29/23 at 10:57 AM an interview was conducted with Resident #19, who stated that food in the facility was not served at the correct temperature. b.) Observation On 08/29/23 at 1:09 PM, lunch trays arrived in the dining room on a cart, and staff began serving residents. At 1:11 PM a tray was selected at random, removed from the cart, and brought to the kitchen, at which time a staff member was requested to test the temperature of each food on the tray with a thermometer. Dietary Employee #55 arrived immediately to test the food temperatures. The tray contained a taco, rice, and pudding. The taco was 129.5 degrees Fahrenheit, the rice was 130.1 degrees Fahrenheit, and the pudding was 68.1 degrees Fahrenheit. c.) Staff Interview At the time the food temperatures were…

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

Based on observation, interview, and policy review, the facility failed to maintain their kitchen and dry storage room in a safe and sanitary manner when they failed to label foods with opened dates, discard expired food, store food and food supplies separately from chemical compounds, and ensure dishes were clean. This deficient practice had the potential to affect all residents in the facility. Facility census: 66. Findings included: a.) Observation of Undated and Expired Items in the Reach-in Cooler On 08/28/23 at 2:45 p.m., surveyors examined the contents of the kitchen 's reach-in cooler. An open container of applesauce was found to have no date on it to show when it had been opened. A plate containing cooked sausage patties and bacon also had no date on it to indicate when it had been placed in the cooler. An unsealed and open-to-air package of American deli slices was found to have no date on it to indicate when it was opened. A five (5) pound carton of dry grated parmesan cheese with a written date of 07/31/23 was found. Six (6) half-gallon jugs of buttermilk had 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 interview, the facility failed to ensure the building was free from avoidable accident hazards when the door to the water main and sprinkler room was left unlocked and accessible to residents. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 66. Findings included: a.) Unlocked Water Main and Sprinkler Room Door On 08/29/23 at 10:31 AM a door to a room labeled Water Main Fire Sprinkler was found to be unlocked. The room was noticeably warmer than the hallway outside the door. The room contained the facility's water main shut-off valve, a floor waxer, hot water tanks, two bottles of air compressor oil, two breaker boxes, and multiple dirty rags. There was a sign on the inside of the door that said Door must remain locked. There was a sign on the outside of the door that read, biohazard. On 08/29/23 at 10:36 AM, the facility's Administrator was asked to open the door. The Administrator did so and then stated the door should not have been unlocked and accessible to residents.

Based on record review, staff interview, the facility failed to implement a comprehensive care plan related to the need for isolation during an active episode of extended spectrum beta-lactamase (ESBL) infection. Resident identifiers: #6, #34 and #5. Facility census: 65. Findings include: a) Resident #6 Review of the monthly infection line listing found Resident #6 was positive for urinary tract infection (UTI) caused by ESBL on 02/05/22 through 02/16/22 and 05/04/22 through 05/11/22. Resident #6 was not placed in contact isolation as directed by the care plan. Review of Resident #6's comprehensive care plan found: -Focus/problem: Resident has a recent history of ESBL placing her at risk for further complications. Date Initiated: 02/07/2022. - Goal: Resident will remain free from further UTI's with ESBL through next quarter. Date Initiated: 02/07/2022. -Intervention: Monitor resident for s/s of UTI, such as: c/o burning, pain, flank pain, urgency, or frequency, and notify physician. Date Initiated: 02/07/2022. - Re-educate staff as needed. Date Initiated: 02/07/2022. - Standard…

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

Based on record review, facility documentation, and staff interview the facility failed to implement an infection control program designed to reduce the transmission of resistant organism (Multidrug-resistant organism (MDRO) transmission. This failed practice had potential to affect a more than a limited number of residents who currently reside at the facility. Resident identifiers: #5, #54, and #6. Facility census 65. Findings included: a) Resident #5 Review of the monthly infection line listing found Resident #5 was positive for urinary tract infection (UTI) caused by Extended-spectrum betalactamase (ESBL) on 06/08/22 through 06/20/22 and 02/08/23 through 02/22/23. Resident #5 was not placed in contact precautions as directed by the care plan. Review of Resident #5's comprehensive care plan found: -Focus/problem: Resident has a history of ESBL in urine placing her at risk for further complications. Date Initiated: 07/17/2020. -Goal: Resident will remain free from further episodes of UTI with ESBL. Date Initiated: 07/17/2020. -Interventions: Monitor resident for s/s of UTI, such…

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 two (2) of 16 residents reviewed during the long term care survey, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to follow physician orders for obtaining blood pressures for Resident #68. In addition, the facility failed to follow physician orders for administration of a medication used to treat diabetes mellitus for Resident #29. Resident identifiers: #68 and #29. Facility census: 65. Findings included: a) Resident #68 Record review found the resident was admitted to the facility on [DATE]. On 12/16/22, the Resident was discharged to home. Review of the physician orders found an order: No sticks, lab draws or BPs (blood pressure's) in the right arm. (The Resident had a mastectomy of the right breast.) Review of the recorded blood pressures in the electronic medical record found the following occasions when…

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

Based on observation, staff interview, and policy review the facility failed to ensure urinary catheter care was consistent with the professional standards of practice. This was true for one (1) out of three (3) residents reviewed for catheter care. Resident identifier: R#46. Facility census 65. Findings included: a) Resident #46 On 02/22/23 at 8:45 AM, an observation of catheter care provided by Nurse Aide (NA) #21: NA #21 failed to fold the washcloth (so a clean part of the washcloth could be used with each stroke or wipe) or change washcloths for each stroke. In addition, NA #21 failed to hold the inner labia open and hold the tubing at the base of the meatus and wipe away from the meatus. After the observation was completed, NA #46 stated it has been a while since she had been in an in-service for catheter care. On 02/22/23 at 9:10 AM, the above observations were discussed with the Director of Nursing. .

Based on record review and staff interviews, the facility failed to follow the pharmacist's recommendations and the physician order for one (1) of five (5) residents reviewed for the category of unnecessary medications during the long term care survey. Resident identifier #54. Census 65. Findings Included: a) Resident #54 Record review on 02/21/23 at 12:15 PM, discovered a consultation report scanned into the electronic medical record under the documents tab, recommending the monitoring of the resident's blood sugar for five (5) days and then to re-evaluate the use of the medication Onglyza and blood sugars. This consultation report was dated 01/17/23. A telephone order was placed in the resident's chart on 01/17/23 at 12:07 PM written as follows, Monitor blood sugar once daily at 0630 x 5 days then re-eval. Notify Physician if >300 or <70. The review of the medication administration record (MAR) indicated a documented blood sugar on 01/18/23 of 87, no other blood sugars documented on the MAR for the 5 days in question. Review of the Weights and Vitals Summary indicated a documented…

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.