Suites at Someren Glen Care Center, the

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Provide family notifications of emergency plan.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

A survey prompted by #CO38730 and #CO39813 was completed from 4/29/25 to 4/30/25. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for one (#6) of three residents out of seven sample residents.Specifically, the facility failed to ensure Resident #6 experienced a dignified learning experience when certified nurse aide (CNA) #1 provided inappropriate redirection to the resident after the resident spilled a drink.Findings include:I. Resident #6A. Resident statusResident #6, age 70, was admitted on 2/1/25. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, severe with mood disturbances and Parkinson' s disease.The 4/17/25 minimum data set (MDS) assessment revealed the resident was unable to participate in the brief interview for mental status (BIMS) assessment. Per the staff assessment for mental status, the resident had short-term and long-term memory impairment and required substantial assistance with decisions regarding tasks of daily life. The MDS assessment revealed the resident did not display physical behaviors directed towards others.B. Resident observationOn 4/29/25 at 12:55 p.m., during observation of the lunch meal service, Resident #6 got up from her dining room chair and walked to the food preparation counter located within the common area space on the unit. Resident #6 spilled a glass of clear l.. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received appropriate treatment and services to maintain personal hygiene for two (#7 and #3) of three residents reviewed for ADLs out of seven sample residents. Specifically, the facility failed to offer toileting or timely incontinence care for Resident #7 and Resident #3. Findings include:I. Facility policy and procedureThe Urinary Management (UM) policy, dated December 2024, was provided by the nursing home administrator (NHA) on 4/30/25 at 7:03 p.m. It read in pertinent part, "The facility will manage urinary incontinence as part of the person-centered resident care. Treatment for urinary incontinence depends on the type of incontinence, its causes, and the capabilities of the resident."A comprehensive assessment will be completed upon move-in, change of condition and annually to determine diagnosis or reason for incontinence. Residents will be monitored through the standard MDS/RAI (minimum data set /resident assessment instrument) process. If incontinence is identified and based on the type of incontinence, a care plan will be written for incontinent residents, utilizing the appropriate interventions to achieve or maintain as much as normal urinary function as possible. The interdisciplinary team (IDT) ..