Centennial Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure pharmacy services met professional standards of practice and facility policy for the accountability and documentation of controlled substances. Specifically, the facility failed to ensure licensed nursing staff consistently completed required shift to shift narcotic count documentation, as evidenced by repeated missing required signatures in narcotic tracking books over a three-month period. This failed practice resulted in incomplete controlled substance records and compromised accountability for narcotic medications, placing 50 out of 97 residents (census) at risk for medication diversion and administration errors.Findings: During an interview on 12/18/25 at 10:07 AM, Licensed Nurse (LN) #3 stated that during shift change, both the incoming and outgoing nurses were required to conduct a narcotic count together. LN #3 further stated this process was documented on the Shift Audit Record, located in the narcotic tracking books and required four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review, observation, and interview, the facility failed to ensure a culture where residents were treated with dignity and respect for 2 residents (#'s 48 and 64), out of 20 sampled residents. Specifically, the facility failed to:1) provide Resident #48 a bed bath at a reasonable time of day;2) maintain Resident #48's dignity and privacy by leaving the catheter urine collection bag uncovered and visible in common areas; and3) maintain Resident #64's dignity and privacy by failing to cover the resident's buttocks while transporting the resident to the resident's room from the shower room through 2 separate courts on 2 separate floors.These failures subjected residents to distressing and undignified care practices and placed them at risk for emotional distress and reduced quality of life.Findings:Resident #48Record review on 12/14-24/25 revealed Resident #48 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs), insomnia and neuromuscular dysfunction…

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

Based on record review and interview, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC - an official notice, issued by Medicare-certified healthcare facilities to inform beneficiaries when their coverage will end, with appeal right information) was provided to and signed by the resident's legally authorized Power of Attorney (POA) for 1 Resident (#113), out of 2 discharged residents reviewed. The resident had a documented POA with authority over insurance and government benefit decisions. The facility obtained the resident's signature on the NOMNC but failed to include the POA's signature, did not document review of the notice with the POA, and did not ensure the POA was informed of appeal rights prior to discharge. This failure denied the POA the opportunity to exercise Medicare appeal rights, resulting in the loss of a protected procedural right .Findings:Resident #113Record review on 12/14-24/25 revealed Resident #113 was admitted to the facility with diagnoses that included dementia, without behavioral disturbance (cognitive decline affecting memory,…

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 comprehensive, person-centered care plans were developed and implemented to address identified needs for 2 residents (#'s 27 and 111) out of 2 residents reviewed for comprehensive care plans. Specifically, the facility failed to develop and implement dementia-related care plan interventions for Resident #27 and failed to develop and implement fall-risk-specific care plan interventions for Resident #111. These failed practices placed Resident #27 at risk for unmet cognitive and behavioral needs and placed Resident #111 at risk of injury Findings: Resident #27Record review on 12/14-24/25 revealed Resident #27 was admitted to the facility with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance (cognitive decline of unclear cause and severity, accompanied by behavioral symptoms), and mild cognitive impairment of uncertain or unknown etiology.Review of Resident #27's MDS (Minimum Data Set- 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 interview, the facility failed to ensure a resident on wander guard elopement precautions received adequate supervision for 1 Resident (#90), out of 2 residents reviewed for wander guard supervision. This failed practice contributed to the resident's ability to leave the facility in a cab, become stranded at a local store, and returned to the facility by entering a stranger's privately owned vehicle, placing him/her at risk for abuse, exploitation, and/or death .Findings:Record review on 12/14-24/25 revealed Resident #90 was admitted to the facility on [DATE] with diagnoses that included a displaced fracture of medial wall of left acetabulum (a fracture in the socket part of the left hip joint where the bone fragments are moved out of their normal alignment), chronic kidney disease, schizophrenia (a mental disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality), and anxiety.Further review revealed Resident #90 left the faciity on [DATE]…

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

Based on record review and interview, the facility failed to ensure 3 residents (#'s 10, 68 and 88), out of 3 residents reviewed for dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood), received the services consistent with professional standards of practice. Specifically, the facility failed to ensure blood pressure measurements were taken on the appropriate extremity. This failed practice placed the residents at risk for damage to their AV (arteriovenous) fistula (connection made between an artery and vein that is used for dialysis access) Findings: Resident #10Record review from 12/14-24/25 revealed Resident #10 was admitted to the facility with diagnoses that included Type 2 diabetes mellitus (DM- a chronic disease characterized by high levels of sugar in the blood) with diabetic chronic kidney disease (CKD- gradual loss of kidney function), dependence on renal dialysis, and end stage renal disease (ESRD- last stage of CKD).Review of Resident #10's Care Plan Report, initiated 11/18/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review and interview, the facility failed to ensure continuity of rehabilitative services for 1 resident (#111) reviewed for rehabilitative services. Specifically, the facility failed to ensure physical therapy services were provided as ordered when the facility's physical therapist went on leave. This failed practice resulted in an interruption of ordered rehabilitative services and placed the resident at risk of negative impacts to their functional status and rehabilitation outcomes Findings:Record review on 12/14-24/25 revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included radiculopathy (compression or irritation of a spinal nerve root, leading to pain, numbness, tingling, or weakness that radiates along the path of the affected nerve), spinal stenosis (spaces within the spine narrow, placing pressure on the spinal cord or nerves and causing pain, numbness, or weakness) and lumbosacral spinal fusion (surgical procedure that joins two or more vertebrae 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 record review and interview, the facility failed to ensure the medical record accurately and completely reflected the resident's current clinical condition for 1 resident (#99) of 3 closed records reviewed. Specifically, the facility failed to update the resident's active diagnosis list and practitioner documentation to include seizure disorder, despite hospital documentation identifying seizure disorder as the primary diagnosis and the continued administration of anticonvulsant medications for that condition following readmission.This failed practice resulted in an incomplete and inaccurate medical record, which placed the resident at risk for inconsistent clinical decision-making, ineffective care coordination, and incomplete communication among caregivers responsible for implementing and monitoring seizure-related treatment and precautions Findings:Record review from 12/14-24/25 revealed Resident #99 was admitted to the facility with diagnoses that included Parkison's disease (movement disorder of the nervous system), unspecified atrial fibrillation (irregular, rapid…

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 record review, the facility failed to ensure medications and medical supplies were properly stored and labeled. Specifically, the facility failed to: 1) remove expired and/or opened medications and supplies from use and 2) maintain emergency medications under safe temperature control. These failed practices had the potential to place all residents (census of 92) at risk of receiving expired and/or compromised medications which may result in reduced efficacy or adverse reaction.Findings: .Expired/Opened Medications/Supplies An observation on 8/29/25 at 10:50 AM, of the treatment cart in the Spruce Court, revealed: -Three packs of Hypodermic Safety needles 23 G (gauge) x 1 expired 6/30/25;-One Diclofenac Sodium Topical Gel 1% (NSAID), a non-steroidal anti-inflammatory drug, expired on 7/27/25; and-One opened pack of IV [intravenous] Start Kit w/ Chloraprep App. During an interview on 8/29/25 at 1:49 PM, Infection Preventionist (IP) and Resident Care Manager (RCM) #1 confirmed the above listed expired and/or opened medication and medical supplies.…

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 the MDS (Minimum Data Set, a federally required assessment) was accurately coded for venous ulcers for 1 resident (#5), out of 8 sampled residents. This failed practice placed the resident at risk for not receiving the necessary and/or appropriate care and services .Findings:Record review on 8/29/25, revealed Resident #5 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), Cerebrovascular Accident (CVA - also known as stroke, is when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) with left sided hemiparesis (partial paralysis of one side of the body), obesity, chronic pain, Diabetes Mellitus type II (disorder characterized by persistent high blood sugar levels and inability to use insulin properly), and neuropathy (nerve damage). Wound Review: Record review on 8/29/25 of SNF [Skilled…

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 provision of necessary care and services were provided in accordance with standards of practice and/or resident care plan for 2 residents (#1 and #3) out of 8 sampled residents.Specifically, the facility failed to ensure escalation of care and interventions that included:1) notifying the physician of a leaking gastrostomy tube (G-Tube - medical device inserted through the abdominal wall directly into the stomach to provide nutrition, hydration, and medication) per facility's standard of practice.2) notifying the physician of acute hypotension and altered mental status per facility's standard of practice as established by policies and resident's care plan.These failed practices prevented the residents from receiving care and services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and placed the residents at risk for significant medical complications due to unaddressed changes 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 record review, observation, and interview, the facility failed to discontinue a medication order when wound care orders had changed for 1 resident (#5) out of 8 sampled residents. Specifically, the facility continued administering Santyl (prescription enzymatic debriding agent used topically to remove dead tissue from chronic skin ulcers promoting healthy wound healing) ointment after the wound care plan was revised to discontinue its use. This failed practice led to thirteen administrations of a medication that was no longer required and further placed the resident at risk for unnecessary treatment, potential adverse effects, and harm .Findings:Record review on 8/29/25, revealed Resident #5 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), Cerebrovascular Accident (CVA - also known as stroke, is when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) with left sided hemiparesis (partial paralysis of one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on record review and interview, the facility failed to ensure proper care for invasive devices such as the gastrostomy tube (G-Tube - medical device inserted through the abdominal wall directly into the stomach to provide nutrition, hydration, and medication) to prevent the development of infections, for one resident (#1) out of 8 sampled residents. Specifically, the facility failed to implement proper techniques for troubleshooting a leaking G-Tube, including using methods such as rubber bands and soiled tape to secure the tube, failing to clean the site with sanitary technique, and not following standard precautions to manage gastric leakage and prevent contamination.This failed practice placed the resident at risk for skin breakdown and infection, which could have affected their overall health and wellbeing Findings:Resident #1Record review on 8/27-29/25, revealed Resident #1 was admitted to the facility with diagnoses that included dysphagia following other cerebrovascular disease (swallowing…

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

Based on record review and interview, the facility failed to ensure timely reporting of abuse allegations for two residents (#s 8 and 15) out of 20 sampled residents. Specifically, the facility failed to report the allegations of abuse within 2 hours from the occurrence of the incident to the State Survey Agency. This failed practice placed all residents based on a census of 94 at risk for continued potential abuse. Findings: Resident #8 Record review on 6/11-13/25, revealed Resident #8 was admitted to the facility with diagnoses that included encounter for other orthopedic aftercare, subluxation (misalignment) of L4/L5 lumbar and fusion (surgical procedure that joins two or more vertebra) of spine, lumbar. Record review of the Facility Reported Incident (FRI), Initial Report, dated 5/6/25 at 7:30 AM, revealed, the FRI was reported to the State Agency on 5/6/25 at 11:30 AM by Resident Care Manager (RCM) #1. During an interview and concurrent record review on 6/13/25 at 10:22 AM, the Administrator (ADM) was provided Resident #8's Initial Report of allegation of abuse, dated 5/6/25 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 record review and interview, the facility failed to ensure 3 Facility Reported Incidents (FRI) for residents (#8, #9 and #15) out of 4 FRIs for allegations of abuse were thoroughly investigated. Specifically, the facility failed to provide evidence of the interventions identified in their investigations. This failed practice placed these residents at risk of having injuries or harm that were not adequately addressed and treated. Findings: Resident #8 Record review on 6/11-13/25, revealed Resident #8 was admitted to the facility with diagnoses that included: encounter for other orthopedic aftercare, subluxation (misalignment) of L4/L5 lumbar vertebra and fusion (surgical procedure that joins two or more vertebra) of spine, lumbar. Record review of the FRI, Final Report, dated 5/6/25, revealed: Interventions: . Resident was placed on Alert Charting. Skin check completed with no new injuries noted. Record review 6/11-13/25 of Resident #8's electronic medical record (EMR), no documentation of skin assessment or alert charting was noted for the interventions identified in Final…

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

Based on interview and record review, the facility failed to update and revise the care plan for 1 resident (Resident #21) out of 1 resident reviewed for care plan. Specifically, the facility failed to update and revise the care plan to reflect new interventions and/or monitoring to address aggressive or escalating behaviors. This failed practice placed the resident at risk for not receiving appropriate and/or accurate care and services. Findings: Review on 6/11-13/25 revealed Resident #21 was admitted to the facility with diagnoses that included unspecified dementia (cognitive decline), aphasia (impaired ability to understand or express speech), and parkinsonism (a group of movement abnormalities such as tremor, stiffness, and slowed movement). During an interview on 6/12/25 at 11:00 AM, Resident #3 allegedly stated during a verbal altercation with Resident #21 on 4/25/25, he/she was struck in the face by Resident #21. Resident #3 then retreated to his/her room, called the police and reported the assault. Review of Resident #21's Nursing notes, dated 4/25/25, revealed: . Behavior…

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

Based on record review, observation and interview, the facility failed to ensure 1 resident (#5) out of a census of 94, had supervised access to an unauthorized location in the facility. This failed practice had the potential to place the Resident at risk of injury due to inadequate supervision and the lack of security measures posed the possibility of hazard including the potential for elopement through unsecured exits. Findings: Record review from 6/11-13/25 revealed, Resident #5 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis (paralysis on one side), following cerebral infarction (stroke), lack of coordination, abnormalities of gait and mobility, muscle weakness, cognitive communication deficit (impaired thinking/speech), epilepsy unspecified, not intractable without status (recurrent seizures), and depression (low mood). Record review of Resident #5's Minimum Data Set (MDS - a federally required assessment), dated 5/7/25, revealed: Wheel 150 feet: once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure an incident of multiple missed doses of anticonvulsant medication that resulted in multiple seizure episodes and subsequent hospitalization for one resident (#1) out of three sampled residents was reported to the appropriate officials in accordance with State law, including the facility's Administrator and the State Survey Agency, within timeframes specified by the 42 CFR 483.12(c)(1). Specifically, the facility failed to notify the facility's Administrator and the State Survey Agency immediately, but not later than 2 hours, or not later than 24 hours of the incident. This failed practice had the potential to cause future harm to the resident and a delay of necessary actions. Findings: Record review on 1/21-22/25, revealed Resident #1 was admitted to the facility with diagnoses that included hemiplegia (weakness or paralysis of one side of the body) and hemiparesis (partial paralysis of one side of the body), anoxic brain damage (lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure an incident of multiple missed anticonvulsant medications that resulted to multiple seizure episodes and subsequent hospitalization for one resident (#1) out of three sampled residents was thoroughly investigated and the results were reported to the State Survey Agency within 5 working days as specified by the 42 CFR 483.12(c). Specifically, the facility failed to investigate neglectful deprivation of goods and services by facility staff and report results within 5 working days of the incident to the facility's Administrator or his/her designated representative and the State Survey Agency. Additionally, staff interviews, and record reviews and subsequently corrective actions had not been completed. The failure to timely report and fully investigate Resident #1's hospitalization and unavailability of medications, and report to the State Survey Agency, placed the resident at risk for further potential harm or neglect. Findings: Record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure medication and/or medical supplies in two medication storage rooms (the main medication storage room and in [NAME] Court), out of five medication storage rooms, and two medication carts (located on the Birch Court and [NAME] Court), out of three medication carts, were unexpired. Specifically, the facility failed to discard expired medications and/or medical supplies. These failed practices placed all residents (based on census of 99) at risk for adverse effects or complications from receiving expired medications and/or medical supplies. Findings: Main Medication Storage Room An observation on 12/10/24 at 8:28 AM, of the facility's main medication storage room revealed the following medications and/or medical supplies on the open shelves were expired: - 4 - 100ml (milliliter) 0.9% Sodium Chloride Injection USP (US Pharmacopeia is a nonprofit organization that sets quality standards for medications to ensure quality and safety),…

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 record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) food was stored under proper sanitation and food handling practices in the main kitchen; 2) the kitchen was kept in a clean, sanitary condition. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 99. Findings: Main Kitchen An observation, during the initial main kitchen tour, on 12/8/24 at 8:20 AM, revealed: 1) Main Kitchen Freezer Unit: - 1 clear plastic bag of chicken nuggets - 3/4 full - not sealed, no label, no date. - 1 clear plastic bag of sausage patties in cardboard box - 3/4 full - not sealed, open to the elements. - Food tray with six small bowls of individual cake-like desserts, covered with clear plastic wrap - No labels, no dates. 2) Main Kitchen Refrigerator Unit: - Metal tray containing sliced fruit - loosely wrapped in clear plastic wrap, leaving some portions of fruit…

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, interview, and record review, the facility failed to ensure electrical equipment was maintained in safe operating conditions. Specifically, the facility failed to ensure: 1) All patient care related electrical equipment (PCREE) had regular, routine preventative maintenance (PM) inspections to ensure they were in safe operating condition; 2) All non-patient care related electrical equipment (N-PCREE) was inspected to ensure it was safe for operation in resident care areas and used in a safe manner; and 3) Space heaters used in non-resident care areas were inspected by maintenance and used in a safe manner. These failed practices placed all residents, based on a census of 99, at risk for: 1) receiving inadequate treatment and/or care, from equipment not subjected to routine preventive maintenance monitoring, that could affect the resident's overall physical, mental, and psychosocial well-being; 2) electrical shock and/or exposure to electrical fire. Findings: PCREE An observation 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, interview and record review, the facility failed to ensure one resident (#41), out of one resident reviewed for dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood), received the services consistent with professional standards of practice. Specifically, the facility failed to ensure: 1) blood pressure measurements were taken on the appropriate extremity; 2) medications used to treat blood pressure were administered according to the medical provider's orders; and 3) documented assessments were completed before and after dialysis treatments. This failed practice placed the resident at risk for: 1) damage to the right AV (arteriovenous) fistula (connection made between an artery and vein that is used for dialysis access), 2) increased risk of blood clot formation, 3) worsening hypertensive chronic kidney disease (condition that occurs when chronic high blood pressure damages the kidney), 4) worsening ESRD (end stage renal disease) symptoms. Findings: Record review on…

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

Based on record review, observation and interview, the facility failed to ensure two residents out of 22 sampled residents, and one resident out of 6 unsampled residents were provided care in a manner that promoted dignity and respect. Specifically, the facility failed to: 1) provide covering of the urinary catheter bags (a tube inserted through the urinary tract into the bladder, connected to a drainage bag) for 2 residents (#1 and #96); and 2) provide unsampled resident #40 a dignified dining experience. This failed practice placed the residents at risk of poor self-esteem and/or self-worth and a potential for poor quality of life. Findings: Resident #1 Record review on 12/8-12/24 revealed Resident #1 was admitted to the facility with diagnoses that included type 2 diabetes mellitus with chronic kidney disease, urinary tract infection, unspecified dementia and recurrent major depressive disorder (a mood disorder characterized by depressed mood and loss of interest and/or pleasure in activities). An observation on 12/11/24 at 11:35 AM, revealed that Resident #1 was being wheeled by…

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 record review the facility failed to ensure self-administration of medication evaluation was completed for three residents (#s 14, 83, and 87) out of three residents reviewed. This failed practice placed the residents at risk of adverse effects of the medications. Findings: Resident #14 Record review from 12/8-12/24, revealed Resident #14 was admitted to the facility with diagnoses that included myocardial infarction and diabetes mellitus. An observation on 12/8/24 at 10:41 AM, revealed ear drops carbamide peroxide 6.5% was on top of Resident #14's bedside table. Resident #14 stated he/she had administered it on his/her own for two days now. Review on 12/10/24 at 11:50 AM, of active physician's order for Resident #14, revealed no physician's order for ear drops Carbamide peroxide 6.5%. During an interview on 12/11/24 at 12:14 PM, Licensed Nurse (LN) #1, stated there was no order in the electronic health record (EHR). Resident #83 Record review from 12/8-12/24, revealed Resident #83 was admitted to the facility with diagnoses that included…

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

Based on observation and interview, the facility failed to ensure a homelike environment was maintained in resident rooms for 3 unsampled residents (#s 34, 47, and 251), out of 6 unsampled residents reviewed. This failed practice denied the residents a functional, maintained, and homelike environment. Findings: Resident #34 An observation on 12/11/24 at 3:40 PM, Resident #34's room, on Birch Court, revealed six large cardboard boxes in the resident's bathroom. Further observation revealed one box was designated for the Birch Court's artificial Christmas tree's display in the common area, and the other five boxes were stored decorations for Birch Court's Halloween and Christmas holidays. During an interview on 12/11/24 at 3:40 PM, the Director of Business Development (DBD) stated the boxes should not have been stored in the resident's bathroom. Resident #47 An observation on 12/11/24 at 12:46 PM, of Resident #47's room, revealed the face plate to the cable outlet was cracked. The DBD acknowledged these findings upon discovery. Resident #251 An observation on 12/11/24 at 4:04 PM, of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, interview and observation, the facility failed to ensure the MDS (Minimum Data Set - a federally required assessment for long term care residents) accurately represented two residents (#37 and #97) out of 22 sampled residents. This failed practice placed the residents at risk for inadequate care planning and services to achieve their highest practicable and functional well-being. Findings: Resident #37 Record review from 12/8-12/24 revealed Resident #37 was admitted with diagnoses that included diabetes mellitus and multiple myeloma (bone marrow cancer). Review of Resident #37's MDS Quarterly review assessment, dated 11/16/24, revealed: Section O .K1.Hospice care .b. While a resident. was checked indicating the resident was on hospice. During an interview on 12/12/24 at 1:30 PM, Nurse Practitioner (NP) #1, Licensed Nurse (LN) #2 and LN#5, when asked if Resident #37 was currently on hospice services, stated Resident #37 was no longer on hospice services. Further record review included 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, interview, and observation and the facility failed to implement care plans for two residents (#41 and #43) based on a sample of 22 residents. These failed practices placed residents at risk for not receiving the necessary and/or appropriate care and services for optimal outcomes. Findings: Resident #41 Record review on 12/8-12/24 revealed Resident #41 was admitted to the facility with a diagnosis that included end stage renal disease (a condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite). The resident also had a right arm AV (arteriovenous) fistula (a connection made between an artery and vein that is used for dialysis access). Record review of Resident #41's blood pressure readings between the dates of 12/13/23 - 12/17/24, revealed staff measured the blood pressure on the right arm 140 times. Review of Resident #41's care plan, revised on 4/24/23, revealed 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, observation, and interview the facility failed to revise care plans to reflect the current level of care and services for two residents (#1 and #18) based on a sample of 22 residents. This failed practice placed residents at risk for not receiving the necessary and/or appropriate care and services for optimal outcomes. Findings: Resident #1 Record review from 12/8-12/24 revealed Resident #1 was admitted with diagnoses that included Type 2 Diabetes Mellitus with Chronic Kidney Disease (non-insulin-dependent diabetes with kidney complications), and Urinary Tract Infection (infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra). An observation on 12/8/24 at 3:30 PM, revealed Resident #1 lying in bed with a foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag), with the bag secured to the left side of the bed. Record review of the care plan, last reviewed on 10/18/24, revealed no care…

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 interview, observation, and record review, the facility failed to communicate effectively with one resident (Resident #12) out of 22 sampled residents. This failed practice had the potential to negatively impact the resident's quality of life and overall activities of daily living (ADL's) due to communication barriers. Findings: Resident #12 was admitted to the facility on [DATE] for diagnoses that included intraspinal abscess (pus-filled infection in the spinal canal that can compress the spinal cord or nerves), osteoarthritis (degenerative joint disease), incomplete paraplegia (partial damage to the spinal cord causing impaired function of the lower half of the body while retaining some degree of movement or sensory perception), and dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). During an interview on 12/9/24 at 8:30 AM, with Resident #12, using the facility's interpreting service, the resident stated he/she like to read the bible and only…

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, interview, and observation, the facility failed to provide an ongoing resident-centered activity program for one resident (#43) out of 22 sampled residents. This failed practice placed the resident at risk of boredom, loneliness, and decreased quality of life and enjoyment. Findings: Resident #43 Record review on 12/8-12/24 revealed Resident #43 was admitted to the facility with diagnosis of primary lateral sclerosis (motor neuron disorder), acute respiratory failure with hypoxia (severe oxygen shortage), moderate protein- calorie malnutrition (insufficient nutrition intake), dysphagia (swallowing difficulty), cellulitis (skin infection) of left toe, retention of urine, and neuromuscular dysfunction of bladder (bladder control loss). Record review of the quarterly MDS (Minimum Data Set - A Federally required nursing assessment) dated 9/13/24, revealed, in the communication section: makes self-understood: rarely/never understands .ability to understand others: rarely/never understands.…

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

Based on record review and interview, the facility failed to: 1) complete a quarterly smoking assessment for one resident (#19) out of one resident who smoked marijuana. Specifically, the facility failed to complete quarterly or annual smoking safety evaluations for Resident #19 since 7/19/23; and 2) maintain accessibility to a crash cart, for immediate use during a life-saving emergency for one resident unit (Spruce Court), out of 6 units reviewed. These failed practices: 1) had the potential for the facility to be unaware of a change in status with regards to the resident's safety while smoking, placing the resident and others at risk of burns and/or fire; and 2) placed all residents of the Spruce Court, based on a census of 16, at risk of potential delay of life-saving measures during an emergency. Findings: Smoking Assessments Resident #19 Record Review on 12/8-12/24 revealed Resident #19 was admitted to the facility with diagnoses that included concussion (temporary brain injury) of unspecified duration and quadriplegia (complete paralysis of the body from the neck down).…

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 interviews, the facility failed to ensure the drug regimen for one resident (#25), out of 22 sampled residents, was free from unnecessary medication. Specifically, the facility failed to prevent duplicate drug therapy was prescribed. This failed practice placed the resident at risk for potential adverse effects from unnecessary medication administration. Findings: Record review on 12/8-12/24, revealed Resident #25 was originally admitted to the facility on [DATE] for rehabilitation services for diagnoses that include heart failure (inability of the heart to maintain adequate blood circulation), type II diabetes (non-insulin dependent diabetes), and Parkinson's disease (degenerative disorder characterized by tremor and impaired muscular coordination). Record review of Resident #25's Pharmacy Notes and Alert Notes, dated 11/17/2024 revealed the following: 1. Patient has two SGLT [Sodium-Glucose Cotransporter-2 Inhibitors] [a class of drugs that lower blood sugar levels by promoting…

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

Based on record review, observation, and interview the facility failed to provide nutritious food substitutions to accommodate the preferences for one unsampled resident (#40) out of a census of 90 residents who received meals from the kitchen. This failed practice had the potential to decrease nutrition and cause unnecessary weight loss. Findings: Record review on 12/11/24 revealed Resident #40 was admitted to the facility with diagnoses that included acquired absence of other specified parts of digestive tract, vascular dementia (dementia resulting from impaired blood flow to the brain), with psychotic disturbance, adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction and low cholesterol), and schizophrenia (mental disorder characterized by symptoms of hallucinations, delusions and cognitive challenges). During observations of the Cedar Court dining area on 12/11/24 from 11:35 AM to 12:30 PM, Resident #40 sat in a recliner chair in the dining area.…

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

Based on record review and interview the facility failed to ensure medical records were accurately completed in accordance with accepted professional standards of practice for one resident (#43) out of 22 sampled residents. Specifically, the facility failed to ensure activities staff accurately documented groups, one-on-one (1:1) and self-directed/independent activities as indicated in Resident #43's chart. This failed practice had the potential to affect the achievement of the resident's plan of care. Findings: Resident #43 Record review on 12/8-12/24 revealed Resident #43 was admitted to the facility with diagnoses of primary lateral sclerosis (motor neuron disorder), acute respiratory failure with hypoxia (severe oxygen shortage), moderate protein-calorie malnutrition (insufficient nutrition intake), dysphagia (swallowing difficulty), cellulitis (skin infection) of the left toe, retention of urine, and neuromuscular dysfunction of the bladder (bladder control loss). Record review of the quarterly MDS (Minimum Data Set - A Federally required nursing assessment) dated 9/13/24,…

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

Based on record review and interview, the facility failed to ensure direct care staff were provided appropriate competencies and skills sets to assure residents who express suicidal ideation (thoughts and/or plans to commit suicide) were safe. Specifically, the facility failed to: 1) provide training for knowledge of how to accurately perform a one-on-one observation; and 2) how to accurately document one-on-one observations for standard accountability. This failed practice placed all residents (based on a census of 96) at risk for improper or inconsistent one-on-one observation which could lead to self-harm, suicide attempt, or completed suicide. Findings: Record review on 6/3-5/24 revealed the facility had no policy, procedure, or protocol for when a resident expressed suicidal ideation, to include initiation of one-on-one observations for safety. During an interview on 6/4/24 at 9:00 AM, the Director of Nursing (DON) stated the facility had no policy, procedure, or protocol established for suicidal ideation, to include one-on-one observations. When asked what kind of training…

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 record review, the facility failed to ensure there was a sufficient system in place for the accurate reconciliation of all controlled medications. This failed practice led to the diversion of controlled medications for approximately a year, without detection. Findings: Medication Dispensing and Administration An observation on 6/3-5/24, of the facility's medication storage process, revealed there were six units, or Courts, in the facility. Each Court had a secured mobile medication cart (accessible by a key, kept in the Court nurse's possession). In each of these medications cart there were two large drawers for medication storage, and in each of these drawers was an additional, fixed, locked box to store controlled medications. In addition, each floor had a Pyxis storage system for additional medication storage. Further observation revealed each resident's medication was usually dispensed monthly, from the pharmacy, in a large bubble pack card, with clear bubbled compartments to segregate each dose of medication (each medication had its own…

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

Based on interview and record review, the facility's administration failed to ensure training, competency, and documentation pertaining to behavioral health care was provided effectively and efficiently to ensure the highest practicable physical, mental, and psychosocial well-being of residents. This failed practice placed all residents (based on a census of 96) at risk for receiving less than optimal care in a safe environment. Findings: During an interview on 6/4/24 at approximately 3:00 PM, the facility's administrator informed the survey team that she was leaving the facility and verbalized the Director of Nursing (DON) would be assuming the responsibility for the remaining survey. During an interview on 6/4/24 at 9:00 AM, the Director of Nursing (DON) stated the facility had no policy, procedure, or protocol established for suicidal ideation. When asked what kind of training direct care staff got for one-on-one training, the DON further stated, there is no official one to one training for staff. When asked if there was any kind of tool that could be available to staff to use…

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

Based on record review, and interview, the facility failed to ensure medical records were complete, accurate, and reflected all services provided, for 2 residents (#s 3 and 14), out of two records reviewed. Specifically, the facility failed to: 1) document established one-on-one interventions in the medical record, that were initiated for safety measures due to suicidal ideation (thoughts and/or plans to commit suicide); and 2) document the exact date and time a Physical Therapy evaluation and also document that this evaluation was completed by telehealth appointment. These failed practices: 1) placed all residents (based on a census of 96) at risk of insufficient or inconsistent one-on-one observations, which could have contributed to risk of self-harm, suicide attempt, or completed suicide; and 2) placed all residents (based on a census of 96), who have the potential to receive telehealth Physical Therapy appointments, at risk for incomplete and/or inaccurate medical records. Findings: Resident #3 Record review on 6/3-5/24 revealed Resident #3 was admitted at the facility 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 record review and interview, the facility failed to ensure training for one-on-one observation (a close and consistent observation, in line of sight, of a resident who is an imminent risk of harming self or others) was provided to direct care staff. This failed practice placed all residents (based on a census of 96) at risk for improper or inconsistent observation which could lead to self-harm, harm to others, suicide attempt, or completed suicide. Findings: Record review on 6/3-5/24 revealed the facility had no policy, procedure, or protocol for when a resident expressed suicidal ideation, to include initiation of one-on-one observations for safety. During an interview on 6/4/24 at 9:00 AM, the Director of Nursing (DON) stated the facility had no policy, procedure, or protocol established for suicidal ideation, to include one-on-one observations. When asked what kind of training direct care staff got for one-on-one observations, the DON further stated, there is no official one to one training for staff. When asked if there was any kind of tool that could be available to…

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

Based on record review and interview, the facility failed to present a Notice of Medicare Non-Coverage (NOMNC) and SNF Advance Beneficiary Notice of Non-Coverage (ABN) prior to the ending of Medicare Part A coverage for 1 resident (#16) and/or their legal representative, out of 6 records reviewed. This failed practice, to meet its obligation to inform the beneficiary of his or her potential financial liability, placed the resident denied the resident the timely opportunity to appeal and placed the resident at risk for financial hardship. Findings: Record review on 6/3-5/24 revealed Resident #16 was admitted to the facility with a primary insurance of Medicare part A and B, and a secondary insurance of Aetna, Alaska Care Retiree. Review of Resident #16's VERIFICATION OF FUNDING FOR REHAB SERVICES - PRESTIGE, dated 1/30/24, revealed: Medicare A funding source was checked. Review of Resident #16's Physical Therapy Treatment Encounter Note (s), dated 4/24/24 at 9:50 AM, revealed: .facility notified [him/her] yesterday that [he/she] would need to pay out of pocket, or DC [discharge]…

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 a post-discharge plan of care was established for 1 Resident (#9), out of one discharge reviewed. Specifically, the facility failed to ensure: 1) required follow up wound care services were properly arranged; and 2) an adequate supply of discharge medications was provided until the resident was established for medication management post discharge. These failed practices resulted in the resident not receiving needed daily wound care for four days and placed the resident at risk of running out of necessary medications which could have affected the resident's health and wellbeing. Findings: Record review on 6/3-5/24 revealed Resident #9 was admitted to the facility with diagnoses that included cellulitis (an acute inflammation of the connective tissue of the skin) of the right lower limb, lymphedema (swelling, most often in arms or legs, caused by a lymphatic system blockage), Chronic Obstructive Pulmonary Disease (COPD - a lung disease 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 interview and observation, the facility failed to ensure satisfying, palatable meal choices were offered and individual resident's food preferences were honored for 9 residents (#'s 16, 44, 52, 53, 62, 75, 83, 84, and 86), out of 21 sampled residents. These failed practices denied the residents, who received meals from the facility's nutrition services, of their preferences and choices and placed the residents at risk for minimal food intake which could result in weight loss and/or poor health outcomes. Findings: Resident #16 During an interview on 10/9/23 at 12:11 PM, Resident #16 stated he/she did not like the food and ordered out a lot. The resident further stated when he/she received his/her meal, it was served cold. Resident #44 During an interview on 10/8/23 at 11:40 AM, Resident #44 stated he/she liked hamburgers, and they were not available when he/she requested them. Resident #52 During an interview on 10/9/23 at 8:35 AM, Resident #52 stated when he/she ordered grilled cheese, the sandwich was only cooked on one side. The resident stated the other side was just…

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

Based on interview and observation, the facility failed to make reasonable efforts to develop a menu based on resident requests and resident groups. The failure to obtain input had the potential to place 9 residents (#'s 16, 44, 52, 53, 62, 75, 83, 84, and 86), out of a sample of 21, at risk for loss of appetite, lower meal consumption, and a potential for decreased nutritional intake and/or weight loss. Findings: Resident #16 During an interview on 10/9/23 at 12:11 PM, Resident #16 stated he/she did not like the food and ordered out a lot. The resident further stated when he/she received his/her meal, it was served cold. Resident #44 During an interview on 10/8/23 at 11:40 AM, Resident #44 stated he/she liked hamburgers, and they were not available when he/she requested them. Resident #52 During an interview on 10/9/23 at 8:35 AM, Resident #52 stated when he/she ordered grilled cheese, the sandwich was only cooked on one side. The resident stated the other side was just bread, meaning the other side of the bread was not toasted. The resident stated that he/she made efforts to write…

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

Based on interview, observation, and record review, the facility failed to involve residents with menu planning, including alternative menu choices, for 3 residents (#'s 52, 83, and 84), out of 21 sampled residents. These failed practices denied these residents, who received food from the facility's kitchen, the opportunity to make choices that would improve their appetite and food satisfaction. Findings: Resident #52 During an interview on 10/16/23 at 10:27 AM, Resident #52 stated he/she used to attend the Food Committee meetings regularly. The last meeting, he/she remembered attending was about a year ago. Resident #52 stated it had been a long time since the Food Committee meeting was on the activity calendar and did not think they held it anymore. Recently it was brought up in residents council that early trays (trays scheduled to be delivered at 4:30 PM) were sporadically delivered late for the past 3 weeks. Resident #52 stated occasionally supper was not served until around 6:00 PM, which made mealtimes run over to the night shift. This had caused issues since night shift was…

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

Based on record review and interview, the facility failed to ensure: 1) residents and/or their representatives received a written notice of transfer that contained the reason, place, and address of transfer for 1 resident (#19), out of 6 residents reviewed for hospitalization; and 2) ensure a copy of the residents' discharge notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This failed practice had the potential to affect all residents, based on a census of 99, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings: Resident #19 Record review from 10/8-12/23 and 10/16/23 revealed Resident #19 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease which causes obstructed airflow from the lungs).…

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, interview, and record review, the facility failed to ensure medication and medical supplies in one medication storage room, out of 4 medication storage rooms, and one medication cart, out of 3 medication carts, were properly labeled and stored. Specifically, the facility failed to: 1) discard expired medication and medical supplies; and 2) ensure the medication refrigerator temperature was within proper temperature controls. These failed practices placed all residents (based on census of 99) at risk of: 1) receiving expired medication and/or supplies; and 2) experiencing potential adverse reactions from medications not stored at proper temperatures. Findings: Medication Storage Room Expired Medication and/or Supplies: An observation on 10/11/23 at 9:35 AM, of the facility's main Medication Storage room, revealed an emergency kit that contained 1 box of Naloxone Hydrochloride [an emergency medication to reverse the effects of an opioid overdose] INJ. USP 1 mg/ml with an expiration date 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 interview, observation, and record review the facility failed to ensure food served from the kitchen was palatable and at acceptable temperatures for service 7 residents (#'s 16, 52, 53, 62, 75, 83, and 86), out of 21 sampled residents. This failed practice placed all resident at risk of poor appetite and decreased nutritional intake and/or weight loss. Findings: Resident #16 During an interview on 10/9/23 at 12:11 PM, Resident #16 stated he/she did not like the food and ordered out a lot. The resident further stated when he/she received his/her meal, it was served cold. Resident #52 During an interview on 10/9/23 at 8:35 AM, Resident #52 stated when he/she ordered grilled cheese, the sandwich was only cooked on one side. The resident stated the other side was just bread. Resident #52 further stated he/she mentioned this to the Director of Dining Services, but the sandwiches were still being served that way. Resident #53 During an interview on 10/8/23 at 2:30 PM, Resident #53 stated his/her food arrived cold. The resident described how the soup had arrived cold with cracks…

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 store food and prepare meals under proper sanitary conditions for residents, (based on census of 96), who received food from the kitchen. This failed practice placed residents at risk for foodborne illnesses and communicable disease. Findings: Food Storage: An observation and concurrent interview on 10/8/23 at 10:46 AM, of the far-left main kitchen refrigerator revealed: 1 - 16 oz container of Sysco Imperial Lobster Base, opened, no date. 1 - 32 oz container of Grove Lemon Juice, opened, no date. The Director of Dietary Services (DDS) stated that these items should have been dated when opened. The DDS immediately threw away the container of lobster base. An observation on 10/8/23 at 10:57 AM, of the downstairs walk-in refrigerator, revealed a large bag of chicken thighs thawing in a steam tray pan above another large bag of chicken thighs thawing on a baking sheet. The bag of chicken thighs in the steam tray pan were noted to fill the steam tray pan entirely, with a small portion of the bag containing the chicken hanging…

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

Based on observation, record review, and interview, the facility failed to ensure infection prevention and control protocols were performed for 13 residents (#'s 12, 19, 30, 31, 45, 48, 59, 68, 75, 81, 85, 90, and 298), out of 99 (census) residents. This failed practice had the potential to increase the development and transmission of communicable disease and infections. Findings: Hand hygiene before dining During an observation of the meal service on 10/8/23 at 12:19 PM, Certified Nursing Assistant (CNA) #11 delivered a meal tray to Resident #'s 12, 48 and 90. Upon delivery to each room, the CNA did not offer hand hygiene, nor ask the residents if hand hygiene was performed prior to his/her entrance. At 12:30 PM, CNA #11 delivered a meal tray to Resident #19. Resident #19 was not offered hand hygiene, nor asked if hand hygiene had already been performed. The CNA placed the meal tray on the bedside table, put on gloves and emptied Resident #19's urinal. CNA #11 then removed his/her gloves and served the resident his/her meal tray without first performing hand hygiene. CNA #12 then…

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

Based on record review, observation, and interview, the facility failed to ensure 2 residents (#36 and #81), out of 24 residents observed for dining, were treated in a dignified manner that respected individuality and their care needs. This failed practice placed the residents at risk of feelings of poor self-esteem and/or self-worth and a potential for poor quality of life. Findings: Resident #36 Record review on 10/8-12/23 and 10/16/23 of the Electronic Health Record (EHR), revealed Resident #36 was admitted to the facility with diagnoses that included hypertension (high blood pressure) and cerebrovascular accident (stroke). Review of the Quarterly Minimum Data Set (MDS- a federally required nursing assessment for long-term care residents) assessment, dated 9/14/23, revealed Resident #36 had a Brief Interview of Mental Status (BIMS-used to determine resident's cognitive status) of 00, which means severe cognitive impairment was present. An observation on 10/8/23 at 12:05 PM, revealed Resident #36 in his/her room, in bed, wearing a brief with fecal material that had leaked out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, interview, and observation, the facility failed to ensure a comfortable and clean homelike environment. Specifically, the facility failed to: 1) keep personal clothing items safe from loss for 1 resident (#71); and 2) keep the bathroom environment clean and sanitary for 2 residents (#'s 71 and 90), for 1 out of 6 survey days. These failed practices had the potential to cause a diminished self -worth and a reduced sense of well-being. Findings: Missing clothing: Record review from 10/8-12/23 and 10/16/23 revealed Resident #71 was admitted to the facility with a diagnosis that included dementia. During an interview on 10/9/23 at 9:17 AM, when asked if he/she had any property go missing, Resident #71 stated some of his/her clothes went missing, and his/her family member was going to speak to the Director of Nursing (DON). During an interview on 10/9/23 at 12:39 PM, Resident #71's Family Member (FM) reported several clothing outfits went missing adding up to about $400. The FM stated he/she…

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 document, investigate, and resolve a grievance for 1 resident (#84), out of 21 sampled residents. This failed practice violated this resident's right to have a grievance investigated and addressed. Findings: Review on 10/8-12/23 and 10/16/23 revealed Resident #84 was admitted to the facility with diagnoses that included infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, and Peripheral Vascular Disease. During an interview on 10/10/23 at 4:00 PM, Resident #84 stated he/she had two grievances that had not been resolved with the Social Services representative: 1) there was a grievance that the billing department had contacted the Resident's Emergency Contact #2 and discussed his/her private financial matters during a recent hospitalization; and 2) there was a grievance that his/her prosthetics and a wheelchair needed to be ordered. Review of the facility's Grievance Manual, included compiled residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, and interview, the facility failed to ensure the MDS (Minimum Data Set- a federally required assessment for long term care residents) assessment accurately represented residents' status for 3 residents (#'s 38, 83 and 96), out of 21 sampled residents and 4 closed records. This failed practice created a risk for inadequate care planning and inaccurate goals to improve the resident's functional abilities. Findings: Resident #38 Record review on 10/8-12/23 and 10/16/23 revealed Resident #38 was admitted with a diagnosis that included incomplete paraplegia (partial paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord). Review of Resident #38's admission MDS, dated [DATE], revealed: Section P0100A .Restraints .A. Bed Rail .1 .Used Less than daily . During random observations from 10/8-12/23 and 10/16/23 of Resident #38, revealed no bedrails were utilized, and Resident #38 was in his/her wheelchair with full use of his/her upper…

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 a comprehensive care plan was developed to address all risk factors to meet 1 resident's (#83) psychosocial needs, out of 21 sampled residents. This failed practice placed the resident at risk for not receiving the necessary and/or appropriate care and services. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #83 was admitted with diagnoses that included, surgical amputation of the right and left fingers and toes, diabetes, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), insomnia, and hyperlipidemia (high cholesterol). During an interview on 10/9/23 at 1:39 PM, Resident #83 stated he/she had Post Traumatic Stress Disorder (PTSD) related to a traumatic childhood event involving his/her parents as well as from the Vietnam War. Resident #83 further stated that hearing conversations in foreign languages was a trigger and had experienced this several times with staff conversing loudly outside…

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 the care plan was updated for 1 resident (#71), out of 21 sampled residents. Specifically, interventions to increase the resident's desire to attend activities he/she enjoyed were not included in the resident's care plan. This failed practice had the potential to place the resident at risk for not receiving necessary services to improve or maintain his/her quality of life. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #71 was admitted to the facility with diagnoses that included dementia and depression. During an interview on 10/9/23 at 12:35 PM, Resident #71's power of attorney (POA) stated the resident enjoyed musical activities. The POA further stated for the longest time, the facility did not assist the resident to the music activities. The POA stated with Resident #71's dementia, there were certain approaches that were helpful to increase the resident's desire to attend. The POA stated finally the Activity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, and interview, the facility failed to ensure the necessary services to maintain good personal hygiene were provided to 2 residents (#'s 16 and 149), out of 21 sampled residents. Specifically, the residents had not been offered or given showers. This failed practice denied the residents from maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: Resident #16: Record review from 10/8-12/23 and 10/16/23 revealed Resident #16 was admitted to the facility with diagnoses that included CVA (cerebrovascular accident-stroke) with hemiparesis (partial weakness or paralysis on one side of the body). Further review revealed the resident had a BIMS score of 13, which indicated the resident was cognitively intact. During an observation and interview on 10/9/23 at 11:48 AM, Resident #16 was observed with unkempt hair. Resident #16 stated few staff members knew how to help him/her with his/her hair, and the staff who usually assisted him/her was on…

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

Based on record review and interview, the facility failed to ensure needed care and services were provided to 1 resident (#53), out of 21 sampled residents. Specifically, the resident's dressing changes were not provided according to the physician's orders. The failure to provide ordered dressing changes placed the resident at risk for infection and decreased wound healing. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #53 was admitted to the facility with diagnoses that included Lymphedema (abnormal buildup of protein-rich fluid in any part of the body resulting from a malfunction in the lymphatic system) and chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease which causes obstructed airflow from the lungs). During an interview on 10/8/23 at 2:09 PM, Resident #53 stated he/she required dressing changes on his/her legs that were being done once a day, then every other day. The Resident stated every other day was okay, except the License Nurse (LN) had gotten too busy and pushed the dressing change off for 5 days. The 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, interview, and observation, the facility failed to ensure necessary services were provided to prevent a pressure ulcer for 1 resident (#73), out of 21 sampled residents. Specifically, skin checks were not documented for the month prior to the resident developing a heel ulceration. This failed practice had the potential to delay necessary treatments to prevent further damage to the resident's skin. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #73 was admitted to the facility with diagnoses that included diabetes and diabetic neuropathy (nerve damage that occurs from diabetes, with symptoms that include numbness or pain in the legs, feet, or hands). Further review revealed the resident had a BIMS (brief interview for mental status) score of 13, which indicated the resident was cognitively intact. During an interview on 10/9/23 at 11:05 AM, when asked about his/her foot and heel ulcers, Resident #73 stated he/she was tall and his/her feet were touching the baseboard of the bed, which created the wounds. When asked what measures were put…

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

Based on record review and interview, the facility failed to ensure one resident (#35), out of 9 investigated complaints/facility reported incidents, received adequate supervision and assistance to prevent accidents during resident's care. This failed practice resulted in physical injury to the resident and hospitalization. Findings: Record review on 10/8-12/23 and 10/16/23 of the electronic health record (EHR), revealed Resident #35 was admitted to the facility with diagnoses that included down syndrome (a genetic disorder associated with physical growth delays), cerebral infarction (stroke), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body). Review of the facility reported incident Initial Report, dated 9/5/23, Resident #35 fell from the bed during resident care which resulted in a fracture to the resident's left femur. Review of the Quarterly Minimum Data Set (MDS- a federally required nursing assessment for long-term care residents) assessment, dated 6/14/23, revealed in Section G- Functional status A. Bed Mobility, 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 and interview, the facility failed to include a Post Traumatic Stress Disorder (PTSD) diagnosis for 1 resident's (#83) medical record and develop a trauma-informed care plan, out of 21 sampled residents. This failed practice had the potential to exacerbate or trigger ongoing psychosocial difficulty and affect the resident's ability to attain the highest practicable mental and psychosocial well-being. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #83 was admitted with diagnoses that included, surgical amputation of the right and left fingers and toes, diabetes, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), insomnia, and hyperlipidemia (high cholesterol). During an interview on 10/09/23 at 1:39 PM, Resident #83 stated he/she had PTSD related to a traumatic childhood event involving his/her parents as well as from the Vietnam War. Resident #83 further stated that hearing conversations in foreign languages was a trigger and had experienced this several times with staff conversing loudly outside 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 record review and interview, the facility failed to ensure an annual performance review was completed for 1 Certified Nurse Assistant (CNA) (#1), out of 2 CNA files reviewed. This failed practice failed to monitor the CNA's performance or provide potentially needed feedback/education for any possible sub-optimal care rendered to residents (based on a census of 99). Findings: Personnel record review on 10/12/23 at 10:40 AM, revealed CNA #1 was hired on 4/23/20. Review of CNA #1's file revealed the last annual evaluation completed was 10/20/21. During an interview on 10/12/23 at 10:40 AM, Assistant Administrator (AA) stated that a new Staff Development (SD) employee was recently hired to update the staffing process and these types of concerns would be addressed. The AA further stated, We are running behind and recognized that was needed so [SD] was hired. It took us a while to hire the right person. Review of the Anchorage Team Member Handbook, undated, revealed: . The performance evaluation process is designed to provide a dialogue between the supervisor and the team member…

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, interview, and observation, the facility failed to ensure 2 residents (#3 and 81), out of 9 complaints/facility reported incidents investigated, were free from significant medication errors. Specifically, the residents received incorrect medications. This failed practice resulted in hospitalization for one resident and placed another resident at risk for adverse reactions. Findings: Resident #3 Record review on 10/8-12/23 and 10/16/23, revealed Resident #3 was admitted with a diagnosis that included type 2 diabetes mellitus. Review of the facility reported incident (FRI) Initial Report, dated 9/25/23, revealed Resident #3 was administered 35 units of Lispro (short acting insulin), instead of 35 units of Lantus (long-acting insulin) by Licensed Nurse (LN) #1. LN #1 recognized the medication error immediately and gave the resident 150 ml of orange juice and breakfast. Physician #1 was called immediately to the bedside, the following orders were given; hold all medications for the rest of the day, perform blood sugar checks every 15 minutes, and give PRN (as…

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

Based on record review and interview, the facility failed to ensure meals were served according to the resident's therapeutic dietary order for 1 Resident (#298), out of 21 sampled residents. This failed practice had the potential to place the resident at risk for adverse medical complications. Findings: Record review on 10/8-12/23 and 10/16/23 revealed Resident #298 was admitted with diagnoses that included pleural effusion (fluid build up around the lungs), fractures of the left and right femurs, and fracture of the left tibia. During an interview on 10/9/23 at 3:02 PM, Resident #298 stated, There was no way my breakfast was low sodium. I should be on a low sodium diet. The resident further stated that he/she needed to watch his/her sodium intake to keep the swelling in his/her legs down and fluid around his/her lungs from accumulating. Review of Resident #298's Diet Order and Communication form, dated 10/6/23, revealed an active diet order: regular texture, heart healthy type, small portion, thin liquids per Diet Order and communication Form. Review of Resident #298's meal tray…

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