Arcadia Care Center

Based on interview and record review, the facility failed to ensure therapeutic diets were served as ordered for one of four sampled residents (Resident 1). Resident 1 had a Physician's Order (PO) for no additional salt. This failure had the potential to result in an increased blood pressure (the force of the blood against the artery walls is too high) due to increased salt levels.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide three of three sampled residents (Residents 10,75 and 119) with dignity and respect, based on the facility's policy and procedure (P&P) titled, Resident Rights, by failing to:a. Ensure Resident 119, who was occasionally (less than seven episodes of incontinence [inability to control the bladder and bowels]) incontinent, was offered alternative means to go to the bathroom. As a result, Resident 119 was instructed by staff to go the bathroom in Resident 119's brief (disposable absorbent garment designed to contain urinary or fecal incontinence). Resident 119 felt pain when having to be turned to be changed and made Resident 119, Feel horrible.b. Ensure Staff do not address Resident 10 as a feeder. As a result, Resident 10 stated Resident 10 felt useless.c. Ensure the Director of Staff Development (DSD) close Resident 75's privacy curtains completely while checking the resident's G Tube site.These deficient practices violated…

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 the residents' call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of four of four sampled residents (Residents 10, 29,114 and 118).These deficient practices had the potential to result in delayed provision of necessary care and services for Residents 10, 29,114 and 118.Findings: a. During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included multiple sclerosis (disease that affects the brain and nerves causing weakness and problems with movement), protein calorie malnutrition (a condition resulting from insufficient intake of both protein and calories), adult failure to thrive (a decline in older adults characterized by weight loss, decreased appetite, and reduced physical activity, often accompanied by cognitive [mental process involved 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow standards of practice and facility protocol for oxygen therapy for four of four sampled residents (Residents 23, 39, 40, and 113) by failing to:a. Ensure Resident 39's nasal cannula ([NC] a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not touching the floor while in use.b. Ensure Resident 23's NC was safely stored without the nasal prongs touching the back of the oxygen concentrator.c. Ensure Resident 40 received two liters per minute (lpm) of oxygen via NC according to the physician's order.d. Ensure Resident 113's NC was not touching the floor while in use.These failures had the potential to result in the transmission of infectious microorganisms and increased risk of infection for Residents 23, 39, and 113 and had the potential to cause complications associated with oxygen therapy for Resident 40.Findings: a. During a review of Resident 39's admission Record (AR), the AR…

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 properly store boiled eggs in one of one facility kitchen. This failure had the potential to result in foodborne illness in the residents who ate the boiled eggs. Findings:During an observation on 7/21/2025 at 8:27 a.m., five eggs without a date and time were observed in a black bowl on the kitchen counter across from the cooking stove.During an interview on 7/21/2025 at 8:28 a.m., with cooking staff, [NAME] 1, the cooking staff stated the eggs were prepared for residents that want their eggs boiled. The cooking staff could not provide an exact date or time the eggs were boiled and placed on the counter. Staff stated the eggs could go bad if I don't know the exact time the eggs were prepared before giving them to a resident.During an interview on 7/23/2025 at 7:59 a.m., with [NAME] 1 and DSS, while in the kitchen, both stated that eggs left out can develop salmonella (a common form of food poisoning) if not dated and timed to determine how long they have been unrefrigerated. If eggs are left out and not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's infection control policy and procedure for two of five sampled residents (Residents 83 and 162).a. Certified Nursing Assistant 1 (CNA 1) did not wear the required Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses like disposable masks, gloves and gowns) and did not perform hand hygiene while taking care of Resident 162 who was on Enhanced Barrier Precaution (EBP- infection control measures implemented in nursing homes to reduce the spread of multidrug-resistant organisms [MDROs- bacteria or other microorganisms that have become resistant to multiple antibiotics]).b. CNA 3 did not wear the required PPE in an EBP room and did not perform hand hygiene before and after touching Resident 83's urostomy bag (a medical device used to collect urine after certain types of bladder surgery).These deficient practices had the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) fed one of one sampled resident (Resident 40) in a respectful manner by not standing over the resident while assisting with eating during a meal. This deficient practice had the potential for Resident 40 to have decreased feelings of self-worth. Findings: During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), hypoxemia (low level of oxygen in the blood) and dysphagia (difficulty swallowing). During a review of Resident 40s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/29/2025, the MDS indicated, Resident 40 had moderately intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 40 was dependent (helper did all the effort and lifted or held trunk…

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 and record review, the facility failed to ensure Resident 11's target behavior and adverse side effects (unwanted or undesirable effect) was monitored for the use of Alprazolam (antianxiety medication to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) for one of five sampled residents (Resident 11) as indicated in the facility's policy Behavioral Assessment, Management, Psychoactive Medications and Monitoring and Resident 11's care plan. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) and PTSD. During…

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 and record review, the facility failed to develop an individualized/person-centered care plan for one of one sampled resident (Resident 11). The facility did not address Resident 11's Post-Traumatic Stress Disorder (PTSD- when a person keeps feeling scared/anxious long after a traumatic event was over) in accordance with facility's Policy and Procedure (P&P) titled Comprehensive Person - Centered Care Planning.This deficient practice had the potential for Resident 11 to not receive necessary care and/or services to address Resident 11's specific needs.Findings:During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) and PTSD.During a review of Resident 11's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/14/2025, the MDS indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 7) was provided a communication device with the language that the resident understood in accordance to facility's policy Communication with Persons with Limited English Proficiency.This deficient practice had the potential result in Resident 7 to not be able to express their needs and receive the necessary care and services. Findings: During a review of Resident 7's admission Record (AR) indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine), chronic kidney disease (CKD, is a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood) and muscle weakness. During a review of Resident 7's Minimum Data Set (MDS - a…

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

Based on interview and record review, the facility failed to minimize the risk for edema (a condition characterized by the swelling of body tissues due to an excessive buildup of fluid) to the legs and feet for one of one sampled resident (Resident 136), according to the facility's policy and procedure (P&P) titled, Applying Anti-Emboli (the blockage of a blood vessel by a substance [embolus] that has moved from another part of the body) Stockings (thrombo-embolic deterrent [TED- also known as anti-embolism stockings, are a type of medical compression stocking designed to prevent blood clots and swelling in the legs] Hose), by failing to: Ensure Resident 136's TED hose was applied nightly starting 7/17/2025 as ordered by Resident 136's physician. As a result of this failure, Resident 136 did not get TED hose applied to Resident 136's left leg and thigh for eight days. This failure had the potential for Resident 136 to develop increased edema and related complications. Findings: During a review of Resident 136's admission Record (AR), the AR indicated the facility admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that opened medication tablets were not placed inside a metal box and left on Resident 64's bed unattended. The Metal box was not labeled with an identifier for Resident 64 such as name, room number or date of birth . The Medication tablets did not have a sealed cover (refers to a tamper-evident seal or packaging feature that provides a visible indicator if the product has been opened or compromised. It's designed to protect the integrity and safety of the medication until administered to the resident) and did not have name or dosage. This deficient practice had the potential to place Resident 64, other residents, visitors or staff at risk of getting hold of the medication and if ingested (swallowed), had the potential for complications that can expose users to risks of abuse, misuse and addiction, which can lead to overdose or death. Findings:During a review of Resident 64's admission Record, the admission Record indicated…

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 and record review, the facility failed to promote bowel and bladder continence (ability to control the bladder and bowels) for one of one sampled resident (Resident 119) according to the facility's policy and procedure (P&P) titled, Urinary Continence and Incontinence (inability to control the bladder and bowels)- Management and Assessment, by failing to: Ensure Resident 119, who was occasionally (less than seven episodes of incontinence) incontinent of bowel and bladder, was offered an alternative means to go to the bathroom. As a result of this failure, Resident 119 was instructed to go to the bathroom in Resident 119's brief (disposable absorbent garment designed to contain urinary or fecal incontinence). This failure had the potential for Resident 119 to lose more function of bowel and bladder and become more incontinent. Findings: During a review of Resident 119's admission Record (AR), the AR indicated the facility admitted Resident 119 on 6/17/2025 with diagnoses that included aftercare…

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:a. Post nurse staffing data in a prominent location readily accessible to residents and visitors for viewingb. Post resident census at the beginning of the shift for which the data was posted on 7/24/2025.c. Maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. These deficient practices of posting inaccurate nurse staffing information had the potential to mislead the residents and visitors and affect the quality of nursing care provided to the residents. Findings: a. During an observation on 7/21/2025 at 9:50 am, there was no Daily Staff posting found at Station four (4) or at a prominent location which was readily accessible to staff, residents and visitors. During a concurrent observation and interview on 7/21/2025 at 9:51 am, with the Director of Staff and Development (DSD), there was no Daily Staff posting posted at Station 4. The DSD stated, there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to record and track a prescribed narcotic for one of one sampled resident (Resident 29).This failure had the potential to result in diversion (the illegal selling of prescribed medications) of a controlled substance. Findings:During a review of the undated Narcotic (a substance used to treat moderate to severe pain) Disposal Log, the Narcotic Disposal Log indicated there were two narcotics, one for Morphine Sulfate IR tablets and Hydrocodone-Acetaminophen tablets, but nothing for the Morphine Sulfate 10 milligrams solution.During a review of the Order Summary Report, dated [DATE], the Order Summary Report indicated an active order for Morphine Sulfate Oral Solution 10mg/5mL to be given by mouth every two hours as needed for severe pain for 30 days.During a review of the Medication Administration Record, for the dated [DATE] and [DATE], the Medication Administration Record indicated that Resident 29 received a dose of 2 milliliters of a…

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

Based on interview and record review, the facility failed to ensure irregularities identified from the monthly drug regimen review (MRR) reported by the facility's pharmacist were acted upon for one of five sampled residents (Resident 119) according to the facility's policy and procedure (P&P) titled, Medication Regimen Review, by failing to:Ensure Resident 119's consultant pharmacist recommendation to order laboratory test to monitor Resident 119's thyroid-stimulating hormone (TSH- blood test used to check how well the thyroid gland is working) while taking levothyroxine (also known as Synthroid- medication used to treat hypothyroidism [a condition where the thyroid gland does not produce enough thyroid hormone]) was acted upon.As a result of this failure, Resident 119 did not have an updated TSH level drawn since Resident 119's admission to the facility. This deficient practice had the potential for Resident 119 to receive the incorrect dose of levothyroxine and result in complications.Findings:During a review of Resident 119's admission Record (AR), the AR indicated the facility…

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 four of four dumpster containers were covered.This failure had the potential to attract and expose the facility to pests and other scavengers to the facility. Findings:During an observation on 7/22/2025 at 7:24 a.m., four outside dumpster containers were uncovered. During an interview on 7/21/2025 at 8:24 a.m. with the IPN, while in the parking lot, the IPN stated that the dumpsters contain used diapers and when the weather is hot, the smell can be a problem for the surrounding community. The IPN also stated that the open dumpster containers with discarded foods can attract rats and raccoons.During a review of the Food-Related Garbage and Refuse Disposal policy, dated October 2017, the Food-Related Garbage and Refuse Disposal policy indicated that outside dumpsters provided by garbage pickup services were to be kept closed and free of surrounding liter.During a review of the facility's Sanitation (the process of keeping places free from dirt, infection, disease, etc. by removing waste, trash, and…

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

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by not notifying one of two sampled residents' (Resident 1's) Representative (R1) when Resident 1 was transferred to the General Acute Care Hospital (GACH 1). This failure resulted in the violation of Resident 1's and R1's right to be notified of any changes of condition/status of Resident 1. Cross Reference F842 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 1/13/2025, and readmitted Resident 1 on 2/6/2025, with diagnoses that included encephalopathy (damage or disease that affects the brain), acute respiratory failure with hypoxia (a condition where the lungs do not get enough oxygen into the blood, resulting in low blood oxygen levels), and pneumonitis due to inhalation of food and vomit (a lung infection that occurs when you breathe in food or liquid instead of swallowing it). The AR indicated R1 was the first emergency contact person for Resident 1.…

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 follow its policy and procedure (P&P) titled, Charting and Documentation, by failing to document notification to one of two sampled residents (Resident 1's) representative (R1) of Resident 1's transfer to the General Acute Care Hospital (GACH 1). This deficient practice had the potential to not provide complete information regarding Resident 1's transfer to GACH 1. Cross Reference F580 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 1/13/2025, and readmitted Resident 1 on 2/6/2025, with diagnoses that included encephalopathy (damage or disease that affects the brain), acute respiratory failure with hypoxia (a condition where the lungs do not get enough oxygen into the blood, resulting in low blood oxygen levels), and pneumonitis due to inhalation of food and vomit (a lung infection that occurs when you breathe in food or liquid instead of swallowing it). The AR indicated R1 as the first emergency contact person for Resident 1. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly (quickly/with little or no delay) notify one of three sample residents' (Resident 2) Responsible Party (RP 2) when Resident 2 experienced a change in condition (CIC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in the facility's policy and procedure (PP) titled, Change of Condition Reporting, by failing to: Ensure RP 2 was notified when Resident 2's Primary Care Provider/Medical Doctor (MD) 1 discontinued Resident 2's Avycaz (brand name for ceftazidime/avibactam- an antibiotic [medicine that stops the growth of or destroys bacteria in the body] used to treat complicated urinary tract infections [UTI- an infection in any part of the urinary tract, the system of organs that makes urine]). As a result of this failure, RP 2 was not informed timely of the change in Resident 2's treatment and plan of care. This failure caused a delay in providing the necessary…

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 and record review, the facility failed to provide care and services for one of three residents (Resident 2), according to the facility's policy and procedures titled, Antibiotic Stewardship (the effort to measure and improve how antibiotics [medicine that stops the growth of or destroys bacteria in the body]) - Orders for Antibiotics, and Urinary Tract Infection (UTI- an infection in any part of the urinary tract, the system of organs that makes urine)/Bacteriuria (bacteria in urine), by failing to: 1. Ensure Resident 2's Primary Care Provider/Medical Doctor (MD) 1 continued Resident 2's intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream) ceftazidime-avibactam (Avycaz- an antibiotic used to treat a wide variety of bacterial infections) therapy for the treatment of Resident 2's Pseudomonas aeruginosa (Pseudomonas- a type of bacteria that are widely found in the environment that can cause infection in the body) UTI 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the laboratory (a room or building equipped for experimental study in science or for testing and analysis) services (laboratory services/laboratory tests included certain blood tests and urinalysis [UA- a medical test that examines a person's urine to detect and diagnose different health conditions], that helped healthcare professionals to detect and treat diseases) for one of three sampled residents (Resident 2) according to the facility's policy and procedures (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, by failing to: Ensure assigned licensed nurses (Licensed Vocational Nurses [LVNs] and/or Registered Nurses [RN] carried out (to do or complete) a physician order dated 1/8/2025 for a UA with culture and sensitivity (C&S- a laboratory test that checks for bacteria or other germs in a urine sample that can cause an infection and checks to see what kind of antibiotic [a medicine that stops the growth of or destroys…

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 maintain the resident's dignity for six of six sampled residents (Residents 13, 15, 75, 86, 120, and 279) when: a. Facility staff failed to answer Residents 120 and 279's call light (a device used by a resident to signal his or her need for assistance from staff) in a timely manner. b. Facility staff stood next to Residents 13 and 15 while feeding lunch. c. Facility failed to ensure Residents 13, 75 and 86 were treated with dignity by protecting the residents' private space. LVN 2 and LVN 7 failed to knock multiple times prior to entering and/or opening the door of the residents' room. These failures resulted for the residents to feel frustrated and embarrassed and had the potential for the residents to experience a decline in psychosocial well-being. (Cross reference F689) Findings: a. During a review of Resident 120's AR, the AR indicated Resident 120 was admitted to the facility 6/28/2024 with diagnoses including spinal stenosis (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's representative was provided education regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as a living will or durable power of attorney [legal document that allows someone to act on your behalf in certain situations] for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) and the information was complete and accurate for two of eight sampled residents (Residents 4 and19). These deficient practices had the potential for the residents to receive life-sustaining care and/or treatment against their will. Findings : a.During a review of Resident 4's admission Record, (AR) dated 7/24/2024, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term…

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 interviews and record review, the facility failed to notify the responsible party of two of three sampled residents (Residents 178 & 179) in writing regarding the Medicare Advance Beneficiary Notice (ABN, written notice that informs Medicare beneficiaries of certain items or services that Medicare may not pay for prior to receiving the items or services). This failure had the potential to negatively affect Residents 178 and 179's physical and psychosocial well-being due to responsible party's lack of information, including the resident's right to appeal. Findings: a. During a review of Resident 178's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 178 on 2/5/2024 with diagnoses including intracerebral hemorrhage (life-threatening bleeding inside the brain), hemiplegia and hemiparesis (paralysis or weakness on one side of the body), atelectasis (lung collapse), and chronic (long-standing) kidney disease. AR 1 indicated Responsible Party 178 (RP 178) was Resident 178's representative. During a review of Resident 178's History and Physical…

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 implement fall safety intervention for two of three sampled residents (Residents 55 and 279) in accordance with the facility's Policy and Procedure (P&P) titled, Falls - Clinical Protocol,, by failing to: a. Ensure the facility staff provided supervision when Resident 279 ambulated in her room and/or while ambulating to the bathroom. b. Ensure the bed for Resident 55 who was assessed as high risk for fall and had a history of falling, was at the lowest position and floor mats were in place. These failures had the potential to result in falls/injury for Residents 55 and 279. (Cross reference F550) Findings: a. During a review of Resident 279's admission Record (AR) the AR indicated Resident 279 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone) of the left knee, cerebral palsy (a group of disorders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based interview and record review, the facility failed to monitor fluid restriction on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024 for one of one sampled resident (Resident 49) in accordance with the physician's orders. These failures had the potential to lead to fluid overload (too much fluid volume in the body) and overall decline in health. Findings: During a review of Resident 49's admission Record (AR), the AR indicated Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure (a condition that develops when one's heart doesn't pump enough blood for the body's needs), end stage renal disease (a condition in which a person's kidney's stop functioning on a permanent basis) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working). During a review of Resident 49's Minimum Data Set (MDS - a standardized assessment and care planning tool)…

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 implement interventions to prevent and control the spread of infections in the facility in accordance with the facility's policies and procedures and national health guidelines. A. One of one Certified Nursing Assistant (CNA 1) did not don (wear) the required protective personal equipment (PPE, equipment worn to minimize exposure to a variety of hazards) prior to entering the room of one of one sampled resident (Resident 55), who was on contact isolation precautions (type of transmission-based precaution requiring the use of gown and gloves to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment). B. One of one Licensed Vocational Nurse (LVN 2) attempted to use the toilet paper in the shared bathroom when administering eye drops to Resident 13. These failures had the potential to result in an increased spread of infection in the facility. Findings: 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 interview and record review, the facility staff failed to notify the physician of one of one sampled resident's (Resident 14) blood sugar value of 420 milligram/deciliter (mg/dL - unit of measurement) on 7/1/2024 as indicated in Resident 14's Medication Administration Record (MAR). This failure had the potential for Resident 14 to experience undesired effects of high blood sugar. Findings: During a review of Resident 14's admission Record, the AR indicated Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), liver cirrhosis (a type of liver disease where healthy cells are replaced by scar tissue) and hyperlipidemia (excess of fat or lipids in the blood). During a review of Resident 14's History and Physical (H&P) dated 2/27/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During a review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 75) was provided with a home-like environment by not allowing Resident 75 to use the [NAME] and [NAME] restroom (a restroom that has two doors and is usually accessible from two bedrooms to share) of other residents. This failure had the potential to result in invasion of privacy for Resident 75 and other residents. Findings: During a review of Resident 75's admission Record (AR), the AR indicated, Resident 75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease (ESRD, kidneys lose the ability to remove waste and balance fluids) and essential (primary) hypertension (high blood pressure). During a review of Resident 75's History and Physical Examination (H&P), dated 10/5/2023, the H&P indicated Resident 75 had the capacity to understand and make decisions. During a review of Resident 75's Minimum Data Sheet (MDS, an assessment and…

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

Based on observation, interviews, and record review, the facility failed to follow the food preferences of one of four sampled residents (Resident 27) during lunch tray line (system of food preparation in which meal trays are moved along an assembly line). This failure had the potential to cause inadequate nutrition related to decreased appetite, refused meal, or meal replacement with less healthier options. Findings: During a review of Resident 27's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 27 on 4/6/2022 with diagnoses including dementia (impairment of brain functions that interfere with daily life), type 2 diabetes mellitus (long-term condition of uncontrolled blood sugar), vitamin B12 deficiency anemia (lower than normal amounts of vitamin B12 in the blood that leads to reduced healthy red blood cells), iron deficiency anemia (too little iron in the body causing reduced healthy red blood cells), ascorbic acid deficiency (vitamin C deficiency), and vitamin D deficiency. During a review of Resident 27's History and Physical Examination (H&P…

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 implement its facility's Policies and Procedures (P&Ps) on dishwashing and standard precautions for one of one dishwasher (DW 1) observed in the facility's kitchen. This failure had the potential to for foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents related to food contamination. Findings: During an observation of DW 1's dishwashing and sanitizing practices on 7/25/2024 at 3:25 PM with the Dietary Services Supervisor (DSS), DW 1 washed and rinsed the dirty pans and trays in the sink, then touched the metal trays that were sanitized in the dishwasher. During an interview on 7/25/2024 at 3:26 PM, DSS stated DW 1 was not supposed to touch or move the sanitized metal trays while washing the dirty pans and trays. DSS stated another staff member, Dietary Aide 2 (DA 2), was assigned to put away the sanitized metal pans and trays to prevent cross-contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) of items…

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 and record review, the facility failed to ensure the Responsible Party (RP 85), who signed the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) for one of three sampled residents (Resident 85) understood the BAA prior to signing. This failure had a potential to result in a decline in Resident 85's physical and/or psychosocial condition due to possible hardships related to arbitration proceedings. Findings: During a review of Resident 85's admission Record (AR 1), AR 1 indicated the facility originally admitted Resident 85 on 6/27/2022 and readmitted on [DATE] with diagnoses including dementia (impairment of brain functions that interfere with daily life), adult failure to thrive (worsening of physical frailty frequently accompanied by cognitive [ability to acquire, process, and recall information] impairment and/or functional disability 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of one sampled resident (Resident 14)'s representative of the facility's policy for bed hold. This failure had the potential for Resident 14's representative to be uninformed of their rights to return to the facility after discharge or transfer. Findings: During a review of Resident 14's admission Record, (AR), the AR indicated Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), liver cirrhosis (a type of liver disease where healthy cells are replaced by scar tissue) and hyperlipidemia (excess of fat in the blood). During a review of Resident 14's History and Physical (H&P) dated 2/27/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care planning tool)…

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 and record review, the facility failed to develop a personalized care plan for one of nine sampled residents (Resident 1) by failing to ensure Resident 1 ' s care plan indicated how many staff were needed to provide care to Resident 1. This failure had the potential to result in Resident 1 not receiving necessary and appropriate care. Cross Reference F726 and F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included functional Quadriplegia (a form of paralysis that affects all four limbs), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of muscles on both arms and legs and dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning…

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 and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) had the competency to provide care to residents who were on a low air loss (LAL) mattress (a kind of mattress used for residents who are at risk of developing pressure sores or already have pressure sores) when CNA 1 did not notify a licensed nurse to set Resident 1 ' s low air loss mattress on static mode (firm surface set in place and unlikely to move) before providing care to Resident 1. As a result, on 1/2/2024 at 11:20 AM, Resident 1 fell from her bed to the floor. Resident 1 sustained acute displaced fracture (bone breaks into two or more pieces and move out of alignment) at the neck of the right humerus (upper arm bone) and acute nondisplaced fracture (fracture in which the bone cracks or breaks but remains in proper alignment) at the neck of the right femur (thigh bone) and the sacrum (S1, a structure located at the base of the spine). Resident 1 was transferred and admitted to General Acute 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 observation, interview, and record review, the facility failed to establish and maintain infection prevention and control practices (a set of practices that prevent or stop the spread the of infection and/or diseases in the healthcare setting) in accordance with the facility ' s policy and procedure and Centers for Disease Control and Prevention (CDC, a federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) guidelines by failing to: Ensure three of four staff performed hand hygiene (procedures that included the use of alcohol-based hand rub (ABHR- containing 60%-90% alcohol) and hand washing with soap and water before entering and after providing care to one of six sampled residents (Resident 6), who was positive for COVID-19 (Corona virus 2019, a contagious virus that causes mild to severe upper respiratory infection). These deficient practices had the potential to spread infectious agents to other residents, visitors, and/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 observation, interview and record review, the facility failed to ensure the needs for eight out of 28 sampled residents were met (Resident 54, 65, 95, 103, 106, and 177) by failing to: 1. Ensure call lights were answered in a timely manner to address the residents needs for Residents 54, 65, 95, 103, 106, and 177. This deficient practice had the potential to affect residents' quality of care and quality of life due to nursing services were not provided to the residents in timely manner. 2. Ensure residents (Residents 95 and 103) were assisted with incontinent care, bathroom use, and with maintaining wellbeing to the extent possible in accordance with their own needs. This deficient practice had the potential for residents' lack of care and not maintaining their well-being in accordance with their own needs. Findings: 1. During an interview on 5/18/2021 at 9:00 a.m., Resident 95 stated no one helps her and facility staff takes a long time to come when she pressed the call light. Resident 95 stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan timely for three of 28 sampled residents (Residents 20, 24, and 25) by failing to: 1. Resident 25 who was on a restorative nursing aide (RNA) program (nursing aide program that help residents to maintain their function and joint mobility) for both lower extremities (hips, knee, ankle, foot) passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises did not have a care plan for RNA. 2. Resident 20 who had sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) did not have a care plan to address her sleep apnea and the use of a Bilevel Positive Airway Pressure (BiPAP; a device that helps push air into the lungs) machine at bedtime. 3. Resident 24 who had on and off episodes of edema (swelling) to her bilateral lower extremities (BLE) did not have a care plan to address her BLE edema. These deficient practices had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two out of five sampled residents (Residents 25 and 76) who had limited joint range of motion received restorative nursing aide (RNA) program (nursing aide program that help residents to maintain their function and joint mobility) treatments and services; a. Resident 76 was not provided an RNA program to put on and take off left and right knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for both knee contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). b. For Resident 25, 1. the RNA order dated 5/12/2021 did not specify site and location to perform RNA exercises to both lower extremities. 2. The RNA program for passive range of motion (PROM, movement at a given joint with full assistance from another person) on both upper extremities (BUE) was not provided since 3/30/2021 when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to two residents (Residents 67 and 77) whose insulin was found to be expired during the inspection of one of two medication carts (Medication Cart 1.) As a result, Residents 67 and 77 received a combined total of eight doses of expired insulin between [DATE] and [DATE]. This deficient practice had the potential to cause Residents 67 and 77 to experience serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization or death. Findings: A review of Resident 67's admission Record, dated [DATE], indicated she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 (a medical condition characterized by the inability to control blood sugar.) A review of Resident 67's Order Summary Report, dated [DATE], indicated on [DATE] and [DATE] the physician prescribed…

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: 1. Ensure one single-use vial of injectable haloperidol (a medication used to treat hallucinations - seeing or hearing things that are not there) was discarded for one resident (Resident 35) in one of two inspected medication carts (Medication Cart 1.) 2. Ensure expired insulin (a medication used to treat high blood sugar) was discarded for five residents (Residents 27, 51, 67, 77, and 374) in one of two inspected medication carts (Medication Cart 1) and one of two inspected Medication Rooms (Medication room [ROOM NUMBER].) 3. Ensure medications were labeled with an open date per the manufacturer's requirement for eight residents (Residents 3, 35, 58, 78, 88, 95, 103, and 373) in two of two inspected medication carts (Medication Carts 1 and 2) and one of two inspected medication rooms (Medication room [ROOM NUMBER].) These deficient practices increased the risk that Residents 3, 27, 35, 51, 58, 67, 77, 78, 88, 95, 103, 373, and 374 could…

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 and record review, the facility failed to report laboratory (Lab) work in a timely manner to the resident's oncologist (doctor that specializes in treatment of cancer) for one of five sampled residents (Resident 60.) This deficient practice resulted in a delay in Resident 60's oncology care and Resident 60 did not receive Sprycel (a medication used to treat CML) medication between 5/5/21 and 5/21/21 (17 days). This deficient practice could have resulted in a negative impact to his overall physical, mental, and psychosocial well-being. Findings: A review of Resident 60's admission Record, dated 5/20/21, indicated the resident was readmitted to the facility on [DATE] with diagnoses including chronic myeloid leukemia (CML - a type of blood cancer.) A review of Resident 60's Order Summary Report, dated 4/30/21, indicated on 1/6/21 the oncology physician prescribed Sprycel (a medication used to treat CML) 100 milligrams (mg- a unit of measure for mass) by mouth once daily. A review of Resident 60's…

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 and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to opt in to certain medication therapy or treatments once they are educated about the risks and benefits) prior to prescribing psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 116.) This deficient practice could have denied Resident 116 the right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being. Findings: A review of Resident 116's admission Record, dated 5/21/21, indicated she was readmitted to the facility on [DATE] with diagnoses including: major depressive disorder (MDD- a mental disorder characterized by depressed mood, a lack of interest in activities or socializing, or poor appetite) and anxiety disorder (a mental…

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 interviews and record reviews, the facility failed to accommodate resident's preference for 1 of 2 sampled residents (Resident 4), to go back inside his room to keep warm rather than stay in the facility hallway without clothes and wrapped in a thin blanket while waiting for his turn to use the facility's common shower room. This failure resulted in not meeting the right to make a choice by the resident. Findings: A review of the admission Record indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (COPD, a lung disease that block airflow and make it difficult to breathe). A review of the Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 5/05/2021, indicated Resident 4 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 4 was able to make needs known and understand others. The MDS indicated Resident 4…

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 provide Resident 323's representative access to residents' medical records when requested. This deficient practice resulted in Resident 323's representative not receiving documents on a timely manner. Findings: During a telephone interview on 5/19/2021 at 10:30 a.m., Resident 323's Legal Representative (LR) stated he requested for Resident 323's medical records on 2/25/2021 but did not receive any response from the facility. LR stated he requested Resident's 323's medical records by fax. A review of Resident 323's Face Sheet (admission record), indicated the facility admitted the resident on 1/14/2021, with diagnoses including Type 2 Diabetes Mellitus (long term condition that affects the way the body processes blood sugar), essential hypertension (high blood pressure that does not have a known secondary cause) and polyneuropathy (when multiple peripheral nerves [nerves outside the brain and spinal cord] become damaged). A review of Resident 323's History and Physical dated 1/16/2021 indicated Resident 323 does not have…

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 complete an advance directives (a written instruction, such as a living will or durable power of attorney for health care recognized under state law) to four of six sampled residents (Resident 35,48, 223 and 224). This deficient practice had the potential to delay emergency treatment or had the potential to execute emergency, life sustaining procedures against the resident's personal preferences. Findings: During a concurrent interview and record review with Social Services Assistant (SSA) on 5/19/2021 at 10:30 a.m., SSA confirmed that Resident 244 have no advanced directives on the chart and no documentation or any evidence showing that the resident's representative was given an option to formulate advance directive. SSA stated she has to call the family right away, obtain advance directives document from the resident's representative if available, if not, SSA will provide the resident and the resident's representative advance directives information on how to obtain and formulate advance directives. 1.A review of Resident…

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

Based on observation, interview and record review, the facility failed to provide an orderly (uncluttered physical environment that is neat and well kept), sanitary (preventing the spread of disease causing organisms by keeping care equipment clean and properly stored), and home-like environment for Resident 14. This deficient practice had the potential to result in an environmental hazard (danger or threat), increased the risk for falls or injury, and increase the spread of infectious disease and illnesses. Findings: During an observation of Resident 14's room on 5/18/2021 at 10:31 a.m., Resident 14's personal belongings that included books, two basins, a toothbrush, crackers, and eyeglasses (were observed laid on the floor to the right side of Resident 14's bed, by the glass sliding door leading to the facility patio. During the observation, Resident 14's urinal was filled with urine and placed adjacent to Resident 14's personal belongings on the floor. Resident 14 was observed lying in bed and had a cast to the left upper extremity and left lower extremity. A review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure Nursing Assistant (NA) 1, NA 2, and Certified Nursing Assistant (CNA) 2 reported an alleged injury of unknown origin/source was reported immediately, but not later than two (2) hours to the local, state and federal agencies and thoroughly investigated by facility management for one of one sampled residents (Resident 76). Resident 76 informed FM 2 that someone pinched her to the arm. Resident 76's family member (FM 2) asked NA 1 and another unidentified staff on 5/14/21 about new bruises found in the resident's bilateral arms. FM 2 did not notify NA 1 about Resident 76's allegation of someone pinching her. NA 1 did not inform the charge nurse of the resident's bruises (from unknown source), to initiate an investigation immediately. NA 2 found the bruises to the resident's arms on 5/18/21 and reported it to CNA 2. CNA 2 did not report it to the charge nurse immediately. Resident 76's bruises to bilateral arms was reported to the facility administrator on 5/19/21. The administrator reported to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the plan of care for one of seven sampled residents (Resident 76 and 116): 1. Resident 76's family member (FM 2) asked Nursing Assistant (NA) 1 and another unidentified staff on 5/14/21 about new bruises found in the resident's bilateral arms. NA 1 did not inform the charge nurse of the resident's bruises (from unknown source), to initiate an investigation immediately and revise the plan of care. 2. Resident 76 who had an existing Stage IV pressure ulcer [full thickness tissue loss with exposed bone, tendon or muscle with or without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft and stringy in texture) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like)] on the coccyx (tailbone) did not have a revised plan of care to include the frequency of repositioning while the resident was up in the wheelchair and/or the duration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment for 2 of 28 sampled residents (Resident 76 and 95) in accordance with the plan of care and the facility's policy and procedures by failing to: 1. Ensure facility staff assessed and monitored Resident 76's bilateral arms bruises/discoloration in a timely manner. This deficient practice had the potential to result in a delay in providing the necessary care and treatment to Resident 76. 2. Ensure facility staff addressed Resident 95's complaint of constipation and administered medication as needed for constipation as ordered by the physician. This deficient practice had the potential to result in abdominal discomfort, fecal impaction, and lead to complication such as bowel obstruction and lead to death. Findings: 1. A review of Resident 76's admission Record, indicated the facility admitted the resident on 8/14/2020, with diagnoses including Parkinson's Disease (a brain disorder that leads to shaking,…

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 interventions were implemented for a resident who had an existing Stage IV pressure ulcer [full thickness tissue loss with exposed bone, tendon or muscle with or without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft and stringy in texture) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like)] on the coccyx (tailbone) by failing to: 1. Reposition Resident 76 while up in the wheelchair to reduce the pressure in the coccyx area. 2. Provide a gel cushion (pressure reducing device) while up in the wheelchair as indicated in the resident's physician order. This deficient practice had the potential to delay Resident 76's wound healing and placed the resident at risk for further skin breakdown. Findings: A review of Resident 76's admission Record, indicated the facility admitted the resident on 8/14/2020, with diagnoses including Parkinson's Disease (a brain disorder that leads to shaking,…

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 maintain an unobstructed urine flow and secure the catheter for two of two sampled residents (Resident 14 and 67). This deficient practice had the potential to increase tension to the catheter and cause urethral tear or potential dislodgment, and decrease the urine flow by increasing kinks in the catheter. Findings: 1. During an observation on 5/18/2021 at 9:22 a.m., Resident 67 was lying in bed with a urinary catheter attached to a drainage bag. Resident 67 was observed holding the urinary catheter tubing in the left hand. The urinary catheter was not secured to Resident 67's inner thigh. A review of Resident 67's admission Record indicated an admission to the facility on 1/4/2019, with medical diagnoses that included obstructive uropathy (blockage of urine flow), history of urinary tract infection (UTI- infection of the urinary system), and dementia (loss of cognitive function). A review of Resident 67's Minimum Data Set (MDS- a care area screening and assessment tool) indicated extensive assistance…

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 provide respiratory care and treatment consistent with professional standards of practice for two of three sampled residents (Resident 6 and 20) who required oxygen administration by failing to: 1. Ensure facility staff provided Resident 20 with a working Bilevel Positive Airway Pressure (BiPAP; a device that helps push air into the lungs) machine at bedtime for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) as ordered by the physician. 2. Ensure facility staff monitored Resident 20's oxygen saturation (refers to the amount of oxygen in the bloodstream) every shift to titrate (adjust based on oxygen need) the oxygen flow rate from 2 liters per minute (L/min) to 5 L/min via nasal cannula (NC; a lightweight tubing with prongs placed in the nose) to maintain the resident's oxygen saturation above 92% continuously as ordered by the physician. 3. Ensure facility staff monitored Resident 6's oxygen saturation…

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 and record review, the facility failed to ensure that the attending physician responded to two recommendations made by the consultant pharmacist (CP) regarding medication therapy for two of five sampled residents (Residents 13 and 116) between 2/24/21 and 4/28/21. 1. For Resident 13's, the clinical record did not indicate documented evidence of the attending physician's response to the consultant pharmacist's recommendation to justify continued use of Protonix on 2/24/21. 2. For Resident 116, the facility failed to obtain a response from the physician regarding the pharmacist's recommendation to add a 14-day stop date to Ambien or limit the PRN Ambien to 14 days. This deficient practice increased the risk that medication therapy for Residents 13 and 116 may not have been optimized for the best possible health outcomes. This deficient practice had the potential to cause a negative impact on the resident's overall physical, mental, and psychosocial well-being. Findings: 1. A review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Limit the use of PRN (as needed) Ambien (a medication used to treat the inability to sleep) to 14 days in one of five sampled residents (Resident 116.) 2. Monitor for adverse effects (unwanted or dangerous medication side effects) of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in one of five sampled residents (Resident 116.) 3. Monitor for behaviors tied to psychotropic medication use in one of five sampled residents (Resident 116.) These deficient practices increased the risk that Resident 116 to experience adverse effects of psychotropic medication therapy leading to an overall negative impact on her physical, mental, and psychosocial well-being. Findings: A review of Resident 116's admission Record, dated 5/21/21, indicated she was readmitted to the facility on [DATE] with diagnoses including: major depressive disorder (MDD- a mental disorder characterized by depressed mood, 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 1.A Review of Resident 39's admission Record, Resident 39 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of the spine, obesity (over weight) anxiety disorder and history of falling, and allergies to sulfa antibiotics. A Review of Resident 39's MDS dated [DATE] indicated the resident was cognitively intact and had no impairments with communication. A review of Resident 39's dietary preference list - a list attached to the resident's Nutritional Screen-Food Preferences dated 3/16/21, indicated Resident 39 was on mechanical soft diet with no added salt, dislike turkey, turkey salad, corn, salad and red sauce. A review of Resident 39's care plan dated 3/15/21 indicated the dietary staff would inquire and provide resident food preferences (like & dislike). During an interview, on 5/20/21 at 9:18 a.m., Resident 39 stated the resident's emergency contact (EC 1), had talked with the facility's administrator and the DS that Resident 39 could not eat salad, red sauce, and…

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

b. A review of Resident 20's admission Record, indicated the facility admitted the resident on 2/17/21, with diagnoses including acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), diabetes mellitus (high blood sugar), and chronic kidney disease. A review of Resident 20's physician's order, dated 2/17/21, indicated BiPAP settings with respiratory rate = 4, fraction of inspired oxygen (FiO2; the concentration of oxygen in the gas mixture) = 30%, and expiratory positive airway pressure (EPAP; set to maintain upper airway patency) = 4 centimeters of water (cmH2O) at bedtime. BiPAP on at 9 p.m. and off at 6 a.m. for sleep apnea and remove per schedule. The order indicated may or may not need heated humidification (uses heat to warm water in the humidifier chamber to produce moisture which is carried by the breathed air). A review of Resident 20's care plan, dated 2/17/21, indicated the resident was at risk for respiratory distress due to respiratory failure and required oxygen as needed (PRN). The care plan goal indicated the…

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

Based on interview and record review, the facility failed to ensure the designated and existing infection preventionist (IP-responsible for the facility's Infection Prevention and Control Plan) completed the required initial specialized training in infection prevention and control no later than 1/1/2021 that meets the minimum set of requirements (14 hours) indicated by the Centers for Disease Control and Prevention (CDC). This deficient practice had the potential to result in the IP not having current knowledge and/ or training on surveilling and monitoring infection control practices and had the potential to further increase the development and transmission of communicable disease and infection in the facility. Findings: During an interview on 5/21/2021 at 9:31 a.m., the DON stated that the IP has been the facility's designated IP since 2019. The DON stated the IP has not begun or completed the current CDC training. The DON stated there was no one else in the facility who have completed the CDC training. The DON stated that the IP was to complete the CDC training within 90 days. 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.