Garden View Post Acute Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its facility's Policy and Procedures (P&P) on the use of cushion pad alarms (safety devices designed to alert caregivers immediately when a person at risk of falling stand up or leave a seated/lying position) for one of one sampled resident (Resident 12). This failure placed Resident 12 at risk of injury and psychological distress related to the use of cushion pad alarms. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness (decrease or loss of strength), osteoporosis (weak and brittle bones), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool) dated 1/23/2026, the MDS indicated Resident had moderately impaired cognition (ability 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 for one of six sampled residents' (Resident 108) order for Remeron (a medication to treat depression [a feeling of severe sadness or hopelessness]) included a specific indication for a specific diagnosed condition and the hours of sleep was monitored, as indicated in the facility's policy titled Chemical Restraints and Psychotropic (medications that alter chemical levels in the brain which impact mood and behavior) Medication Management. 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 108.Findings: During a review of Resident 108's admission Record (AR), the AR indicated Resident 108 was admitted to the facility on [DATE] with diagnoses including depression (a feeling of severe sadness or hopelessness) and polyneuropathy (damage or disease affecting peripheral nerves featuring weakness, numbness, and burning pain). During 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 observation, interview, and record review, the facility failed to update the resident's care plan for one of three sampled residents (Resident 72).This failure had the potential to compromise Resident 72's safety and prevent the provision of necessary care.Findings:During a review of Resident 72's face sheet, the face sheet indicated Resident 72 had an initial admission on [DATE] with the diagnoses but not limited to: chronic obstructive pulmonary disease ( a chronic lung disease causing difficulty in breathing) , protein-calorie malnutrition , essential hypertension (high blood pressure ) , fracture of right pubis , a history of falling and need assistance with personal care.During a review of Resident 72's Minimum Data Set (MDS-a resident assessment tool) dated 12/29/2025, the MDS indicated Resident 72 is dependent on lying- to-sitting on side of the bed and had history of fall on admission and fracture related to a fall prior to admission.During a review of Resident 72's Clinical admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide required assistance during activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) for one of one sampled resident (Resident 51).This failure placed Resident 51 at risk of physical injury during bed mobility and overall decline in quality of life.Findings: During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms), left hand contracture (a stiffening/shortening at any point, that reduces the joint's range of motion) and cerebral palsy (condition that affects how the person moves and controls their muscles) During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 51 had severely impaired cognition (ability to understand and process information). 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 provide necessary care and services for a resident with indwelling catheter (also known as foley catheter {FC}, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) in accordance with the facility's Policy and Procedure (P&P) on urinary catheter care for one of four sampled residents (Resident 46). This failure had the potential for Resident 46 not to receive care or receive delayed care and treatment for urinary tract infection (UTI, an infection in the bladder/urinary tract). Findings: During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer of sacral (large, triangular bone at the base of the spine) region, stage 4 (ulcer that extends into the muscle and bone and causing extensive damage), pressure ulcer of right heel, retention of urine, and acute…

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 necessary care and services for gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) site in accordance with the physician's order for one of one sampled resident (Resident 51). This failure had the potential for complications related to tube feedings for Resident 51.Findings: During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms), left hand contracture (a stiffening/shortening at any point, that reduces the joint's range of motion) and gastrostomy (a surgical opening fitted with a device to allow feedings/medication to be administered directly to the stomach). During a review of Resident 51's untitled Care Plan (CP) dated 2/19/2024, the CP indicated Resident 51 had a tube feeding related to dysphagia…

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 seven sampled residents (Resident 109) was free from significant medication error by failing to administer Morphine Sulfate Contin (MS Contin- controlled medication used for pain) Oral Tablet Extended Release (ER-long acting) 15 milligrams (mg- unit of measurement) at the correct administration time. The medication was administered too early than the ordered scheduled time of administration. This failure had the potential to place Resident 109 at risk for adverse side effects related to overdosing, such as lethargy, respiratory depression (slow breathing and carbon dioxide retention) and hypotension (low blood pressure).Findings: During a review of Resident 109's admission Record (AR), the AR indicated Resident 109 was admitted to the facility on [DATE] with diagnoses including cutaneous abscess (pocket of pus in the skin from an infection) of the left upper arm and pain in the left shoulder. During a review of Resident 109'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.

Based on observation , interview and record review , the facility failed to maintain medication related equipment and storage areas in a clean and appropriate manner, resulting in the presence of contaminated equipment and unsecured, loose medication pills in the medication room.This deficient practice had the potential to cause contamination, medication errors, and unsafe conditions for residents.Findings:During a review of the facility's map, it was noted that the facility has four shower rooms, three nurses' stations (north, center, and south), and two medication rooms located in the center and south stations.During a concurrent observation and interview on 2/26/2026 at 1:15 pm with Registered Nurse Supervisor (RNS) 1 in the center station medication room, crackers were observed stored inside one of the medication room cabinets, and a can of insect repellent spray was observed on top of the cupboard in close proximity to medications. Five unidentified loose medication pills were found on the floor next to the medication destruction container. RNS1 stated food items should not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of four sampled residents (Resident 80) by failing to ensure the resident's nasal cannula (NC- a flexible tube with two small prongs that sits in the nostrils to deliver oxygen) was not touching the floor. This deficient practice had the potential to result in infection to Resident 80. Findings: During a review of Resident 80's AR, the AR indicated Resident 80 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing food or liquids) and gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach for medication/feeding). During a review of Resident 80's MDS dated [DATE], the MDS indicated Resident 80's cognitive (ability to think and reason) skill for daily decision making…

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 and maintain dignity for two of two sampled residents (Residents 138 and 238) by failing to: a. Close Resident 138's privacy curtain and Resident 138's body was exposed and can be seen from the hallway. b. Close Resident 238's privacy curtain and Resident 238's upper extremities were exposed when Minimum Data Set Nurse (MDSN) checked the resident's surgical site. These deficient practices violated Residents 138 and 238's right to privacy. Findings: a. During a review of Resident 138's admission Record (AR), the AR indicated Resident 138 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and generalized muscle weakness. During a review of Resident 138's History and Physical (H&P, a formal assessment that a doctor performs for information about a patient's health) dated 11/28/2024, the H&P 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 on observation, interview, and record review, the facility failed to provide reasonable accommodation of residents' needs for four of four sampled residents (Residents 13, 20, 39, and 57). For Residents 13, 20 and 57, the call light (device that allows the resident to request assistance from nursing staff) was not within reach. For Resident 39, the resident did not know how to use the call light and the purpose of the call light was not explained to the resident. These failures had the potential for the residents not to receive care or receive delayed services to meet the residents' needs and could result in a fall or injury. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares,…

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 necessary care and services for residents with indwelling catheter (including Foley Catheter- a soft flexible tube inserted into the bladder to drain urine, nephrostomy tube- a thin, flexible tube that drains urine from the kidney into a bag outside the body, and suprapubic catheter- a catheter inserted through a hole in the abdomen and then directly into the bladder) in accordance with the facility's Policy and Procedure (P&P) for four of five sampled residents (Residents 19, 26, 32 and 78) by failing to: a. Ensure Resident 19's Foley Catheter (FC) tubing was kept secured and monitored for the presence of white sediments (visible particles) in the urine. b. Ensure Resident 26's Suprapubic Catheter (SC) tubing was kept secured and the suprapubic catheter site dressing clean and dry. c. Ensure Resident 32's Nephrostomy Tubes (NT) were covered with a privacy bag and positioned lower than the bladder. d. Ensure Resident 78's FC 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 implement its Policy and Procedure (P&P) on the use of bedrails (a bar that runs along the side of a bed) and grab bars (a bar or loop that helps the resident move in and out of the bed) for two of two sampled residents (Residents 33 and 51) by failing to: a. Ensure the use of appropriate alternatives to grab bars were attempted and did not meet the needs of the resident before its installation for Resident 51. b. Ensure the use of appropriate alternatives to bedrails were attempted and did not meet the needs of the resident. In addition, the facility failed to ensure the use of siderails was consented before its installation for Resident 33. These failures placed Residents 33 and 51 at risk for entrapment and injury from the use of bedrails or grab bars. Findings: a. During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses that included displaced fracture…

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 its policy and procedure on infection control by failing to: a. Ensure one of one Certified Nurse Assistant (CNA 2) wore the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care for a resident on enhanced barrier precaution (EBP, a set of infection control practices that use PPE to reduce the spread of multidrug-resistant organisms [MDROs}]) for one of one sampled resident (Resident 34). b. Follow infection prevention guidelines for Resident 62 on Enhanced Barrier Precaution on 1/8/2025 when one of one Licensed Vocational Nurse (LVN 4) entered Resident 62's room without donning/wearing the required PPE prior to checking the resident's gastrostomy tube (G-tube, feeding tube that is inserted into the stomach) placement for medication administration. c. Ensure one of one Certified Nurse Assistant (CNA 6)…

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 an effective communication method for one of one non-English speaking sampled resident (Resident 138). This failure had the potential for Resident 138 not to receive necessary care and services. Findings: During a review of Resident 138's admission Record (AR), the AR indicated Resident 138 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and generalized muscle weakness. During a review of Resident 138's History and Physical (H&P, a formal assessment that a doctor performs for information about a patient's health) dated 11/28/2024, the H&P indicated Resident 138 had the capacity to understand and make decisions. During a review of Resident 138's Minimum Data Set (MDS, a resident assessment tool) dated 11/30/2024, the MDS indicated Resident 138 had clear speech, had the capacity to understand others and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazard for one of two sampled residents (Resident 40) by failing to ensure Resident 40's bed was in the lowest position. This deficient practice had the potential to place Resident 40 at risk for recurrent fall with injury. 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 metabolic encephalopathy (a brain dysfunction that occurs when there's an imbalance of chemicals in the blood), muscle weakness, Parkinsonism (movement disorder), end stage renal disease (condition when the kidneys can no longer function on their own), gout (a type of arthritis[swelling of the joints]) and need for assistance with personal care. During a review of Resident 40's Care Plan (CP) titled, At risk for Falls related to multiple Medical Conditions, initiated on 7/29/24, the CP indicated Resident 40 was at risk…

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 label the nasal cannula (NC) tubing (an oxygen delivery device) for one of two sampled residents (Resident 64). This failure had the potential to result in infection for Resident 64. Findings: During a review of Resident 64's admission Record (AR), the AR indicated Resident 64 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (lungs cannot adequately provide oxygen to the body) and dysphagia (difficulty swallowing). During a review of Resident 64's Minimum Data Set (MDS, a resident assessment tool) dated 12/6/2024, the MDS indicated Resident 64 had clear speech, had the ability to understand others and usually made self understood. The MDS indicated Resident 64 was dependent (helper does all of the effort) for toilet hygiene and chair/bed-to-chair transfer. During a review of Resident 64's Order Summary Report (OSR) for 1/2025, the OSR indicated Resident 64 was ordered continuous oxygen via NC…

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 act upon the consultant pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication use) recommendation for one of five sampled residents (Resident 40). This deficient practice had the potential for Resident 40 to receive unnecessary medication and adverse (harmful) consequences related to medication therapy. Findings: During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was readmitted to the facility on [DATE] with diagnoses that included depression disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) and hypertension (high blood pressure). During a review of Resident 40's Physician's Order (PO) dated 7/29/2024, the PO indicated Resident 40 was prescribed Ondansetron (medication to prevent…

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 identify and document specific indication for the use of Mirtazapine (antidepressant- medication to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning]) for one of five sampled residents (Resident 20) as indicated in the facility's policy titled Psychotropic Medications This deficient practice had the potential to result in unnecessary psychotropic drug use which could result in significant adverse (harmful) consequences to Resident 20. Findings: During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included Spondylolisthesis (a condition where a vertebra in the spine slips out of place) and major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 20's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated…

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 keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 4). This failure had the potential to affect Resident 4's quality of life and health. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently) and asthma (a condition in which a person's airways become inflamed, narrowed, and swollen). During a review of Resident 4's Minimum Data Sheet (MDS, a resident assessment tool) dated 10/30/2024, the MDS indicated Resident 4 had severely impaired cognition (ability to understand). The MDS indicated Resident 4 was dependent (helper did all of the effort, resident did…

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 and implement a resident-centered comprehensive care plan (CP - a document that describes a resident's needs and how the nursing home will meet them) for one of three residents (Resident 1) by failing to ensure Resident 1 had a care plan for Resident 1's oral/dental status. This failure had the potential for Resident 1 to not receive the care and services needed to address Resident 1's edentulous (the complete loss of all natural teeth) mouth. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of left cerebral vascular accident (CVA - a medical condition that occurs when blood flow to the brain is suddenly interrupted), type 2 diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received proper treatment and care for foot health by failing to arrange Resident 1's consult with a podiatrist (a medical professional who specializes in the diagnosis and treatment of foot, ankle, and lower limb disorders) in a timely manner. This failure resulted in a delay of the provision of foot care and treatment for Resident 1 which could result in podiatric complications. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of left cerebral vascular accident (CVA - a medical condition that occurs when blood flow to the brain is suddenly interrupted), type 2 diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's untitled care plan (CP) dated 8/11/24, the CP…

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 to provide information regarding Advance Directives (AD, legal document that provide instructions for medical care which go into effect when a person becomes disabled) to two of two sampled residents (Resident 82 and 47). This deficient practice had the potential for facility staff to provide care and treatment against the resident's will. Findings: a. During a review of Resident 82's admission Record, the admission record indicated Resident 82 was admitted on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and hemiplegia and hemiparesis (hemiplegia is paralysis of partial or total body function on one side of the body, hemiparesis is onesided weakness, but without complete paralysis). During a review of Resident 82's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 12/8/2023, the MDS indicated Resident 82 had clear speech, sometimes understood others, and sometimes made self-understood. The MDS…

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 Low Air Loss Mattress (LAL mattress, a pressure reducing device that helps prevent skin breakdown) settings for four of four sampled residents (Residents 68, 66, 31 and 32) were carried out as ordered by the physician and/or as recommended by the manufacturer. a. For Resident 68, the facility failed to ensure the LAL setting was according to the resident's weight as ordered by the physician and as recommended by the manufacturer. b. For Resident 66, the facility failed to ensure the LAL setting was according to the resident's weight as ordered by the physician and as recommended by the manufacturer. c. For Resident 31, the facility failed to ensure the LAL mattress setting was accurate. d. For Resident 32, the facility failed to ensure the LAL mattress setting was accurate. These deficient practices had the potential to worsen Residents 68 and 31's pressure ulcer (lesion/wound caused by unrelieved pressure that results 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 provide an environment free of accident hazard for two of four sampled residents (Residents 50 and 32) by failing to: a. Utilize bilateral landing mats for Resident 50 who had history of fall, as ordered. b. Ensure Resident 32's pad alarm ( a pad placed under a resident while on the bed and sends an alarm to alert staff when the resident gets up from pad) was turned on while the resident was in bed for fall prevention, as ordered. These deficient practices had the potential to result in serious consequences of fracture (break in the bone) and/or bleeding that may accompany a fall. Findings: a. During a review of Resident 50's admission record indicated, the facility admitted Resident 50 on 6/18/2021 with diagnoses that included unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), difficulty in walking, muscle weakness and history of falling.…

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 perform a Gradual Dose Reduction (GDR, an attempt to decrease or discontinue) for two of five sampled residents (Residents 55 and 41) in accordance with the facility's Policy and Procedure titled, Psychotropic Drug Use. a. There was no GDR completed for Resident 55 who received Remeron (a medication to treat depression [a feeling of severe sadness or hopelessness]) with no symptoms of depression for 11 months. b. There was no GDR completed for Resident 41 who received Risperdal (a medication to treat schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real]) since 1/21/2021. This deficient practice resulted in Residents 55 and 41 receiving psychotropic (drug that affects brain activities associated with mental processes and behavior) medication without adequate clinical reason for use and had the potential to result in adverse consequences for Residents 55 and 41. Findings: During 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 failed to ensure infection prevention and control program practices were implemented for two of two sampled residents (Residents 41 and 20), by failing to: a. Ensure the facility administered antibiotics (medicine that fights infection) to Resident 41 with adequate indication for its use. For Resident 41, the criterion was not met for the use of antibiotics based on Mc Geer's criteria (the criteria that define infections for surveillance purposes were selected to increase the likelihood that the events captured by application of the definitions are true infections). This deficient practice had the potential for Resident 41 to develop antibiotic resistance (when bacteria/germs develop the ability to defeat medications designed to kill them). b. Ensure Resident 20's indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) tube did not touch the floor. This deficient practice…

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 reasonable accommodation of needs for one of one sampled resident (Resident 65) who was at risk for fall by failing to ensure Resident 65's call light was within reach as indicated in the facility's Policy and Procedure titled, Call Light, and Resident 65's plan of care. This deficient practice had the potential for Resident 65 not to receive and/or receive delayed assistance when needed that could potentially result in falls and/or accidents. Findings: During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted Resident 66 on 9/5/2023, with diagnoses that included muscle weakness and need for assistance with personal care. During a review of Resident 65's untitled care plan initiated on 9/6/2023, the care plan indicated Resident 65 was at risk for fall related to history of falls. The care plan interventions included for the nursing staff to be sure the call light was within reach and encourage Resident 65 to use the call light to call for assistance as needed.…

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 three sampled residents (Resident 14) reviewed for communication/sensory was assessed accurately. For Resident 14, the admission assessment for hearing was not accurately assessed to reflect Resident 14's hearing problem. This deficient practice had the potential risk for Resident 14's hearing problem not identified and worsen. Findings: During a review of Resident 14's admission record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Acute Myocardial Infarction (permanent damage to the heart muscle due to inadequate oxygen supply), Type II Diabetes Mellitus (high levels of sugar in the blood) with Diabetic Neuropathy (a complication of diabetes that affect the nerves that control movement, sensation and other functions), and unspecified epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time). During a review of Resident 14'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 observation, interview and record review, the facility failed to provide an effective communication method to one of one non-English speaking sampled resident (Resident 185). This deficient practice had the potential for Resident 185 to not be able to express needs which may result in Resident 185 not receiving necessary care and services. Findings: During a review of Resident 185's admission Record, the admission record indicated Resident 185 was admitted on [DATE], with diagnoses that included hemiplegia and hemiparesis (hemiplegia is paralysis of partial or total body function on one side of the body, hemiparesis is one sided weakness, but without complete paralysis) and difficulty walking. During a review of Resident 185's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 12/30/2023, the MDS indicated Resident 185 had clear speech, usually understood others, and usually made self-understood. The MDS indicated Resident 185 was dependent (helper does all of the effort) 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 one of three sampled residents (Resident 14) reviewed for communication/sensory was provided necessary treatment and/or services for resident's difficulty in hearing. Resident 14 had problems with hearing and was not addressed. This deficient practice had the potential risk for Resident 14's hearing problem to get worse. Cross reference F641. Findings: During a review of Resident 14's admission record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Acute Myocardial Infarction (permanent damage to the heart muscle due to inadequate oxygen supply), Type II Diabetes Mellitus (high levels of sugar in the blood) with Diabetic Neuropathy (a complication of diabetes that affect the nerves that control movement, sensation and other functions), and unspecified epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time). 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.

Based on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for one of five sampled residents (Resident 22) with indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's policy and procedure, titled Catheter Drainage Bag and the resident's care plan for foley catheter. This deficient practice had the potential for Resident 22 to not receive care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system). Findings: During a review of Resident 22's admission record, the admission record indicated the facility admitted Resident 22 on 8/22/2022 with diagnoses that included personal history of UTI, neuromuscular dysfunction of the bladder (the nerves and muscles don't work…

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 correct oxygen flow rate was administered to one of one sampled resident (Resident 25) This deficient practice had the potential to result in complications associated with oxygen (odorless and colorless reactive gas) therapy (treatment that provides extra oxygen to breathe in). Findings: During a review of Resident 25's admission Record, the admission record indicated the facility admitted the resident on 7/11/2023, with diagnoses that included acute and chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood). During a review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/5/2023, the MDS indicated the resident had no cognitive (ability to understand and process information) impairment and required extensive assistance with bed mobility, dressing and personal hygiene. During a review of Resident 25's recapped Physician Orders dated 12/30/2023, the order indicated for Resident 25 to receive oxygen at 2 l/min via…

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 supervise medical care by a licensed physician according to the facility ' s policy and procedure (PP) titled, Physician Services, for one of four sampled residents (Resident 1) by failing to: 1. Ensure Medical Doctor 1 (MD 1) provided care after attempting to be notified by RN 1 and RN 2 to resume Resident 1 ' s home medications in a timely manner for the following medications: a. Xarelto 20 (medication to treat and prevent blood clots (an important process that prevents excessive bleeding when a blood vessel is injured]) milligram (mg, unit of measurement) by mouth one time a day for atrial fibrillation (a type of irregular heartbeat). b. Rhopressa Ophthalmic Solution eyedrop (medication to treat loss of vision), instill one (1) drop in both eyes at bedtime for glaucoma (nerve connecting the eye to the brain is damaged). c. Prolensa eyedrops (medication to treat dry eyes, swelling, or pain in the eyes) 0.07 percent (%, one part of every hundred),…

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.