Victoria Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe environment for two of three sampled residents (Resident 1 and Resident 2), as indicated in the facility's policy and procedures (P&P) titled, Accidents and Supervision, and Resident Right to Access and Visitation, by failing to ensure: 1. There was adequate resident visitation monitoring (continuous observation) at the facility's main front door entrance during the night shift (11 PM to 7 AM). This failure resulted in an unknown visitor walking inside the facility without staff awareness and entering Resident 1' and Resident 2's room. The failure had the potential to result in physical, emotional, and mental harm for Resident 1, Resident 2, and other residents residing at the facility. Findings 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included hemiplegia (total paralysis of one side of the body) and hemiparesis (weakness of one…

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 an Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) was discussed and written information was provided to the resident and/or responsible party and a current copy of the AD was in the medical chart for two of two sampled residents (Residents 145 and 5), consistent with the facility's policy and procedure on AD. These failures had the potential for facility staff to provide medical treatment and services against the residents' will. Findings: a. During a review of Resident 145's admission Record (AR), the AR indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and congestive heart failure (a heart disorder which causes the heart to not pump efficiently). During a review of Resident 145's Minimum Data Set (MDS, a resident assessment tool) dated 2/14/2025, 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 to administer oxygen as ordered and in accordance with the facility's Policy and Procedure (P&P) on oxygen administration for two of two sampled residents (Residents 3 and 193). These failures had the potential to result in adverse consequences for Residents 3 and 193. Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure (lung cannot adequately provide oxygen to the body) with hypoxia (low blood oxygen level) and immunodeficiency ( the body's ability to fight infection and other diseases is reduced or absent). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 11/23/2024, the MDS indicated Resident 3 had clear speech, had the ability to understand others and to make self-understood. The MDS indicated Resident 3 was dependent (helper does all the effort)…

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 bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) and grab bars (bars installed on the side of the bed) for two of two sampled residents (Residents 145 and 9). These failures placed Residents 145 and 9 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed) and injury from the use of siderails and grab bars. Findings: a. During a review of Resident 145's admission Record (AR), the AR indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs) and ulcer (a small open sore or wound generally found in the stomach or on the skin) of bilateral lower extremity. During a review of Resident 145's Minimum Data Sheet (MDS, a resident assessment tool) dated 2/14/2025, 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, for two of five sampled residents (Residents 10 and 94), the facility failed to ensure: a. Resident 94's physician order for Lorazepam (medication used to treat anxiety disorders [a condition that involves excessive fear, worry, or dread that interferes with daily life]) had a stop date as indicated in the facility's policy and procedures (P&P) on the use of psychotropic medication (drugs that alter the brain chemistry and affect metal processes, emotions and behavior). b. Resident 10's target behavior was monitored for the use of Haloperidol (antipsychotic medication to treat serious mental disorder in which people interpret reality abnormally) as indicated in the facility's P&P on the use of psychotropic medication. These deficient practices had the potential to result in the use of unnecessary psychotropic medications, which may result in significant adverse (harmful) consequences to Residents 10 and 94. Findings: a. During a review of Resident 94's admission Record, 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 safe and sanitary environment to prevent the development and transmission of communicable diseases (one that is spread from one person to another) for two of five sampled residents (Residents 145 and 2) by failing to: a. Ensure Certified Nurse Assistant 3 (CNA 3) wore the required Personal Protective Equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care to Resident 145 who was on Enhanced Barrier Precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs]). b. Ensure the Treatment Nurse (TN) who entered Resident 2's room and administered medication to Resident 2, wore a gown. Resident 2 was on EBP. These failures had the potential to result in the spread of infection from Residents 2 and 145 to staff members and other residents in the facility. Findings:…

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 call light was within reach for one of one sampled resident (Resident 194) in accordance to facility's policy titled Call Lights: Accessibility and Timely Response. This failure had the potential for Resident 194 not to receive care or receive delayed services to meet the residents' needs and could result in a fall or injury. Findings: During a review of Resident 194's admission Record (AR), the AR indicated Resident 194 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and dependence on supplemental oxygen. During a review of Resident 194's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 1/23/2025, the FRA indicated Resident 194 was assessed as high risk for fall due to being chair…

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 a resident on hemodialysis (a treatment to cleanse the blood of wastes through a machine when the kidneys failed) an emergency kit (E-kit, contains the main items needed in an emergency) at bedside for one of two sampled residents (Resident 15). This failure had the potential for Resident 15 not to receive or received delayed care and treatment for complications caused by unexpected bleeding from the hemodialysis access site. Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) and dependence on hemodialysis. During a review of Resident 15's Care Plan (CP), dated 10/4/2024, the CP indicated Resident 15 needed hemodialysis related to renal failure. The CP goal indicated Resident 15 would have immediate intervention should any signs and symptoms of complications…

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 locate one of one sampled resident (Resident 1), who eloped (the act of leaving a facility unsupervised and without prior authorization) from the dialysis center (a facility that provides treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential to result in compromise to Resident 1's safety and well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/15/2024, with diagnoses that included encounter for surgical aftercare (the medical care a person receives after surgery, including care in the hospital and after discharge) following surgery on the digestive system (a group of organs that break down the foods eaten so they can be absorbed into the body and used for energy and nutrients), end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function), and dependence on renal dialysis. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to readmit one of one sampled resident (Resident 1) as indicated in the facility's policy and procedure titled readmission to Facility. This failure resulted in Resident 1 to remain in General Acute Care Hospital 1 (GACH 1) for two days from 6/10/2024 to 6/11/2024. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2023 and readmitted on [DATE] with diagnoses that included asthma (chronic lung disease that inflames and narrows the airways) with exacerbation (worsening) and dependence on renal dialysis (treatment for kidney failure [loss of kidney function] that removes unwanted toxins, waste products and excess fluids by filtering the blood). During a review of Resident 1's History and Physical (H&P) dated 11/3/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized…

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 from accident hazards for three of three sampled residents (Residents 7, 9 and 29) by failing to: a. Ensure the bed was at the lowest position for Residents 9 and 29 who were assessed as high risk for falls. b. Ensure the floor mattress (device used to reduce fall related trauma if a patient gets up from bed, loses balance, and falls to the floor) was placed close and not away from bed for Resident 7 who was assessed as high risk for fall. These deficient practices had the potential for accidents and severe injury secondary to falls for Residents 7, 9 and 29. Findings: a. During a review of Resident 9's admission Record, the admission record indicated the facility admitted the resident on 12/17/2021, with diagnoses that included seizures (abnormal movements or behavior due to unusual electrical activity in the brain,) and contractures (shortening and hardening of muscles, tendons, or other tissue, often leading…

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 document fluid intake every shift for one of one sampled resident on fluid restriction from 1/20/2024 to 2/10/2024 (Resident 19). This failure had the potential to result in adverse consequences for Resident 19. Findings: During a review of Resident 19's admission Record, the admission record indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD, is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [procedure to remove metabolic waste products or toxic substances from the bloodstream]), dependence on renal dialysis and type 2 diabetes mellitus (a chronic condition that affects the way the body metabolizes sugar). During a review of Resident 19's Order Summary Report dated 1/20/2024, the order summary report indicated Resident 19 was placed on fluid restriction of 1200 milliliters (ml)…

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 follow its Policy and Procedure (P&P) on Food Storage by failing to clearly label with open date, one opened mayonnaise container jar in one of one kitchen refrigerator and one opened bag with two pieces of chicken patties inside, in one of one kitchen freezer. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents. Findings: During an observation of the facility's kitchen and a concurrent interview with the Dietary Supervisor (DS) on 2/9/2024 at 5:54 pm, there was one opened mayonnaise jar without open date label in the facility's kitchen refrigerator. There was also one opened bag with two pieces of chicken patties inside, in the kitchen freezer that was not labeled with open date. The DS stated, the kitchen staff needed to label the bag with the date it was opened. The DS stated labeling with an open date was to identify the food's expiry date to ensure expired foods were not served to the residents. The DS stated…

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 staff failed to assist the resident at eye level during meal for one of one sampled resident (Resident 20). This failure had the potential to affect Resident 20's self-esteem, self-worth, and psychosocial well-being. Findings: During a review of Resident 20's admission Record, the admission record indicated Resident 20 was readmitted on [DATE], with diagnoses that included dysphagia (difficult swallowing) and right hand contracture (a fixed tightening of muscle, tendons, ligaments, or skin, it prevents normal movement of the associated body part). During a review of Resident 20's Minimum Data Set (MDS- a resident assessment and screening tool) dated 12/25/2023, the MDS indicated Resident 20 had unclear speech, usually understood others and usually made self-understood. The MDS indicated Resident 20 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes…

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 Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) and/or code status (describes the type of resuscitation procedures one would like the health care team to conduct if one's heart stopped breathing) were in the resident's medical record for one of one sampled resident (Resident 95). This failure had the potential to result in the delay of treatment to Resident 95 and provide care against the resident's will in the event of a medical emergency. Findings: During a review of Resident 95's admission Record, the admission record indicated Resident 95 was admitted on [DATE], with diagnoses that included acute respiratory failure (lungs cannot adequately provide oxygen to the body, leading to low blood oxygen level) 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 ensure one of one sampled resident (Resident 7) was free from physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body). Resident 7's bed was against the wall on one side. This failure had the potential to result in accidents or decline in Resident 7's quality of life. Findings: During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted on [DATE], with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way your body metabolizes sugar), history of falling and age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). During a review of Resident 7'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 interview and record review the facility failed to develop and implement an individualized person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 4) as indicated in the facility's Policy and Procedure, titled Comprehensive Care Plans. This deficient practice had the potential for Resident 4 not to receive the necessary care, treatment, and services. Findings: During a review of Resident 4's admission record, the admission record indicated, the facility admitted Resident 4 on 5/27/2023 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow).…

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 95). This failure had the potential to result in infection for Resident 95. Findings: During a review of Resident 95's admission Record, the admission record indicated Resident 95 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) and immunodeficiency (decreased ability of the body to fight infections). During a review of Resident 95's Order Summary Report for 2/2024, the order report indicated Resident 95 had an order for oxygen via NC at 4 liters per minute every shift. During an observation on 2/9/2024 at 6:06 pm, Resident 95 was in bed with eyes closed. Resident 95 had ongoing oxygen via NC at 4 liters per minute. During a concurrent interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 95's NC was not labeled…

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 conduct annual competency for one of four sampled facility staff (Certified Nursing Assistant 2 (CNA 2). A CNA is a healthcare professional who provides basic care to patients under the supervision of a licensed nurse. This deficient practice had the potential for staff to not have the necessary skills to provide care to the residents. Findings: During a review of employee's files on 2/11/2024 from 11:32 am to 12:10 pm, the employee files indicated the facility did not conduct an annual competency assessment for CNA 2 for the Certified Nursing Assistant Skills. During a concurrent interview, the Director of Staff Development (DSD) stated CNA 2 worked both as CNA and Restorative Nursing Assistant (RNA - is a type of nursing assistant trained to help nurses in restoring mobility of residents). The DSD stated there was no competency assessment for the CNA skills for CNA 2. The DSD stated competency skills assessment needed to be completed annually to ensure the staff have the skills to take care of the residents at 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 act upon the pharmacist's monthly 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 and potential risks associated with medication)'s recommendations for one of five sampled residents (Resident 7). This failure had the potential to result in ineffective medication management that could result in adverse consequences (undesirable or non-therapeutic effect of the medication) to Resident 7. Findings: During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way the body metabolizes sugar), history of falling and age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes).…

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, facility failed to follow the facility's policy and procedure titled Confidentiality of Personal and Medical Records by ensuring one of one sampled resident's identifiable, personal, and medical information were not exposed on the computer screen unattended and in view of unauthorized persons to view and access without the resident's consent or knowledge (Resident 4). This deficient practice resulted in violation of Resident 4's right to privacy. Findings: During a review of Resident 4's admission record, the admission record indicated, the facility admitted Resident 4 on 5/27/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 4's History and Physical (H&P), dated 12/19/2023, the H&P indicated, Resident 4 did not have the capacity to understand and make decision.…

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 oxygen simple mask (a basic disposable mask, made of clear plastic, to provide oxygen therapy) was kept in the storage bag when not in use for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Oxygen Concentrator. This deficient practice had the potential to increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified asthma (chronic lung disease that inflames and narrows the airways) with exacerbation (worsening) and dependence on supplemental oxygen. During a review of Resident 1's History and Physical (H&P), dated 11/3/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. 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 staff failed to provide privacy to one of four sampled residents (Resident 3) while providing bed bath to Resident 3. This failure resulted in violation of Resident 3's right to privacy. Findings: During a review of the Resident 3 ' s admission Record, the admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficult swallowing) and hypertension (increased blood pressure). During a review of Resident 3 ' s Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/21/2023, the MDS indicated Resident 3 had clear speech, had the ability to understand others and to make self-understood. Resident 3 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene. Resident 3 was dependent (helper does all of the effort) for rolling left and right, sit to lying and chair/bed-to-chair transfer. During an observation on 1/8/2024 at…

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