Highland Springs Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician order for oxygen administration, for one of 19 residents reviewed (Resident 13). This failure had the potential for Resident 13 to receive ineffective oxygen therapy, and had increased risk of hospitalization and adverse outcomes including death for Resident 13. Findings:On August 25, 2025, at 10:05 a.m., a concurrent observation and interview was conducted with Resident 13. Resident 13 was observed wearing an oxygen mask over his nose and mouth, with the oxygen concentrator (a device that concentrates oxygen from the air into a highly purified, breathable form to provide supplemental oxygen therapy to individuals with low blood oxygen levels) at the right side of his bed. Resident 13 observed receiving 3.5 L/min of oxygen (LPM - liters per minute; unit of measurement). Resident 13 stated he used oxygen all the time, including when he sleeps. A review of Resident 13's admission Record, indicated Resident 13 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 ensure dental care services and follow up treatment was provided, for one of 19 residents reviewed (ResidentThis failure had the potential for pain, infection, poor nutrition, and further decline in oral health for Resident 18. Findings:On August 26, 2025, at 9:42 a.m., an observation and concurrent interview was conducted with Resident 18. Resident 18 was observed with a left lower side tooth missing and a partial, blackened tooth remaining in the gums. Resident 18 stated he felt discomfort chewing his food. Resident 18 stated he wanted to know the status of his dental appointment. Resident 18 stated he could not recall the last time he saw the dentist.On August 27, 2025, at 12:50 p.m., an interview with Certified Nursing Assistant (CNA) 3 was conducted. CNA 3 stated the CNAs provide oral hygiene care for residents. CNA 3 stated if he found a resident with a broken tooth or denture, he would report it to the charge nurse.On August 27,…

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 appropriate food texture was provided, for one out of one resident reviewed (Resident 25), when Resident 25's meal was not fully pureed and had chunks in his meal during lunch on August 25, 2025.This failure had the potential for Resident 25 to aspirate and cause harm to Resident 25.Findings:On August 25, 2025, at 12 p.m., a dining observation was conducted in the designated RNA (Restorative Nurse Assistant) Feeding Program Room. Resident 25 was observed to have puree food and was spitting out a few chunks of his food onto his napkin. In a concurrent interview with Resident 25, he stated that he did not know what the chunks were. Resident 25's meal ticket was reviewed and indicated that Resident 25 was on a puree diet.On August 25, 2025, at 12:21 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 4 who sat next to Resident 25 during his meal. LVN 4 stated the puree food should be smooth and with no solids 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.

Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control practices were implemented in accordance with its policy and manufacturer's instructions, when: 1. For Resident 67, a licensed nurse did not properly clean and disinfect the shared stethoscope before and after use, as required by the facility's policy; and 2. For Resident 30, a licensed nurse did not disinfect the rubber seal of an insulin pen prior to attaching a needle, in accordance with the manufacturer's instructions for use. These failures had the potential to cause the spread of infection, placing residents at risk, and compromise their health and well-being. Findings:1. On August 25, 2025, at 9:17 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 6, LVN 6 was observed using a shared blood pressure cuff and stethoscope to measure Resident 67's blood pressure (BP). LVN 6 disinfected the shared blood pressure cuff before and after use with a Micro-Kill One Germicidal Wipes (Environmental Protection Agency [EPA] -…

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, for one of three residents (Resident 1):1.The depakote (medication to treat mood disorder) dosage recommended by the general acute hospital (GACH) was carried out when Resident 1 was re-admitted back to the facility; and2.The facility psychiatry nurse practitioner (PNP- an advanced practice registered nurse specializing in mental health care) review the acute hospital assessment and medication adjustment recommendations.These failures had the potential to contribute to unmanaged behavior of Resident 1 and affect overall behavioral condition of the resident. Findings:On July 14, 2025, at 8:38 a.m., Resident 1 was observed awake and lying on bed, with a Certified Nursing Assistant (CNA) sitting outside Resident 1's room.On July 14, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) with behavior disturbance.A review of Resident 1'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 ensure for one of one residents (Resident 1) was appropriately monitored by their sitter in two instances when:Certified Nursing Assistant (CNA) 1 was not fully implementing a 1:1 (one sitter/staff member assigned to closely watch one resident) monitoring on Resident 1; andCNA 2 left Resident 1 unattended during 1:1 monitoring.These failures had the potential to cause harm to Resident 1 and to fellow residents.Findings: On July 14, 2025, at 8:22 a.m., an unannounced visit was made at the facility in order to investigate a complaint stating Resident 1's Certified Nurse Assistant (CNA) was reported asleep while on a 1:1 monitoring duty during the morning of July 4, 2025.1. On July 14, 2025, at 8:35 a.m., Resident 1 was observed asleep in her bed without a staff member nearby. On July 14, 2025, at 12:10 p.m., Resident 1's medical records were reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia…

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 two of eleven sampled residents' (Resident 4 and Resident 5) call lights were within reach. This failure has the potential for Resident 4 and Resident 5 to have unmet needs due to inability to be able to call for assistance. Findings: On August 22, 2024, at 11:20 a.m., an unannounced visit to the facility was conducted for the investigation of two Facility Reported Incidents and one complaint. On August 22, 2024, at 12:48 p.m., a concurrent observation and interview was conducted with Resident 4. Resident 4 was sitting on the right side of her bed in her wheelchair. Resident 4 ' s call light was hanging above the right side of the head of the bed. Resident 4 stated she needed help to be changed and was not able to call for help. Resident 4 stated she was unable to reach her call light. On August 22, 2024, at 12:59 p.m., observed Resident 5 sitting in her wheelchair on the right side of the foot of Resident 4 ' s bed. Resident 5 ' 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 ensure the comprehensive assessments for six of 22 sampled residents (Residents 14, 34, 49, 51, 53, and 82) were completed within 14 calendar days after admission. This failure had the potential for residents to not receive resident centered care (care focusing on the needs of individuals) for Residents 14, 34, 49, 51, 53, and 82. Findings: On July 25, 2024, at 11:20 a.m. a concurrent interview and review of the Minimum Data Set (MDS - an assessment tool) comprehensive assessments were conducted with the MDS Nurse. The MDS nurse stated comprehensive assessment should be completed within 14 days after admission. The MDS nurse stated, it is important to complete the resident's MDS on time and submit to Center for Medicare Services (CMS - an agency that manages various aspects of healthcare delivery and funding) within 14 days to assess the residents' health status and provide a resident-centered care plan. The MDS nurse stated the comprehensive assessments for Residents 14, 34, 49, 51, 53, and 82 were not completed within 14…

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, for four of seven residents (Residents 46, 10, 40, and 76) to ensure: 1a. Resident 46 was provided privacy by Licensed Vocational Nurse (LVN) 1, when she assessed the resident for back pain; and 1b. Resident 10 was provided privacy by LVN 2, when he applied the Voltaren Cream (pain medication cream applied topically). These failured had the potential toi violate residents rights to privacy during medication administration. and 2a. Resident 40's narcotic medication Norco (brand name or narcotic pain medication) 5-325 milligrams (mg- unit of measurement) was documented as administered by the Licensed Nurse (LN) on June 18 and 27, 2024; and 2b. For Resident 76, the medication Ativan (anti-anxiety medication) was documented as administered by the LN on July 16 and 24, 2024. These failures resulted to the delay in the identification of drug discrepancies and possible medication diversion of controlled medications. Findings: 1a. On July 24, 2024,…

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 dietary staff could carry out the functions of food and nutrition services safely and effectively when [NAME] (CK) 1, Dietary Aide (DA) 3 and DA 4 were unable to accurately describe the cooldown process for hot food and ambient food temperatures. This failure had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On July 23, 2024, at 11 a.m., during an interview with DA 3 of the cooldown process for hot food and ambient food temperatures inside the kitchen, she stated the hot food cooldown temperature starts at 186 degrees. DA 3 stated the temperature should be checked after two hours, with a goal temperature of 140 degrees. DA 3 further stated she would check the food temperature after another 2 hours with a goal temperature of 34 degrees. DA 3 stated the cooldown process for ambient food temperature, like tuna salad is after the food was made, it should be placed in the refrigerator and checked…

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 a sanitary environment, to prepare, and serve food in accordance with professional standards for food service safety when: 1. The toaster dial control had a build up of brown-yellowish grime. 2. Multiple cutting boards had yellowish discoloration, deep cuts, indentations, and damaged. 3. The left and right sides of the oven, the front inside surfaces of the left and right oven doors showed brown discoloration. (cross reference F908) 4. The front metal areas of two meal tray carts were stained with brown discoloration. (cross reference F908) These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On July 22, 2024, at 8:30 a.m., during a concurrent walk-through observation and interview inside the kitchen with the Dietary Manager (DM), the following were observed: 1. One toaster had brown-yellowish grime buildup in the front dial control. The DM stated the the toaster is…

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

Based on observation, interview, and record review, the facility failed to ensure, one toaster, two oven doors, the left and right sides of the oven and four meal tray carts were maintained in a safe operating condition. These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On July 22, 2024, at 8:30 a.m., during a concurrent observation and interview inside the kitchen of the toaster with the Dietary Manager (DM), the toaster dial had chipped and peeled plastic film. The DM stated the toaster was old and needs to be replaced. The DM further stated bacteria can grow into the chipped and peeled areas, can cross contaminate the food and cause food-borne illness. On July 22, 2024, at 8:40 a.m., during a concurrent observation and interview inside the kitchen with the DM, the left and right sides of the oven were observed with chipped and peeled paint, and had brown discoloration. During further observation, the front inside surfaces of the left 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, interview, and record review, the facility failed to provide a comfortable homelike environment for one of eight residents (Resident 87) when multiple damaged window blinds were observed. This failure had the potential to disrupt the residents' daily living needs and environment. Findings: On July 22, 2024, at 11:30 a.m., during a concurrent observation and interview with Resident 87's room. Multiple damaged blinds were observed. Resident 87 stated it is too bright and she used curtains to block the light coming through the damaged blinds. On July 24, 2024, at 8:19 a.m., during an interview with the Maintenance Supervisor (MS), He stated he was aware about the damaged window blinds in Resident 87's room. He stated, the blinds need to be replaced. On July 24, 2024, at 8:35 a.m., during an interview with the Facility Administrator (FA), the FA stated she was aware that the damaged window blinds needed to be repaired. The FA further stated the blinds should have been replaced or repaired to provide home like environment for the residents. A review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure education and resources regarding Advance Directive (AD - written statement of a person's wishes regarding medical treatment) were provided to one of the three residents reviewed for AD (Residents 44), and or the Resident Representative (RP). This failure had the potential for Resident 44 and the RP to remain uneducated and uninformed about AD and could result in the facility being unable to know and honor the resident's wishes regarding medical treatment. Findings: On July 23, 2024, Resident 44's record was reviewed. Resident 44 was admitted to the facility on [DATE]. A review of Resident 44's History and Physical, dated June 9, 2024, indicated Resident 44 cannot make decisions. A review of Resident 44's Minimum Data Set (an assessment tool), dated June 12, 2024, indicated, Resident 44 had severely impaired cognitive skills. A review of Resident 44's Advance Directive Acknowledgement Form, dated June 10, 2024, indicated Resident 44 had 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.

Based on observation, interview, and record review, the facility failed to ensure for one of seven residents reviewed for environment (Resident 28) was provided with a clean, safe, and comfortable environment when: 1. The resident's call light button (a device that alerts healthcare staff for help in a facility) cord was damaged and cracked. In addition, the staff did not report the damaged and cracked call light button cord to maintenance for replacement. This failure had the potential to prevent Resident 28 from receiving assistance as needed. 2. The cabinet above the sink inside the bathroom had rust buildup on the bottom shelf. This failure had the potential to place Resident 28 at risk of living in an unkempt and un-homelike environment. Findings: 1. On July 23, 2024, at 10:34 a.m., during a concurrent observation and interview with Resident 28 in the resident's room, the call light button cord was found to be cracked and with exposed wires. Resident 28 stated he used the call light for help but was not aware his call light was damaged. On July 24, 2024, at 3:04 p.m., 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 notify the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an agency reponsible for advocating on behalf of residents) of a discharge for one of two residents (Resident 39) reviewed for closed records. This failure had the potential to result in the LTC Ombudsman not to be informed about Resident 39's plan of care and condition. Findings: On July 25, 2024, Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with a diagnosis which included dementia (a group of brain disease that causes loss of memory) and Alzheimer's (a type of dementia). A review of Resident 39's Minimum Data Set (an assessment tool), dated April 5, 2024, indicated, Resident 39 had Brief Interview of Mental Status (quick assessment to check a person's thinking, memory, and overall mental functioning) Score of 5 (severe cognitive impairment). A review of Resident 39's Discharge Summary Report, dated June 3, 2024, indicated, .discharged 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 observation, interview, and record review, the facility failed to ensure, Licensed Vocational Nurse (LVN) 1, administered the medication Nifedipine (brand name of medication used for high blood pressure) ER (extended release) 20 milligrams (mg - unit of measurement) as ordered by the physician for one of seven residents (Resident 10) observed for medication administration. This failure has the potential for the resident to not receive the full therapeutic effects of the medication. Findings: On July 24, 2024, at 9:34 a.m., a medication administration observation was conducted with LVN 1 on Resident 10. LVN 1 proceeded to prepare Resident 10's medications that included Nifedipine ER 20 mg one tablet. Indicated on the Nifedipine ER medication label instruction was to hold (not give) the medication if the systolic blood pressure reading (SBP- pressure in the arteries when the heart contracts) is less than 110 mmHg (millimeter of mercury - unit of measurement) and pulse rate is below 60 (normal pulse rate…

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, an edema (swelling caused by too much fluid in the tissues) on the left upper and left lower extremity was appropriately assessed and a care plan was initiated and developed, for one of eight residents reviewed (Resident 24). This failure has the potential for the edema to not be monitored for complications and may also result to the delay in treatment of possible worsening symptoms. Findings: On July 23, 2024, at 10:34 a.m., an observation with a concurrent interview was condcuted with Resident 24. Resident 24 was alert, interviewable, and was sitting sitting on his wheelchair in the activities room. Resident 24's left arm and hand was observed to be swollen and not supported on the wheelchair arm rest. In a concurrent interview, Resident 24 stated the staff did not put any treatment, including elevating or icing, on his left arm and hand. On July 23, 2024, Resident 24's record was reviewed. Resident 24 was admitted 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 interview and record review, the facility failed for one of two residents (Resident 54), to address vision deficits when a recommendation for reading glasses was not followed up. This failure had the potential for Resident 54 to have a decline in his vision. Findings: On July 22, 2024, at 8:56 a.m., an interview with Resident 54 in his room, he stated he loved reading books and used to have readers. Resident 54 further stated having reading glasses could help him read better. A review of Resident 54's admission RECORD, printed date July 24, 2024, indicated, Resident 54 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of Resident 54's History and Physical dated May 28, 2024, indicated the resident had the capacity to make own decisions. A review of Resident 54's physician's order, dated May 21, 2024, indicated, .Eye-Health and Vision Consult with Follow-Up Treatment as indicated . A review of Resident 54's document from the optometrist (a healthcare…

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 following medications were not stored readiliy available for use in the medication cart and medication room: - One bottle of Nutricia UTI Stat Liquid 30 FL Oz (Fluid Ounce - unit of measurement) 887 milliliters (unit of measurement) with an expiration date of [DATE]; - Four acetaminophen suppositories 650 milligrams (mg-unit of measurement) labeled for use on a resident that expired [DATE]; and - One vial of Comimaly Intramuscular Suspension 30 MCG (micrgogram- unit of measurent)/0.3ml (type of Covid{(highly contagious type of respiratory infection}vaccine ) labeled for use on a resident that was discharged from the facility on [DATE]. This failure has ther potential for the residents to receive expired and/or ineffective medications. Findings: On [DATE], at 11:37 a.m., an interview was conducted with Registered Nurse 1 (RN) 1. RN 1 stated all medications stored in the medication cart one (1) was readily available for use. On…

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

Based on observation, interview, and record review, facility failed to provide assistive devices such as plate guard (equipment to prevent food from falling off the plate), for two of eight residents (Resident 13 and Resident 58) observed during mealtime. This failure had the potential for Resident 13 and 58 not meeting the daily nutritional needs, which could lead to weight loss. Findings: a. On July 22, 2024, at 12:05 p.m., a concurrent observation and interview were conducted with Resident 13 in the dining room. Resident 13 was observed scooping the food onto her plate but the food fell off the plate. She stated the food was spilling out of the plate and stated oops my food just fell. On July 24, 2024, at 12:30 p.m., Licensed Vocational Nurse (LVN) 6 was interviewed. LVN 6 stated, Resident 13 spilled food on the floor. LVN 6 stated, Resident 13 could eat by herself, a plate guard should have been provided to prevent food from spilling. On July 24, 2024, at 12:45 p.m., during an interview with the Director of Nursing (DON), she stated Residents13 should have been evaluated 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 safe and sanitary storage of personal food for one of one resident (Resident 56) when two expired bags of marshmallows were found inside the resident's closet and were readily available for consumption. This failure had the potential to place Resident 56 at risk for foodborne diseases (illness that result from ingestion of contaminated food). Findings: On July 24, 2024, at 5:17 p.m., a review of Resident 56's medical records indicated he was admitted to the facility on [DATE]. A review of Resident 56's History and Physical, dated November 5, 2023, indicated he had a fluctuating capacity to understand and make decisions. On July 23, 2024, at 9:40 a.m., during a concurrent observation and interview inside Resident 56' room, two bags of expired marshmallows were found in the resident's closet. One of the bags was opened and had a hardened texture. Resident 56 stated the marshmallows were gifts from last Christmas (7 months ago).…

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 proper infection control practices were observed when: 1. Registered Nurse (RN) 2, did not perform the appropriate hand hygiene prior to, in between, and after a resident contact during a blood sugar check and administration of insulin (medication used for high blood sugar) for one of seven residents observed (Resident 4); and 2. For one of two residents (Resident 347), when a Physical Therapy Assistant (PTA) failed to perform hand hygiene and disinfect ankle weights used after providing care on the resident, who is on an enhanced barrier precautions (EBP - infection prevention and control practices that can help reduce the spread of infection). These deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of diseases and infection to the facility staff, residents, and visitors. Findings: 1. On July 24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of five residents reviewed for immunizations (Resident 58) was offered the pneumococcal vaccine (vaccines against the bacterium Streptococcus pneumoniae [bacteria that can cause pneumonia]). This failure had the potential for Resident 58 not fully protected against pneumonia (infection of lungs). Findings: A review of Resident 58's admission RECORD, indicated, .Resident 58, is [AGE] year old, admitted to the facility on [DATE], with diagnoses which included chronic obstructive lung disease (COPD-respiratory problem). On July 24, 2024, at 8:37 a.m., during a concurrent interview and review of Resident 58's immunization record, with the Infection Preventionist (IP), the IP stated Resident 58 received one dose of pneumococcal (PPSV23) on april 24, 2023. The IP stated residents who received one dose of Pneumococcal (PPSV23) should be offerred a second dose of pneumococcal (PCV20) after one year. The IP further stated the facility follows…

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 sampled residents' (Resident 2) whereabout was being frequently monitored. This failure potentially could have contributed for Resident 2 to be able to wander to Resident 1's room and was found on top of the resident on April 27, 2024. Findings: A review of Resident 2 ' s medical record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s History and Physical (H&P), dated November 17, 2023, indicated Resident 2 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interfered with doing everyday activities). A review of Resident 2 ' s Minimum Data Set (MDS- an assessment tool) dated March 29, 2024, indicated Resident 2 had severely impaired cognition. A review of Resident 2 ' s care plan dated May 16, 2022, indicated Resident 2 was . at risk for leaving safe area without authorization, leaves premises without authorization secondary to dementia as evidenced by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST-a legal document signed by the resident if with capacity to make decision or resident legal representative, and physician, that indicate a resident's preference for life sustaining treatment) was identifiable, accurate, and updated, for three of seven residents reviewed (Resident 2, 6, and 7). This failure had the potential for Residents 2, 6, and 7 to receive inappropriate or delayed treatment. Findings: 1. On April 24, 2024, Resident 2's record was reviewed. Resident 2 was admitted on [DATE], with diagnoses including primary hypertension (elevated blood pressure), and syphilis (sexually transmitted disease caused by bacteria). The following documents of Resident 2 were reviewed: - The Physician's History and Physical, dated March 5, 2024, indicated Resident 2's decision making capacity was fluctuating; - The POLST, dated March 4, 2024, indicated, Do Not Attempt Resuscitation/DNR 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 interview and record review, the facility failed to ensure a resident representative or surrogate decision maker (authorized individual to make healthcare decisions for the resident) was assigned for decision making, for one of seven residents reviewed (Resident 7). This failure had the potential to result in medical services to not be coordinated in accordance with the resident's needs due to the lack of appropriate decision- making capacity and advocacy for the resident. Findings: On April 24, 2024, at 5:18 p.m., an interview with a concurrent record review was conducted with the Medical Records (MR). Resident 7 was admitted to the facility on [DATE], with diagnoses including schizophrenia (type of personality disorder that affects a person's ability to think, feel, and behave clearly). The following documents of Resident 7 were reviewed with the MR: The Physician's History and Physical, dated March 15, 2024, indicated, .This resident .does not have the capacity to understand and make decisions…

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 resident was monitored following an allegation of sexual abuse, for one of two sample residents (Resident 2). This failure had the potential to affect Resident 2 ' s physical, emotional, and psychosocial wellbeing. Findings: On February 6, 2024, an unannounced visit to the facility was conducted to investigate an allegation of sexual abuse. On February 6, 2024, at 11:58 a.m., during an interview with the Director of Nursing (DON), she stated, Resident 1 alleged Resident 2 had touched her breast and private area on January 23, 2024, at around 4 p.m. The DON further stated, Resident 1 and Resident 2 were monitored after the alleged abuse incident for emotional distress, changes in behavior, and bodily injuries. A review of Resident 2 records indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included altered mental status. A review of Resident 2's History and Physical, dated June 7, 2023, 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 ensure for one of three sampled residents (Resident B), treatments were completed, as ordered, for a right hip surgical wound. This failure had the potential to delay wound healing, increase the risk of complications and further infections for Resident B. Findings: On November 14, 2023, at 1:00 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. On November 14, 2023, Resident B ' s medical record was reviewed. Resident B was admitted to the facility on [DATE], with diagnoses which included Osteomyelitis (bone infection) of the right hip and Hepatitis C (an infection in the liver caused by a virus). A review of Resident B ' s History and Physical, indicated Resident B has the capacity to make decisions. A review of Resident B ' s Treatment Administration Record (TAR), dated November 2023, indicated the following: .Treatment R (right) hip surgical wound: cleanse with wound cleanser, pat dry apply TAO (triple…

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 two of three residents (Resident A, Resident B), the following: 1) Resident A, a care plan was developed with specific goals and interventions addressing the Resident A's dementia ; and 2) Resident B, monitoring of behaviors and non-pharmacological interventions were implemented prior to starting psychotropic medication. These failures had the potential to result in inconsistent and inadequate management of care for both residents. Findings: On June 28, 2023, at 10:45 a.m., an unannounced visit was conducted at the facility for a facility reported incident. 1) On June 28, 2023, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included psychosis (a mental disorder characterized by a disconnection from reality) and dementia (thinking and social symptoms that interfere with daily functioning). A review of Resident A ' s, History and Physical, indicated Resident A does not have 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 develop a comprehensive care plan for addressing the resident's hearing problem for one of three sampled residents (Resident 1). This failure had the potential to negatively impact the resident's quality of life, inability to communicate his needs effectively, and staff not being aware of the resident's care needs. Findings: On May 23, 2023, at 10:00 a.m., an unannounced visit was conducted at the facility for the investigation of an allegation of abuse. On May 23, 2023, at 10:51 a.m., an interview was conducted with Resident 1. Resident 1 stated, he could not hear well. Resident 1 stated, he needed hearing aids. Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included psychosis (a mental disorder characterized by disconnection from reality) and sensorineural hearing loss (caused by damage to the inner ear) bilateral (both). A review of Resident 1's ENT (a medical specialist that focuses…

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

Based on observation and interview, the facility failed to provide a clean and safe environment for the residents and visitors when one out of one dumpster garbage bin located outside the kitchen was overflowing with trash, and the deformed (bent) lid was not securely closed. This failure had the potential for an unsafe environment for the residents and the visitors due to possible pest infestation and spread of diseases in the facility. Findings: During the kitchen initial tour on January 23, 2023, at 10:09 a.m., one dumpster bin located outside the facility's kitchen was observed overflowing with trash and the lid was not securely closed. In addition, the dumpster lid was observed deformed (bent) and would not close tightly to prevent rodents or pests from entry. A concurrent interview with the Certified Dietary Manager (CDM), she stated the trash should not be overflowing and the lid should be securely closed. On January 24, 2023, at 3:39 p.m., the Registered Dietitian (RD) was interviewed. The RD stated the trash should not overflow and the dumpster lid should completely close…

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 Resident 31's closet space was free from belongings left by a resident who had been discharged . This failure had the potential to inhibit Resident 31's ability to have adequate closet space for her belongings. Findings: On January 23, 2023, at 8:40 a.m., Resident 31's closet was found to contain personal belongings of another resident. On January 23, 2023, at 8:49 a.m., an interview with Licensed Vocational Nurse (LVN) 1, was conducted. LVN 1 stated if a resident is no longer in the room, all personal belongings should be removed. On January 23, 2023, at 8:53 a.m., an interview with a Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated, when residents are discharged all personal belongings should be sent with them, donated, or thrown away. CNA 1 further stated a discharged resident's personal belongings should not be left in the closet. On January 23, 2023, at 8:58 a.m., an interview was conducted with The Infection Preventionist (IP). The IP stated the belonging's left in Resident 31'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 ensure proper behavior monitoring was implemented for the use of Provera (medication to treat behavior in men) medication for one of five residents (Resident 50) reviewed for unnecessary psychotropic medication (medication which affects behavior). This failure had the potential for Resident 50 to receive unnecessary psychotropic medication. Findings: On January 25, 2022, Resident 50's record was reviewed. Resident 50 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's (brain disorder), depressive disorder (mood disorder), anxiety disorder (mood disorder), schizoaffective disorder (mental health disorder), and psychosis (mental health disorder). Resident 50 had a BIMS (Brief Interview Mental Status) score of 06 (impaired mental status). The Progress Notes dated, November 13, 2022, at 4:38 p.m., indicated, Pharmacy recommendations noted with MD (doctor) notified with new order for monitoring inappropriate sexually (sic)…

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 two of twenty-nine opportunities observed during medication administration were free from a medication error rate of five percent or more when: 1. Lidoderm patch (medication for pain) was not removed as scheduled per the physician order; and 2. Albuterol inhaler (medication to help with breathing) was not administered as recommended by the manufacturer's instructions. These failures resulted in a mediation error rate of 6.9% and could potentially result in residents not receiving the full therapeutic effect of the medication. Findings: 1. On January 24, 2023, at 9:14 a.m., during medication administration, Licensed Vocational Nurse (LVN) 1 was observed. Resident 446 was noted with a white patch on his lower back. LVN 1 removed white patch and then applied a new Lidoderm patch on Resident 446's lower back. On January 24, 2023, Resident 446's record was reviewed. Resident 446 was admitted to the facility on [DATE], with diagnoses…

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 medications were stored according to the facility's policy and procedure and per state and federal requirements when: 1. Diclofenac gel (medication for pain) had the incorrect drug label on the medication when compared to the physician's order; and 2. Two multi-dose vials of Tuberculin for injection had an opened date that was expired. These failures had the potential for medication error to occur or medication to be used with less efficacy. 1.On [DATE], at 9:36 a.m., during medication administration observation, License Vocation Nurse (LVN) 1 was observed preparing diclofenac gel 1% for Resident 31. The diclofenac gel label indicated, .Apply 2 gm (gram- unit of measurement) topically to left shoulder . LVN 1 was observed to apply diclofenac gel to Resident 31's right shoulder. On [DATE], at 3:11 p.m., a concurrent interview and record review with LVN 1 were conducted. LVN 1 stated the diclofenac gel 1% was to be applied topically…

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 the menu was followed during the lunch meal on January 24, 2023, when: 1. Resident 18, with CCHO (Controlled Carbohydrate Diet - a meal plan consisting of having the same amount of carbohydrates every day), low fat and low cholesterol diet (a diet that helps reduce the risk of heart disease), received one whole slice of wheat bread instead of half a slice of wheat bread; and 2. Resident 63, with regular low fat and low cholesterol diet, received regular chicken jambalaya with sausage, instead of the chicken jambalaya without sausage. These failures had the potential to result in compromising the medical and nutritional status of Residents 18 and 63. Findings: 1. During an observation of the lunch meal service on January 24, 2023, beginning at 11:55 a.m., the dietary staff was observed to serve one whole slice of wheat bread instead of half a slice of wheat bread, for Resident 18. A concurrent review of the undated facility document titled, Winter Menus Week 4 TUESDAY 1/24/23, indicated residents with 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 observation, interview and record review, the facility failed to ensure proper dishwashing procedure was completed when several various sized metal pans were stacked and stored wet. This failure had the potential to cause food-borne illnesses in a medically vulnerable population who consumed food in the facility. The facility census was 80. Findings: On January 23, 2023, at 9:16 a.m., during the initial kitchen tour, one three-quarter (3/4) sheet metal pan, two half (1/2) sheet metal pan, and one, one-third (1/3) sheet metal pan were observed stacked wet and stored in the storage area for clean, dry, and ready for use items. On January 23, 2023, at 9:19 a.m., the [NAME] was interviewed. The [NAME] verified the various sized metal pans were wet. The [NAME] stated the metal pans should have been completely dried before they were be stored. On January 23, 2023, at 9:50 p.m., the Certified Dietary Manager (CDM) was interviewed. The CDM stated the dishes, pots, and pans should all be completely air-dried before storing them away. On January 24, 2023, at 3:39 p.m., a follow-up…

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.