Briarcrest Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the urine characteristics and document urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) care for one of one sampled residents (Resident 127), with an indwelling urinary catheter.These deficient practices had the potential to lead to delayed treatment and identification of urinary tract infections (UTI- an infection in the bladder/urinary tract) and improper urinary catheter management for Residents 127.Findings:During a review of Resident 127's admission Record, the admission Record indicated Resident 127 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 127's diagnoses included neuromuscular dysfunction of bladder (a bladder problem caused by damaged nerves that makes it hard to control when urinate), dependence on respiratory ventilator (a medical device to help support or replace breathing), and urinary tract infection (UTI- an infection in the bladder/urinary…

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 feeding assistance was provided to one of four sample residents (Resident 2) who required feeding assistance with meals.This deficit practice placed Resident 2 at risk for choking, aspiration (accidental inhalation of food, liquid, or stomach contents into the airway), inadequate nutritional and fluid intake, weight loss, dehydration, and a decline in overall health status.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dysphagia (difficulty swallowing), lack of coordination, dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure), and acute respiratory failure with hypoxia (a life-threatening medical emergency where the lungs cannot adequately oxygenate the blood).During a review of Resident 2's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility's consultant pharmacist's Medication Regime 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, to the physician) recommendations for ammonia level (a blood test used to measure the amount of ammonia [a waste product] in the blood) laboratory test were completed for two of two sampled residents (Residents 14 and 40). This deficient practice resulted in Residents 14 and 40's recommended blood laboratory tests not being performed and had the potential to place the residents at risk for delayed identification and treatment of elevated ammonia levels and adverse drug reaction. Cross reference F580Findings: a. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and Midodrine (medication used to treat hypotension [low blood pressure]) were administered within the ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for two of three sampled residents (Residents 8 and 40). This deficient practice placed Resident 8 at risk for hypoglycemia (low blood sugar) and related complications, and placed Resident 40 at risk for an unsafe increase in blood pressure, headache, dizziness, slow heart rate, and other adverse effects related to medication administration outside of ordered parameters. Findings: 1. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE]. Resident 8's diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 101) who was prescribed a fortified diet (diet enhanced to increase caloric content) was served a fortified lunch.This deficient practice had the potential to place Resident 101 at risk of decreased caloric intake and unmet nutritional needs.Findings:During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE]. Resident 101's diagnoses included hypertension (HTN- high blood pressure), dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities).During a review of Resident 101's History and Physical (H&P) dated 2/28/2026, the H&P indicated Resident 101 had fluctuating capacity to understand and make decisions.During a review of Resident 101's Minimum Data Set (MDS- a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 101 had severe cognitive (ability to think 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 follow Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) protocol for one of four residents (Residents 107) by not wearing 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 107.This deficient practice placed Resident 107 and other residents at increased risk for infections.Findings:During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE]. Resident 107's diagnoses included dementia (a progressive state of decline in mental abilities), hyperlipidemia (high cholesterol), dysphagia (difficulty swallowing), urinary tract infection (UTI, an infection in the bladder/urinary tract) and metabolic encephalopathy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the resident with an appropriate call light system that accommodated the resident's physical limitations for one of six sampled residents (Resident 95). This deficient practice resulted in Resident 95 being unable to independently summon staff assistance and placed the resident at risk for delayed response to care needs, delayed assistance, unmet needs, and potential injury due to inability to effectively communicate the need for assistance. Findings: During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95 diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and dementia (a progressive state of decline in mental abilities). During a review of Resident 95's History and Physical (H&P), dated 10/31/2025, the H&P indicated Resident 95 did not have the capacity…

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 care plan interventions were documented every shift for one out of three sampled residents (Resident 1) who was identified as a fall risk. This deficient practice resulted in Resident 1 suffering a fall on 5/5/2026 and sustaining a fracture (broken bone) to the right medial orbital wall (thin bone separating the eye socket from the sinuses). 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]. Resident 1's diagnoses included cerebral infarction (ischemic stroke, occurs when a blood vessel in the brain becomes blocked or severely narrowed), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (partial weakness or the inability to move one entire side of the body), aphasia (a disorder that makes it difficult to speak), gastrostomy status (a surgical opening fitted with a device to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the protection of residents' privacy and confidentiality when Certified Nursing Assistant (CNA) 2 recorded and photographed two of two sampled residents (Resident 1 and Resident 2) without Residents 1 and 2's knowledge or consent on her cell phone. CNA 2 shared the recordings and photographs with CNA 1.This deficient practice resulted in a violation of Resident 1 and Resident 2's rights to privacy and confidentiality, and placed Resident 1 and Resident 2 at risk for unauthorized disclosure of protected health information, loss of dignity, and emotional distress.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs ), depression (a common but serious, treatable mental illness characterized by persistent sadness, loss of interest in activities, and low…

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 follow their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, which indicated the nurse would notify the resident's attending physician (PCP) for changes in condition for one of three sampled residents (Resident 2) when:Registered Nurse (RN) 1 identified a discoloration/bruise to Resident 2's left hip area on 3/14/2026. Resident 2 alleged that on 3/14/2026, she was hit by a Certified Nurse Assistant (CNA).This failure had the potential to result in delayed medical care for Resident 2 and had the potential to negatively affect the resident's psychological and physical well-being. Cross Reference F842Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included fracture (broken bone) of right femur (thighbone), dementia (a progressive state 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 interview and record review, the facility failed to provide a Bed-Hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital [GACH] in anticipation of their return to the facility) written notification as indicated in its policy and procedure (P&P) titled, Bed-Holds and Returns to one of three residents (Resident 3), who was transferred to the GACH on 3/10/2026.This failure had the potential to violate Resident 3's right to a bed-hold and result in the resident's inability to return to his home at the facility. Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included respiratory failure (a serious condition that makes it difficult to breath on your own) with hypoxia (low levels of oxygen in the body's tissues).During a review of Resident 3's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate clinical medical records, for one of three sampled residents (Resident 2) by failing to:Ensure Registered Nurse (RN) 1 documented Resident 2's full body (head-to-toe) assessment and skin discoloration/bruise identified on 3/14/2026 in the resident's medical records.Ensure RN 1 did not document a recommendation of PCP (Primary Care Physician) in Resident 2's Change in Condition (COC) form without speaking with the PCP. This deficient practice had the potential to result in miscommunication between staff and a delay in the provision of care or interventions for Resident 2. Cross Reference F580Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included fracture (broken bone) of right femur (thighbone), dementia (a progressive state of decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct monitoring for one of two sampled residents' (Resident 4) who had behavior of aggressive angry outbursts.This deficient practice had the potential to result in the inaccurate assessment of the effectiveness of Resident 4's medication regimen. Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (high blood pressure). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 1/6/2026, the MDS indicated Resident 4's cognitive skills (process of thinking) for daily decision making was moderately…

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 follow its policy and procedure (P&P) titled, Resident-to-Resident Altercations which indicated to separate residents after an altercation for two of two sampled residents (Residents 4 and 5).This deficient practice resulted in Resident 4 and 5 being involved in a verbal altercation which escalated to Resident 5 pushing Resident 4 into the nightstand and sustaining an abrasion (scratch) above his right eyebrow. Findings:1. During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and hypertension (high blood pressure). During a review of Resident 4'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 submit a Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1 Screening for one of five sampled residents (Resident 4).This deficient practice had the potential to result in Resident 4 not receiving the necessary and appropriate psychiatric level treatment and evaluation in the facility.Findings:During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and hypertension (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered care plan with interventions for one of three sampled residents' (Resident 1) use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility).This deficient practice had the potential to result in Resident 1 not receiving the necessary care to safely utilize the side rails.Cross Reference F700.Findings:During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included generalized muscle weakness (decrease in muscle strength), dementia (a progressive state of decline in mental abilities), and chronic atrial fibrillation (long-term heart condition where the heart beats quickly and irregularly). The admission Record indicated Resident 1 had a Responsible Party (RP 1).During a review of Resident 1's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct a side rail utilization assessment prior to installing side rails, obtain an order for the use of side rails, and ensure informed consent was obtained prior to the use of side rails for two of three sampled residents (Residents 1 and 2).These deficient practices had the potential for the unsafe use of Resident 1 and 2's side rails which could lead to entrapment (becoming caught, trapped, or tangled in between a small space) and injury. Findings:1. During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included generalized muscle weakness (decrease in muscle strength), dementia (a progressive state of decline in mental abilities), and chronic atrial fibrillation (long-term heart condition where the heart beats quickly and irregularly). The admission Record indicated Resident 1 had 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 honor one of three sampled residents' (Resident 6) privacy.This deficient practice resulted in Resident 6 feeling frustrated and distrust in the facility to honor his privacy request.Findings:During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and chronic kidney disease (progressive damage and loss of function in the kidneys). The admission Record indicated Resident 6 was self-responsible and Family Member (FM) 1 was listed as his first emergency contact.During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 11/27/2025, the MDS indicated Resident 6's cognition (process of thinking) was intact. The MDS indicated Resident 6 required supervision or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the low air loss mattress (LALM- a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) guideline for the use of linens for one of three sampled residents (Resident 2).This deficient practice had the potential to result in worsening of Resident 2's pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and the development of new skin breakdown.Findings:During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included acute and chronic respiratory failure with hypoxia (a sudden worsening of a long-term condition where the blood oxygen levels drop severely), contracture of muscle (when a muscle becomes permanently short, tight, and stiff, making it hard or impossible to move normally), 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 interview and record review, the facility failed to install bilateral (both sides) half side rails (short rails on both sides of the bed that can be used to assist in bed mobility) as ordered and provide two-person assistance prior to providing care to one of four sampled residents (Resident 5).These deficient practices resulted in Resident 5 falling off her bed on 12/26/2025.Findings:During a review of Resident 5's admission Record (Face Sheet), the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - caused by a blocked blood vessel in the brain) affecting the left side, hypertension (high blood pressure), and aphasia (disorder that affects how an individual communicates) following cerebral infarction.During a review of Resident 5's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of staff-to-resident abuse to the California Department of Public Health (CDPH) timely for one of two sampled residents (Resident 1). This deficient practice placed Resident 1, and other facility residents, at risk of sustaining abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and recently re-admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), quadriplegia (inability to move the extremities), tracheostomy (a surgical opening in the neck into the trachea (windpipe) that creates a new airway for breathing through a tube), gastrostomy (the surgical procedure to create an opening through the abdominal wall into the stomach). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/31/2025, the MDS indicated Resident 1 had severe cognitive…

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 allegation of staff-to-resident abuse was investigated for one of two sampled residents (Resident 1). This deficient practice placed Resident 1, and other facility residents, at risk of potential abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and recently re-admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), quadriplegia (inability to move the extremities), tracheostomy (a surgical opening in the neck into the trachea (windpipe) that creates a new airway for breathing through a tube), gastrostomy (the surgical procedure to create an opening through the abdominal wall into the stomach). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/31/2025, the MDS indicated Resident 1 had severe cognitive impairment (a significant loss of mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, Registered Nurse (RN) 1 failed to conduct neurological assessments ( neuro-checks, assessments that evaluate brain and nervous system functioning) at the required frequency/interval for one of two sampled residents (Resident 1) after Resident 1 was allegedly hit on the head by a male Certified Nursing Assistant (CNA). This deficient practice placed Resident 1 at risk of staff not identifying, or being delayed in identifying, potential neurological complications.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and recently re-admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), quadriplegia (inability to move the extremities), tracheostomy (a surgical opening in the neck into the trachea (windpipe) that creates a new airway for breathing through a tube), gastrostomy (the surgical procedure to create an opening through the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility's medical records were complete and accurately documented for one of two sampled residents (Resident 2) by not ensuring licensed nurses1. Documented the number of behavioral episodes on the Medication Administration record (MAR);2. Monitored Resident 2 for behavioral episodes (period or event marked by unusual, disruptive, or problematic behavior);3. Had the knowledge to complete monitoring section in the MAR; and4. Licensed nurses documented Resident 2' s return to the facility.These deficient findings could potentially place other residents in the facility at risk to Resident 2's behavioral episodes. These deficient findings created miscommunication on when and at what time Resident 2 returned to the facility.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 2's diagnosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop an individualized resident care plan for one of six sampled residents (Resident 1), who had a diagnosis of dementia (a progressive state of decline in mental abilities).This deficient practice had potential to result in the nurses not being able to provide quality care and could affect in maintaining the highest practicable physical, mental and psychosocial well-being of the resident. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including unspecified dementia (a progressive state of decline in mental abilities,) epilepsy (a neurological disorder characterized by recurrent seizures, which are caused by abnormal electrical activity in the brain,) generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities.)During a review of Resident 1's History 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 interview, and record review, the facility failed to develop a comprehensive, resident-centered care plan for one of three residents (Resident 1), who had a physician's order for fluid restriction (the amount of water the resident can drink in a day). This failure had the potential to result in Resident 1 not receiving the care and services the physician had ordered and placed the resident at risk to worsening clinical condition. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1 had a history of edema (swelling, abnormal accumulation of fluid in body tissues), chronic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and chronic kidney disease (kidneys malfunctioning over a prolonged period, sometimes resulting in fluid retention). The admission Record indicated Resident 1 was discharged on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the food allergies (abnormal response after a certain food is eaten) for one of four sampled residents (Resident 1) by serving Resident 1 fish, who was allergic to seafood. This deficient practice resulted in Resident 1 having an allergic reaction and had the potential to cause Resident 1 to have an anaphylactic shock (severe, potentially life-threatening allergic reaction) the reaction may include itchy skin, edema, collapsed blood vessels, fainting, difficulty in breathing, and death). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included Dysphagia (difficulty swallowing) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). The admission Record indicated Resident 1 was allergic to caffeine, cheese, citrus…

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, record review and interview, the facility failed to implement its infection prevention and control measures for two of four sampled residents (Residents 2 and 4) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 and Restorative Nursing Assistance (RNA) 1 wore personal protective equipment (PPE-specialized clothing or equipment such as gloves and gown worn to minimize exposure to serious illness) while providing care to Residents 2 and 4, who was on Enhanced Barrier Precautions (EBP-an approach to the use of to reduce transmission of Multidrug-Resistant Organisms [MDRO- bacteria that are resistant to multiple antibiotics].) 2.Ensure clear signage was posted to inform staff of the EBP to be followed when providing care to Resident 4. This deficient practice had the potential to result in potential transmission of a disease-causing organisms leading to illness and a delay in wound healing for Residents 2 and 4. Findings: During an observation on 5/22/2025 at 10:00 a.m. a signage for…

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) supervised the medication administration for one of three sampled residents (Resident 2), who had not been assessed by the Interdisciplinary Care Team (IDT- a group of healthcare professionals who work together to manage the resident ' s care) for medication self-administration. This failure placed Resident 2 at risk for medication errors including delayed doses or missed doses and could lead to adverse drug events for the resident. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2 ' s diagnoses included osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) of the left hip, hypertensive urgency (a significantly elevated blood pressure [normal pressure is 120/80 millimeter of mercury ([mmHG], 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 assess and notify Resident 1 ' s Medical Doctor (MD) when one of three residents (Resident 1), had tachycardia (heart rate faster than normal) and tachypnea (rapid breathing) on 2/17/2025. This failure resulted in delayed treatment and the resident's transfer to a general acute care hospital (GACH) for evaluation. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1 had a history of chronic respiratory failure (chronic lung disease causing difficulty breathing), tracheostomy (a surgically placed breathing tube) status, pneumonia (an infection/inflammation in the lungs), and sepsis (a life-threatening blood infection). During a review of Resident 1 ' s History and Physical (H&P), dated 2/13/2025, the H&P indicated Resident 1 was not able to make medical decisions. During a review of Resident 1 ' s Physician progress notes,…

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 Minimum Data Set Nurse (MDSN) 1 demonstrated the competencies required of her job position and failed to evaluate MDSN 1's ability to accurately perform MDS assessments on an annual basis. This failure placed all facility residents at risk of receiving inaccurate Minimum Data Set (MDS, a resident assessment tool) assessments, which could negatively impact the care the residents received because their care plans were based on data contained in the MDS. Cross-reference F-tag F641. Findings: During an interview on 3/13/2025 at 2:07 PM, with the Assistant Director of Nursing (ADON), the ADON stated the purpose of the MDS was to accurately identify and document the resident's condition. The ADON stated MDS assessments allowed staff to identify changes in a resident's condition and care areas that needed follow up and/or intervention. The ADON stated the MDS also guided the plan of care, including interventions that staff provided to the resident. The ADON stated that to conduct the MDS assessment accurately, the MDSN…

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 to failed ensure infection control measures were implemented for five of 26 sampled residents (Residents 84, 6, 40, 101, and 104) when: 1. Signage for enhanced barrier precautions (EBP, precautions utilized to prevent the spread of multi-drug-resistant organisms [MDROs, microorganisms, primarily bacteria, that have developed resistance to multiple classes of antibiotics] to residents) was not posted outside of Resident 84's room or Resident 6's room. 2. Resident 101's oxygen tubing (flexible clear tubing used to connect to an oxygen source), nebulizer (a medical device that turns liquid medicine into a mist that can be easily inhaled) and respiratory (related to breathing) setup bag (a plastic bag with drawstring closure used to store and transport respiratory equipment) were not changed according to the facility's policy and procedure (P&P). 3. Resident 104's oxygen humidifier (a medical device used to add moisture to supplemental oxygen) was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label the personal belongings of one of one sampled resident (Resident 120). This failure placed Resident 120 at risk of not maintaining possession of her belongings due to staff being unaware of who the item belonged to. Findings: During a review of Resident 120's admission Record, the admission Record indicated Resident 120 was admitted on [DATE]. Resident 120's admitting diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 120's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, The MDS indicated Resident 120 had had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and independence). The MDS indicated Resident 120 required partial to moderate assistance from staff for mobility while in and out of bed. 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 needs and preferences were accommodated for two of 26 sampled residents (Resident 65 and Resident 40) when: 1. Staff failed to ensure the call light was within reach for Resident 40. 2. Staff failed to ensure the call light was within functional reach of Resident 65, and ensure staff assisted Resident 65 to put on her bifocal glasses. These deficient practices created the potential for a delay or an inability for Resident 40 and Resident 65 to obtain necessary care and services as needed. These deficient practices also created the potential to negatively impact Resident 65's quality of life due to her inability to see clearly without her glasses. Findings: 1. During a review of Resident 40's admission Record (a document that contains a summary of basic information about the resident), the admission Record indicated Resident 40 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction…

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 Minimum Data Set (MDS, a resident assessment tool) assessments for four of 26 sampled residents (Residents 65, 84, 23, and 109) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Residents 65, 84, 23, and 109's health status. This deficient practice also created the potential for Residents 65, 84, 23, and 109 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being. Findings: 1. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted on [DATE]. Resident 65's admitting diagnoses included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level II Evaluation was completed for one of six sampled resident (Resident 86). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Residents 86. Findings: During a review of Resident 86's admission Record, dated 3/13/2025, the admission record indicated Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 86's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), delusional disorder (a mental illness characterized by having false or unrealistic beliefs), bipolar disorder (sometimes called manic-depressive disorder; mood swings…

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 care plans were developed and/or implemented for 7 of 26 sampled residents (Residents 66, 21, 65, 62, 72, 109, and 12) when: 1. Resident 66's call light was not within reach on 3/11/2025 and fall mats (cushioned floor pads designed to help prevent injury should a person fall) were not placed at the bedside on 3/11/2025, 3/12/2025, and 3/13/2025. 2. Resident 21 and Resident 66 did not have care plans for their use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). 3. Resident 65 did not have a care plan developed for her use of corrective lenses (glasses). 4. Resident 62 did not have care plans for his use of Levetiracetam (a drug used to help control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and Valproic Acid (a drug used to treat seizures). 5.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of six sampled residents (Residents 49 and 62) by failing to keep Resident 49's fingernails, and Resident 62's toenails clean and neat. This failure had the potential to result in a negative impact on Residents 49 and 62's quality of life and self-esteem and had the potential for the development of infection. Findings: 1. During a concurrent observation and interview on 3/10/2025 at 11:18 AM, with Resident 49, in Resident 49's room, observed Resident 49's fingernails were long with a brown substance underneath the nails. Resident 49 stated, No one cuts or cleans my nails. Resident 49 stated his fingernails looked long and that he would like to have his fingernails cut and cleaned. During a review of Resident 49's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 49 was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a mattress designed to distribute the individual's body weight over a broad surface area and help prevent skin breakdown) was set according to the resident's weight for one of six sampled residents (Resident 282). This deficient practice had the potential to cause the development, worsening or reinjury of pressure sores (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to Resident 282. Findings: During an observation on 3/10/2025 at 11:42 a.m., in Resident 282's room, observed Resident 282 lying on a low air loss mattress (LALM - a mattress designed to distribute the individual's body weight over a broad surface area and help prevent skin breakdown). Resident 282's LALM was set to [PHONE NUMBER] pounds (lbs., measure of weight). A weight of 293 lbs. and a date of 1/21/2025 was posted on the LALM control panel. During a review of Resident 282'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 the Director of Rehabilitation (DOR), or the assigned Licensed Vocational Nurse (LVN) were made aware of the development of a resident's right-hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) for one out of two sampled residents (Resident 95). This failure had the potential to result in the worsening of Resident 95's right hand contracture. Findings: During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95's diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), aphasia (a disorder that makes it difficult to speak), muscle weakness, gastrostomy (a surgical opening fitted with a device to allow feedings to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the midline (a long thin, flexible tube inserted into a large vein used to administer medication) insertion site at least every shift and change the dressing every seven (7) days for two of six sampled residents (Residents 330 and 72). This deficient practice had the potential for Residents 330 and 72's Midline insertion site to develop an infection. Findings: 1. During an observation on 3/10/2025 at 11:11 AM, in Resident 330's room, observed a midline to Resident 330's left upper arm. The midline dressing was dated 2/27/2025. During a review of Resident 330's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 330 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis (a life-threatening infection), peritonitis (infection of an abdominal organ), and hypertension ([HTN]- high blood pressure).…

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 interventions were provided for one of three sampled residents (Resident 65) when: 1. Resident 65's call light was not placed within reach to allow Resident 65 to call for assistance. 2. Staff failed to reposition Resident 65 at least every two hours. These failures placed Resident 65 at risk for avoidable undue pain due to staying in the same position for a prolonged period. These failures also created the potential for a delay or an inability for Resident 65 to request help from staff for repositioning, also interfering with Resident 65's ability to report her pain to staff, and request interventions to address the cause of her pain and treat it. Findings: During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted on [DATE]. Resident 65's admitting diagnoses included generalized muscle weakness, abnormalities of gait (walking pattern) and mobility, right shoulder pain, dorsalgia…

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 for one of one sampled residents (Resident 15): 1. Adequate documentation indicating Resident 15's physician (MD) 1 was made aware of Resident 15's newly prescribed antipsychotic (a class of medications used to treat mental health conditions medication) after being readmitted from the general acute care hospital (GACH). 2. Carry out MD 1's order for a psychiatrist consult (focusing on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders, including substance use disorders) when Resident 15 displayed physically aggressive behaviors on 3/8/2025. These failures had the potential to result in a delay of necessary behavioral health treatment and services to maintain the highest practicable physical, mental and psychosocial well-being for Resident 15. Findings: During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was originally 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 observation and interview, the facility failed to ensure a resident window screen was the correct size and without gaping, and the toilet seat was not broken for one of six sampled residents (Resident 133). These deficient practices had the potential to place Resident 133 at risk for injury, entry of insects into the room, and negatively impact Resident 133's well-being. Findings: During a concurrent observation and interview on 3/10/2025 at 1:19 PM, with Resident 133, in Resident 133's room, observed two gaps around the window screen. Resident 133 stated flies and mosquitos were entering his room through the gaps of the screen. Resident 133's bathroom seat was not anchored in place and was broken. Resident 133 stated he felt scared while using the bathroom because the seat was moving around and he could fall. During a review of Resident 133 Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 133 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.

Based on observation, interview and record review, the facility failed to implement infection control practices designed to provide residents a safe, sanitary, and comfortable environment, by failing to follow the posted Novel (a newly identified respiratory pathogen that cause respiratory infections) Respiratory Precautions (NRP, a precaution to minimize spread of respiratory infection in caring for infected resident in a health care settings), indicating to wear a gown (a piece of protective clothing worn to prevent the spread of disease and contamination) on room entry, wear N-95 (a respiratory protective device designed to achieve a very close facial fit to form a seal around the nose and mouth to efficiently filter airborne particles)and face shield or goggles (protective covering for the eyes to reduce the spread of a transmissible disease) prior to entry of three COVID-19 [a highly contagious respiratory infection caused by a virus that can easily spread from person to person) isolation rooms, (Rooms A, B and C). This failure placed all the residents, staff, and the community…

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 follow its Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating which indicated injuries of unknown source would be reported to the State Licensing/Certification Agency within two hours for one of four sampled residents (Resident 1) when Resident 1 developed new, multiple skin discolorations and bruising (collection of blood underneath the skin that is caused by an injury)to the left cheek and chin. This failure delayed the investigation by the State Agency and placed Resident 1 at risk for continuous abuse. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), hepatic encephalopathy (brain dysfunction due to liver dysfunction that can cause issues with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate injuries of unknown source for one of four residents (Resident 1) when Resident 1 developed new, multiple skin discolorations and bruising (collection of blood underneath the skin that is caused by an injury) to the left cheek and chin. This failure had the potential to result in unidentified abuse and placed Resident 1 at risk for continuous abuse. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), hepatic encephalopathy (brain dysfunction due to liver dysfunction that can cause issues with thinking and mobility) and coagulation defect (a condition that affects the ability to control bleeding). During a record review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received treatment and care in accordance with the comprehensive person-centered care plan. This failure resulted in Resident 1 sustaining Moisture-Associated Skin Damage ([MASD] damage in the skin in response to prolonged skin exposure to moisture) to the sacrococcyx area and bilateral groin. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] with diagnoses including acute (sudden) respiratory failure (a serious condition that makes it difficult to breathe on your own) unspecified whether with hypoxia (inadequate supply of oxygen to the tissues) or hypercapnia (too much carbon dioxide [CO2] in the blood due to the lungs being unable to remove CO2 or when the body produces too much). During a review of Resident 1 ' s care plan titled The resident has total bladder incontinence, dated 1/25/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe administration of gastric tube feeding (the administration of milk/nutrition via gastric tube [a surgical opening in the abdomen into the stomach] to one of three residents (Resident 1), by failing to ensure: 1. The gastric tube feeding was paused (on hold), while the staff was lowering the head of bed (HOB) prior to performing nursing care. 2. Licensed personnel paused Resident 1's tube feeding pump. These failures had the potential to cause Resident 1 to aspirate (inhale a substance into the lungs) and placed Resident 1 at risk for complications such as pneumonia (lung infection) and hospitalization. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included acute (sudden) respiratory failure (a serious condition that makes it difficult to breathe on your own) unspecified whether with hypoxia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident had the right to be free from neglect for one of four sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall, sustain an acute (immediate) fracture (broken bone) through the fifth (C5) vertebral (neck bone), was admitted to a general acute care hospital (GACH), and had the potential to place other residents at risk for neglect. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally 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 observation, interview, and record review that facility staff failed to ensure one resident out of 3 sampled residents (Resident 1) was served the correct therapeutic diet, per doctors ' order. 1. The facility did not ensure Resident 1 received food that was prepared for a minced/moist diet (MM5, food that requires minimal chewing and food that is equal or less than 4 millimeters (mm) width and no longer than 15 mm in length). Resident 1 ' s food was not finely minced and a regular bread roll was served to resident. This deficient practice had the potential for Resident 1 to have problems chewing and swallowing. This deficient practice increased the risk for Resident 1 to choke while eating. Findings: During an observation on 8/20/2024 at 12:42 p.m., in the dining room, Resident 1 was eating lunch. Resident 1 ' s food tray contained slices of squash, full size spiral shaped pasta and a bread roll. During a review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain an informed consent (process of communication between resident/responsible party and health care provider that often leads to agreement or permission for care, treatment, or services) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior) for one out of one sampled resident (Residents 1). 1. The facility did not ensure an informed consent was obtained when lorazepam (medication that relieves symptoms of anxiety, causes paranoid or suicidal ideation and impairs memory, judgment, and coordination) medication dosage was increased from 0.5 milligrams (mg, unit of measurement) to 1 mg for Resident 1. This deficient practice violated Resident 1 ' s right to make an informed decision prior to the administration of lorazepam medication. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 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 During an interview and record review, the license nurses failed to review, update, and/or revise a care plan (written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) to reflect the physician current order for lorazepam (medication that relieves symptoms of anxiety [feeling of unease, excessive worry]) for one out of one sampled resident (Resident 1). This deficient practice had the potential to result in Resident 1 not receiving an accurate dose of lorazepam and had the potential to negatively affect Resident 1 ' s physical and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations) and depression (a common and serious…

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 answer call lights in a timely manner for three out of three sampled residents (Resident 1, 2, and 3). This deficient practice had the potential to cause a negative impact on Resident 1, 2, and 3's health and psychosocial well-being. Findings: 1. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of the pubis (bone that forms the lower and anterior part of each side of the hip bone) and fracture of the sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis [area of the body below the abdomen that contains the hip bones, bladder, and rectum]). A review of Resident 1's History and Physical (H&P) dated 2/14/2024, indicated Resident 1 had the capacity to understand make medical decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/21/2024, 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 observation, interview, and record review the facility failed to provide safe oxygen administration practices for one of three sampled residents (Resident 2) when the facility failed to: 1. Ensure Resident 2 received oxygen at 2 liters per minute (LMP) per the physician's order. 2. Label Resident 2's nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils). 3. Replace Resident 2's nasal cannula tubing after the nasal tubing prongs (portion of nasal tubing that goes into nostrils) touched the floor. These deficient practices had the potential to cause a negative respiratory outcome and increased the risk for Resident 2 to acquire a respiratory infection. Findings: During an observation on 7/10/2024 at 10:59 a.m., in Resident 2's room, Resident 2 was observed sitting up on the edge of the bed. Resident 2's nasal canula was observed on the floor. The oxygen was set at three liters ([unit of measurement]…

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 six sampled residents (Resident 5) received food according to his preference. This deficient practice had the potential to result in decreased meal intake, weight loss and malnutrition (when the body does not get enough nutrients). Findings: A review of Resident 5's admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including orthopedic (relating to the branch of medicine dealing with correction of deformities of bones or muscles) after care, diabetes (abnormal blood sugar) and hypertension (high blood pressure). A review of Resident 5's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/6/2023, indicated Resident 5 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 5 required supervision to substantial/maximal assistance (staff does more than half the effort) for Activities 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 The facility failed to support four out of five residents (Resident 1, 3, 25, and 28) in their choice of activities for by failing to ensure: 1. Resident 1 was assisted out of bed every day. 2. Resident 3 was assisted to group activities and special events. 3. Resident 25 participated in activities in a group setting and was allowed to go outside to get fresh air when the weather was good. 4. Resident 28 participated in activities in a group setting. These deficient practices had the potential to cause depression, anxiety, and other psychosocial harm to Resident 1, 3, 25, and 28 due to a lack of socialization, stimulation, and self-esteem. Findings: 1. During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed lying in bed, awake, and nonverbal. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/8/2018. Resident 1 ' s admitting diagnoses included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Serving Drinking Water, for six out of 14 sampled residents (Resident 1, 2, 3, 20, 25, 27), after the air conditioner stopped working by not: 1. Offering water and providing adequate fluids to Resident 1 and Resident 3, who were completely dependent on staff for activities for daily living. 2. Ensuring fresh water was available at the bedside for Residents 2, 3, 20, 25, and 27. These deficient practices had the potential for Resident 1, 2, 3, 20, 25, 27 to become dehydrated and/or suffer from heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). Findings: a. During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed awake in bed covered with a blanket, nonverbal and unable to understand or respond to words. Resident 1 had dry, cracked lips. Resident 1 had an undated pitcher of water that was room…

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 accurately document the activity attendance records for one out of three residents (Resident 1). This deficient practice had the potential to result in Resident 1 not receiving services needed such as getting out of bed to prevent a lack of mobility related injuries such as skin break down, and psychosocial injuries such as anxiety (excessive worry) and depression (lowering of a person ' s mood) related to isolation and a lack of stimulation. Findings: During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed lying in bed, awake, and nonverbal. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/8/2018. Resident 1 ' s admitting diagnosis included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dementia (an umbrella term for cognitive disorders of the brain with impaired ability to remember,…

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 remove medication labels that contain resident medical information from medication containers prior to disposing in the pharmaceutical (relating to medications, drugs) waste containers, in one of one inspected medication room. This deficient practice resulted in the privacy and confidentially of residents' medical records being jeopardized and not securely maintained. Findings: During an observation on 3/4/2024 at 2:16 PM, with Licensed Vocational Nurse (LVN) 5, in the medication room, there was a pharmaceutic white waste container with a blue lid that contained wasted medication tablets, capsules, medication measuring cups, 5 insulin (medication used to treat high blood sugar levels) pens (medication device), an inhaler (a medication used to help with breathing) and an orange colored medication pill bottle. 3 of the insulin pens and the orange-colored pill bottle had the pharmacy label (a label that includes the residents name, name of medication, dose of medication, instructions and use of medication) intact and attached…

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 care and services were provided to prevent pressure ulcer (injury to the skin and/or underlying tissue) and/or pressure injury development for five of five sampled residents (Resident 106, Resident 96, Resident 15, Resident 17, and Resident 50). The facility failed to: 1. Ensure nursing staff turned and repositioned, and monitored Resident 106's skin integrity for skin breakdown to prevent a sacral (sacrum, tail bone) Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer from reopening. 2. Ensure the nursing staff monitored the settings of Resident 96's low air loss mattress (mattress designed to prevent and treat pressure wounds by redistributing airflow and positioning) for functionality. 3. Ensure the nursing staff turned and repositioned Resident 15 and Resident 17 every hours or sooner as needed. 4. Ensure Resident 50's heels were offloaded from the mattress. These deficient practices…

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

Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for the 56 residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services. This deficient practice had the potential for 56 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move). Cross Referenece to F-tag F688. Findings: During a review of the Order Listing Report of RNA orders for 2/2024, the order list indicated 56 residents of the skilled nursing side of the facility had physician's orders for RNA to provide either assistance with sit-to-stand transfers, ROM exercises to arms and legs, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and / or increase range of motion), ambulation (walking), feeding, stair climbing, or exercises on the stationary bike (exercise machine with pedals that stays in one place).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Account for one dose of controlled substance (CS) for Resident 420 in one of three inspected medication carts (Medication Cart 3). 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug (also known as Controlled Medication or Controlled Substance [CM, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) accountability logs for 29 of 29 sampled records. As a result, the control and accountability of CS awaiting final disposition (process of returning and/or destroying unused medications) were not followed as indicated in the facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and increased the risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 25 total opportunities contributed to an overall medication error rate of 8% affecting one of four residents observed for medication administration (Resident 63). The medication errors were as follows: Resident 63 did not receive a form of aspirin (a medication used to prevent stroke [condition where there is blockage of blood supply to the brain]) and was not instructed to rinse mouth after the administration of mometasone (a corticosteroid [an anti-inflammatory medication also known as steroid] medication used for wheezing [difficulty in breathing]) as ordered by Resident 63's physician. This deficient practice had the potential to result in Resident 63 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 63's health and well-being to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Store one insulin (medication used to regulate blood sugar levels) Humulin N (intermediate acting insulin) kwikpen (type of insulin injection device) for Resident 4, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 3.) 2. Store one insulin Humulin R (short-acting insulin) vial for Resident 116 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 3.) 3. Provide a safe storage and label of medication for one of one sampled resident (Resident 51). These deficient practices increased the risk that Residents 4 and 116 could have received ineffective or toxic medications due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death, and had the potential to place Resident 51 at risk for medication errors. These deficient practices had the potential for…

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's dietary staff failed to ensure sanitary food preparation, food storage and food distribution practices, were followed by: 1. Failing to ensure the trash can lid opened correctly at the handwashing station. 2. The Dietary Supervisor (DS) touching the lid of the trash bin after performing hand hygiene. 3. Failing to properly package and label open food items in the dry storage area. 4. Failing to ensure poured milk and poured juices were labeled with the correct date in the refrigerator. 5. Failing to discard outdated poured milk and poured juices in the refrigerator. 6. Failing to ensure gloves were changed and hands were washed after touching face and mask during meal preparation. 7. Failing to ensure kitchen staff did not come in contact with the food and plates and cause food contamination during food preparation. 8. Failing to keep a thermometer inside the walk-in freezer. These deficient practices had the potential to cause cross contamination (transfer of harmful bacteria from one place to another) that could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control program, were maintained by failing to ensure: 1. Facility staff's personal and opened beverage containers were not stored on areas designated for clean resident clothing items; soiled linens and supplies were not stored in a handwashing sink in the laundry room and not placed on top of a storage cart containing personal protective equipment ([PPE] protective garments or equipment designed to protect the wearer's body from infection) in the laundry room. 2. Treatment Nurse (TN) 2 failed to follow facility policy and procedure for transmission-based precautions (TBP, precautions initiated when someone is at risk of spreading an infection to others) while providing care for Resident 15, who was on contact isolation precautions (intended to prevent the transmission of infectious agents from spreading from person to person). 3. Nursing staff stored Resident 274's nasal cannula (tube that provides oxygen…

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 walk-in freezer was maintained in good working condition. This deficient practice had the potential to cause foodborne illnesses and affect the quality of food for all 124 residents in the facility. Findings: During a concurrent observation and interview on 3/4/2024 at 9:15 a.m., with the Dietary Supervisor (DS), while in the kitchen, the walk-in freezer was observed. The walk-in freezer had large frozen clumps of ice that had accumulated on the floor as well as large clumps of ice surrounding the pipes inside the freezer. The walk-freezer also had drips came from the ceiling that were frozen. The DS stated that the clumps of ice located on the floor accumulated around the pipes were not normal. The DS stated that an outside company needed to be called to clean the freezer. During a concurrent observation and interview on 3/6/2024 at 1:20 p.m., with the Housekeeping Supervisor (HS), while in the kitchen, the HS observed the ice chunks accumulated on the floor and surrounding the pipes in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that call lights were within reach for two of 25 sampled residents (Resident 28 and Resident 14). These deficient practices had the potential to cause avoidable harm to Resident 28 and Resident 14 from an inability to call staff for assistance and the potential for falls and associated injuries. Cross Reference See F-tag F656 and F-tag F689. Findings: 1. During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted on [DATE]. Resident 21's admitting diagnoses included Parkinson's disease (a movement disorder characterized by involuntary movements, tremors, stiffness in the limbs or the trunk of the body, or impaired balance), difficulty walking, lack of coordination, reduced mobility, generalized muscle weakness, and abnormal gait and mobility. During a review of Resident 28's History and Physical (H&P), dated 1/22/2024, the H&P indicated Resident 28 could make his needs known, but could not make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs for one of six residents (Resident 29) by failing to: 1. Ensure Resident 29's call light was within reach at the bedside. 2. Ensure Resident 29's call for assistance was answered timely. These deficient practices had the potential to cause avoidable harm to Resident 29 from an inability to call staff for assistance and the potential for falls and associated injuries and skin breakdown. Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (muscle weakness) and hemiparesis (one-sided muscle weakness), diabetes ( high blood sugar), major depression ( loss of interest in activities), hypertension( high blood pressure), and heart failure ( a condition in which the heart doesn't pump enough blood to meet the body needs). 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 certified nursing assistants (CNA)failed to notify the licensed nurse, and the licensed nurse failed to notify the physician of loose bowel movements for one of one sampled resident (Resident 50). This deficient practice had the potential for Resident 50 to exhibit dehydration, the continued unnecessary use of a laxative medication, electrolyte imbalances (important minerals in the blood), and an undetected infection of Clostridium Difficile ([C. Diff]- a bacteria that causes life-threatening diarrhea). Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to cerebral infarction (an interruption of blood flow to the brain), hemiplegia (loss of strength on one side of the body) and hemiparesis (weakness to one side of the body) affecting the right dominant side. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions for six of 25 sampled residents (Residents 14, 28, 81, 15, 17, and 96) as indicated in the care plan when the following occurred: 1. Resident 28 and Resident 14 did not have theirs call lights in reach, as indicated in their fall risk care plans. 2. Resident 81 did not have a care plan in place for his tendency to wander into other facility residents' rooms. 3. Resident 15, Resident 17, and Resident 96 were not repositioned every two hours and/or provided with pressure relieving devices as indicated in their pressure ulcer (PU, injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) prevention care plan. These deficient practices had the potential for staff to be unaware of the interventions needed to prevent complications in the residents' health conditions and had potential to cause injuries related to accidents. Cross Reference F-tag F689 and F-tag F686. Findings: 1. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 35), who had difficulty with speech and spoke a language other than English, was provided a communication device in the language that the resident was able to understand. This deficient practice prevented Resident 35 from communicating with staff and had the potential to negatively affect Resident 35's physical, mental, and psychosocial needs and potentially causing missed or delayed care and/or treatments. Findings: During a review of Resident 35's admission Record, the admission record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (bleeding between the spaces in the brain), hemiplegia (paralysis [loss of muscle function] on one side of the body) on the right dominant side, hemiparesis (inability to move one side of the body) on the right dominant side, hypertension (high blood pressure), encephalopathy (any brain…

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 Restorative Nursing Aide (RNA) therapy orders were performed as ordered by the physician for four out of 10 sampled residents (Residents 83, 45, 82, and 79). This deficient practice had the potential to cause a decline in the mobility and range of motion for Residents 83, 45, 79, and 82. Cross reference to F-tag F725. Findings: a. During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiplegia (unable to move on one side of the body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (interruption of blood flow to the brain) affecting left non-dominant side and muscle weakness. During a review of Resident 83's Minimum Data Set (MDS- an assessment tool), dated 2/8/2024, the MDS indicated Resident 83's cognition (ability to think and reason) was intact. 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 interview and record review, the facility failed to ensure that a safe and hazard free environment was maintained for four of four sampled residents (Resident 28, Resident 14, Resident 81, and Resident 43) when the following occurred: 1. Resident 28 did not have his call light in reach. 2. Resident 14 did not have his call light in reach. 3. Resident 81 entered Resident 43's room unsupervised and without permission and Resident 81 did not have a care plan in place for his tendency to wander into other facility residents' rooms. This deficient practice had the potential to cause avoidable harm to Resident 28 and Resident 14 from an inability to call staff for assistance and the potential for falls and associated injuries. This deficient practice also had the potential to cause avoidable harm to Resident 43 related to Resident 81 accidentally interfering with or disrupting Resident 43's personal belongings and medical equipment, including Resident 43's mechanical ventilator (a machine that helps someone…

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 oxygen as ordered by the physician and ensure the resident's nasal cannula (small, flexible tube that contains two open prongs intended to sit inside the nostrils for oxygen administration) was not on the floor for two of six sampled residents (Resident 274 and 60). These deficient practices had the potential to cause Resident 274 and 60 avoidable harm and respiratory distress. Findings: a. During a review of Resident 274's admission Record, dated 3/6/2024, the admission record indicated Resident 274 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM 2 - condition that results in too much sugar circulating in the blood), hypertension (high blood pressure), atherosclerosis (blockage of blood supply to the heart muscle due to buildup of plaque in the arteries), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the policy and procedure titled, Certified Nurse Assistant (CNA) that indicated CNA will relay all pertinent information concerning a resident ' s condition to a charge nurse when required, was followed, when 1 of 3 sampled residents (Resident 1), had a fall. This failure resulted in a delayed body assessment to Resident 1. Findings: During a concurrent interview and record review on 1/26/2024 at 2:55 p.m., with the Assistant Director of Nursing (ADON), the ADON stated a Certified Nursing Assistant (CNA 1) put Resident 1 back in bed without informing the charge nurse that Resident 1 had a fall. The ADON stated CNA 1 should not have moved Resident 1, not until the charge nurse can do an assessment of his body and injuries. The ADON stated CNA 1 was suspended pending the facility ' s investigation. During a review of Resident 1 ' s admission record, dated 1/24/2024, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis 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 elevate head of bed at 30 to 45 degrees during tube feeding (nutrition administered via tube surgically inserted into the stomach) as indicated in the physician ' s order and care plan interventions for 1 of 3 sampled residents, Resident 2. This failure had the potential to result in aspiration (when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing and death. Findings: During a concurrent observation and interview on 1/24/2024 at 12 noon with Licensed Vocational Nurse (LVN 1), at Resident 2 ' s bedside, Resident 2 was observed lying in bed receiving the g-tube feeding infusing at a rate of 55 cc (cubic centimeter) an hour with the head of the bed elevated 10 degrees. LVN 1 stated the head of the bed is low and Resident 2 may aspirate (the drawing in of a foreign substance into the lungs). During a review of Resident 2 ' s admission record, dated 1/24/2024, the admission record…

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 infection control policy and procedures (P&P) by failing to: a. Ensure staff properly wore Personal Protective Equipment ([PPE] specialized clothing or equipment such as a gown, respirator, surgical mask and faceshield worn to minimize exposure to serious illness) while in the facility. b. Ensure staff performed hand hygiene after exiting one of one resident ' s room (Resident 4) who was on Enhanced Standard Precautions ([ESP] an infection control measure designed to reduce the spread of multidrug resistant organisms ([MDRO] bacteria that are resistant to certain antibiotics). These failures had the potential to spread the Coronavirus ([Covid 19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person) and infections to residents, staff, and the community. Findings: a.During a concurrent observation and interview on 1/8/2024 at 12:15 p.m. with Certified Nursing Assistant (CNA…

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 three sampled residents (Resident 2 and Resident 4) who had long rough edges toenails received foot care and treatment according to the facility's policy and procedure (P&P). This deficient practice placed Residents 2 and 4 at risk for infection of the toenails, pain and injury. Findings: a. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted on [DATE], and re-admitted on [DATE] with a diagnoses including respiratory failure with hypoxia (respiratory system cannot adequately provide oxygen to the body), diabetes ([DM] high blood sugar), and muscle weakness (lack of exercise, aging, muscle injury) During a review of Resident 2's Care Plan for ADL self-Care performance Deficit dated 7/31/2023, the Care Plan indicated Resident 2 Interventions indicated to check nail length and trim and clean on bath day as necessary. The Care Plan also indicated to report any…

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 4 sampled residents (Resident 2 and Resident 3) gastrostomy tube ([GT] tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was labeled with the date and time according to the facility ' s policy and procedure (P&P). This deficient practice had the potential to result in Residents 2 and 3 receiving enteral tube feeding formula over the expiration or maximum formula hang time (how long a tube feeding formula should hang safely prior to discarding or changing) and could adversely affect the resident ' s health and wellbeing. Findings: During a review of Resident 2 ' s admission record (Facesheet), the admission record indicated Resident 2 was admitted on [DATE], and re-admitted on [DATE] with diagnoses including Dependence on Respirator ([ventilator] a machine that helps a resident breathe or breathes for the resident), Amyotrophic Lateral Sclerosis…

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 expired gastrostomy tube ([GT] tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was discarded according to the facility policy and procedure (P&P) and not kept in the facility storage room. This deficient practice had the potential to result in the residents ingesting expired feeding formula which could lead to symptoms such as nausea, vomiting, stomach cramps, diarrhea, and hospitalization. Findings: During a concurrent observation and interview on [DATE] at 2:20 p.m., with Maintenance Supervisor (MS), MS stated, there were 4 bottles and one closed box with Jevity 1.2 Cal (high-protein, fiber-fortified formula that provided complete, balanced nutrition for long- or short-term tube feeding) GT feeding formula with expiration dates of [DATE]. MS stated, it was very dangerous to keep the expired feeding formula without an alert, because nurses could…

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