Holiday Manor Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship program (set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) by failing to conduct infection surveillance for a resident who was prescribed a long-term (being prescribed for more than seven to ten days) antibiotic for one (Residents 4) of three residents sampled for antibiotic usage. This deficient practice had the potential for Resident 4 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a review of Resident 4's admission Record (face sheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 1/29/2021and re-admitted on [DATE] with diagnoses that included liver cirrhosis (condition where healthy liver tissue is permanently replaced by scar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a physician for one of three sampled residents (Resident 1) regarding the following:1. Resident 1's elevated blood sugar (BS) levels greater than 200 milligrams per deciliter (mg/dl - unit of measurement) per the physician orders.2. Resident 1's refusal to undergo a complete blood count (CBC - an essential blood test that measures the cells circulating in the blood, including the red blood cells [oxygen transport], white blood cells [infection fighting], and platelets [clotting], used to evaluate overall health and diagnose medical conditions) for anemia (a condition in which the body lacks sufficient healthy red blood cells) on 4/6/2026.These deficient practices may result in worsening symptoms, increased risk of hospitalization or complications and a decline in the resident's overall health status. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 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 licensed nurses failed to accurately assess and complete fall risk evaluations for two of three sampled residents (Resident 1 and Resident 2).These deficient practices had the potential to place the residents at increased risk for injury related to falls.a. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged 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's licensed nurses failed to follow physician orders for one of three sampled residents (Resident 1) to check blood sugar (BS) two times a day for diabetes mellitus (DM - a disorder characterized by difficulty in BS control and poor wound healing) before breakfast and before dinner, and to notify the physician when BS levels exceed 200 milligrams per deciliter (mg/dl - unit of measurement). These deficient practices had the potential to result in medication errors and negatively affect the delivery of care and services to Resident 1.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of 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 a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of three sampled residents (Resident 1).This deficient practice had the potential to delay staff response and result in unmet resident needs. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the Physician Progress Notes (records documenting the physician's assessment, evaluation, and management of resident care) were maintained as required for one of three sampled residents (Resident 1).This deficient practice had the potential to result in inconsistent care coordination due to incomplete documentation and placed Resident 1 at risk for poor continuity of care and unmet care needs.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke,…

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. Ensure a copy of the resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was readily available in the resident's medical record for one (Resident 49) out of six sampled residents investigated for Advance Directives. 2. Ensure two of six sampled residents (Resident 20 and Resident 291) were provided written information concerning the right to refuse or accept medical or surgical treatments and formulate an Advanced Directive upon admission. These deficient practices had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care. Findings: 1. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction resulting from a chemical imbalance in the blood, often caused by underlying systemic…

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 person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) by failing to: 1. Develop a care plan addressing a resident's diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) for one of one sampled resident (Resident 49) investigated for trauma-informed care. 2. Develop a care plan addressing a resident's restorative nursing assistant (RNA - an ongoing program that focuses on helping individuals, especially those in long-term care, maintain and improve their functional abilities and independence, often following rehabilitation) therapy for one of two sampled residents (Resident 47) investigated under the care area of position and mobility. 3. Resident 85's refusal of vaccination for Covid-19 (disease cause by the SARS-CoV-2 virus, that spreads throiugh respiratory droplets. Most…

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 licensed nurses attempted nonpharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (PRN) morphine sulfate (a drug used to treat moderate to severe pain) to one of one sampled resident (Resident 17) investigated under the care area of pain management. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 10/20/2021 and readmitted the resident on 5/1/2024 for diagnoses including polyneuropathy (a condition that affects multiple peripheral nerves, which are the nerves outside the brain and spinal cord) and spinal enthesopathy in the lumbar region (a condition where the entheses [the points where tendons and ligaments attach to bone] in the lower back are affected,…

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. Ensure licensed nurses attempted nonpharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (PRN) lorazepam (used to treat anxiety disorder [a mental health condition characterized by persistent and excessive worry or fear that interferes with daily life]) for one of two sampled residents (Resident 29). 2 Ensure the physician's order for a resident's PRN lorazepam had a stop date (the date on which a specific medication or treatment order, as written by a physician, is scheduled to be discontinued unless the physician extends or modifies the order) for one of five sampled residents (Resident 17). These deficient practices had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: 1. During a review of Resident 29'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 2. During a review of Resident 61's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 5/13/2022, and readmitted on [DATE], with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 1/31/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 61 required staff partial/moderate assistance (helper does less than half…

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 complete and accurate baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) within 48 hours of a resident's admission to the facility for one of two sampled residents (Resident 21) by failing to complete oxygen use, pain, safety risks, and skin risk sections in the resident's baseline care plan. This deficient practice had the potential of Resident 21 to not receive appropriate care and treatments. Findings: During a review of Resident 21's admission Record, the admission Record indicated that the facility admitted the resident on 1/7/2025 with diagnoses including acute (rapid onset and relatively short duration) respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), difficulty in walking, dementia (a progressive state of decline in mental abilities), and history of falling.…

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

Based on interview, and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's change of condition (a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) on 2/17/2025, for one of two sampled residents (Resident 18). This deficient practice had the potential to result in Resident 18 receiving inadequate care and supervision at the facility. Findings: During a review of Resident 18's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), paranoid schizophrenia (type of schizophrenia [a mental illness that is characterized by disturbances in thought] accompanied by paranoia [way of thinking that involves feelings of distrust and suspicion about others without a good reason]), and encephalopathy (a general…

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 low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was set correctly for one of one sampled resident (Resident 291). This deficient practice had the potential to place Resident 291 at risk for discomfort and development of pressure ulcers/injuries. Findings: During a review of Resident 291's admission Record, the admission Record indicated the facility admitted the resident on 2/19/2025 with diagnoses of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). During a review of Resident 291's History and Physical (H&P- a formal assessment by a healthcare…

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

Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 13) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to follow Resident 13`s physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) exercise program. This deficient practice had the potential to place the resident at risk for further decline in range of motion (ROM- full movement potential of a joint) decline. Findings: During a review of Resident 13's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 9/19/2023 and readmitted the resident on 2/10/2025, with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and difficulty in walking. During…

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

Based on interview and record review, the facility failed to ensure Fall Risk Evaluations were completed accurately for one of three sampled residents (Resident 16). This deficient practice placed the resident at risk of not receiving appropriate care and services after a fall incident and had the potential to place the resident at an increased risk for falls. Findings: During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 9/3/2021 and readmitted the resident on 2/1/2025 with diagnoses including metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and generalized muscle weakness. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool) dated 2/5/2025, the MDS indicated the resident was able to make herself understood and usually understands others. The MDS further indicated Resident 16 is dependent on staff to complete most activities of daily…

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 trauma-informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) to a resident with a diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) by failing to complete a timely trauma-informed care assessment and conduct an interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) meeting to address the resident's specific needs for one of one sampled resident (Resident 49) investigated under the care area of trauma-informed care. This deficient practice had the potential to place the resident at increased risk of being triggered by and experiencing symptoms of their PTSD. Findings: During a review of Resident 49's admission Record, the admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure titled, Social Assessment, for one of two sampled residents (Resident 18) by failing to conduct a social service assessment within 14 days of the resident's admission to the facility. This deficient practice had the potential for the resident not to attain the highest practicable physical, mental, and psychosocial well-being and delay in the delivery of care and services. Findings: During a review of Resident 18's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), paranoid schizophrenia (type of schizophrenia [a mental illness that is characterized by disturbances in thought] accompanied by paranoia [way of thinking that involves feelings of distrust and suspicion about others without a good reason]), and encephalopathy (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: 1. Ensure licensed nurses documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering as needed (PRN) tramadol (medication used for moderate to severe pain) for one of two sampled residents (Resident 29). 2. Ensure licensed nurses documented on the MAR after administering PRN oxycodone (medication used to treat moderate to severe pain) for one of two sampled residents (Resident 8). This deficient practice had the potential to place the residents at increased risk of being given extra doses of a narcotic medication (medications used to treat moderate to severe pain) leading to an increased risk of the residents experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: 1. During a review of Resident 29's admission Record, the admission Record indicated the…

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

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Resident 34) by failing to administer clozapine (medication used to treat schizophrenia [mental disorder in which people interpret reality abnormally]) as ordered. This deficient practice had the potential for the medication to not be effective or cause adverse reaction (undesired harmful effect resulting from a medication or other intervention) to Resident 34. Findings: During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on 12/18/2019 and readmitted the resident on 5/9/2024 with diagnoses that included encephalopathy (brain disease, damage, or malfunction of brain), paranoid schizophrenia (type of schizophrenia accompanied by paranoia [way of thinking that involves feelings of distrust and suspicion about others without a good reason]), and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can…

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 store unopened insulin (hormone that lowers the level of glucose [sugar] in the blood) pens (a medical device used to inject insulin subcutaneously [SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle]) inside the refrigerator for two of two sampled residents (Resident 80 and 391). This deficient practice had the potential for the insulin to lose efficacy and can result in uncontrolled blood glucose. Findings: 1. During a review of Resident 80's admission Record, the admission Record indicated the facility originally admitted the resident on 1/21/2024 and readmitted the resident on 12/16/2024 with diagnoses including type two (2) diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]) with ketoacidosis (a complication of diabetes in which acids build up in the blood to levels that can be life-threatening).…

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

Based on observation, interview, and record review, the facility failed to follow safe food handling practices when Dietary Aide 1 (DA 1) was wearing an uncovered, dangling bracelet in the kitchen. This deficient practice had the potential to place 89 out of 90 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 3/12/2025 at 12:08 p.m., in the facility's kitchen with the Dietary Supervisor (DS), observed DA 1 wearing a bracelet while taking plates from the steam table and putting them into a delivery cart. Observed DA 1's bracelet not covered by the gloves DA 1 was wearing. The DS stated they do not usually wear bracelets in the kitchen. During a concurrent interview and record review on 3/13/20254 at 9:35 a.m., with the DS, reviewed the facility's policy and procedure (P&P) titled, Dress Code for Women and Men, dated 2018. The policy indicated no excessive jewelry should be worn. The policy further 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.

Based on observation, interview, and record review, the facility failed to: 1. Implement its policy titled, Enhanced Barrier Precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) by failing to ensure one of one sampled resident (Resident 57) who had a colostomy bag (a medical device that collects stool from a surgical opening in the abdomen) was placed on EBP. This deficient practice had the potential to transmit infectious microorganisms to staff and other residents in the facility. 2. Ensure a resident's urinal (a bottle for collecting urine) was labeled with a resident identifier for one of five sampled residents (Resident 52) investigated for infection control. This deficient practice had the potential to place the resident at increased risk of contracting an infection. Findings: 1. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free of unnecessary psychotropic drugs (medications capable of affecting the mind, emotions, and behavior) for one of three sampled residents (Resident 1) by failing to summarize a resident's monthly behavior and side effects summary. This deficient practice had the potential to result in the resident receiving unnecessary psychotropic drugs potentially increasing Resident 1's risk of adverse reactions (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that affects how a person thinks,…

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 maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1), by failing to document on a resident's Activities of Daily Living (ADL - activities related to personal care) Flow Sheet. This deficient practice resulted in incomplete resident medical care information for Resident 1 and had the potential to result in confusion with the care and services for Resident 1 which could place the resident at risk for not receiving appropriate care. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]). During a review of…

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

Based on interview and record review, the facility failed to notify the physician and the resident's family regarding a skin discoloration on a resident's coccyx (tailbone) for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily…

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 a neurological assessment (evaluation of a person's nervous system [includes the brain, spinal cord, and a complex network of nerves]) was completed after an unwitnessed fall for one of three sampled residents (Resident 4). This deficient practice had the potential to result in confusion in the care and services for Resident 4, which could place the resident at risk of not receiving appropriate care due to incomplete resident medical care information. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 12/23/2023 and readmitted the resident on 3/11/2024 with diagnoses that included encephalopathy (any brain disease that alters brain function or structure), other lack of coordination, and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 9/11/2024, the MDS indicated Resident 4's cognitive skills (thought processes) 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: 1. Ensure no more than two layers of linen were used with the use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) for two of three sampled residents (Resident 2 and Resident 3). 2. Ensure the LALM was set to the correct setting as ordered for two of three sampled residents (Resident 2 and Resident 3). These deficient practices had the potential to increase the residents' risk of skin breakdown. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted the resident on 10/25/2023 with diagnoses that included gangrene (a serious medical condition where tissue dies due to a lack of blood supply) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data…

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 staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily for two of two days on 12/17/2024 and on 12/18/2024. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility. Findings: During an observation on 12/17/2024 at 3:00 p.m., observed in the facility's lobby, a facility document titled, Posted Nursing Hours for Direct Care Staff, dated 12/17/2024. During an interview on 12/17/2024 at 4:28 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that nursing hours posted in the lobby are projected (expected) hours. During a concurrent observation, interview, and record review on 12/17/2024 at 5:06 p.m., with the Director of Nursing (DON), observed the facility's document titled, Posted Nursing Hours for Direct Care Staff, dated 12/17/2024, posted in the facility's lobby. The DON stated that the…

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

Based on interview and record review, the facility failed to obtain a physician's order prior to applying zinc oxide (treats or prevents skin irritation like cuts, burns, or incontinent [loss of bowel or bladder control] brief rash) cream for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through…

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 promptly notify the physician of the results of a Stat (without delay, immediately) X-ray (a type of medical imaging that uses radiation to take pictures of the inside of your body) for one of three sampled residents (Resident 1). This deficient practice resulted in the delay of necessary care and services for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/28/2022 and readmitted the resident on 10/6/2022 with diagnoses that included left hip fracture (broken bone) and presence of left artificial hip joint, osteoporosis (condition in which bones become weak and brittle), and diabetes mellitus (DM, a chronic [long-term] condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2022, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through…

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 its policy and procedure for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of sexual abuse (any sexual activity that occurs without consent [permission]) within two (2) hours of the incident for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 9/19/2022 and readmitted Resident 1 on 12/2/2023 with diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical…

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 infection control practices by: 1. Failing to store a mouthpiece (used to inhale a mist of liquid medicine that is created by a handheld nebulizer [HHN - a small, portable device that turns liquid medication into a mist that can be inhaled into the lungs]) and tubing of HHN in a bag when not used for one of five sampled residents (Resident 5). 2. Failing to report more than two suspected cases of scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching) for two of five sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in the spread of cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) and scabies among staff and other residents. Findings 1. During a review of Resident 5's 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 notify two of five sampled residents (Resident 2 and Resident 3) physician, when on 9/24/2024, Resident 2 and Resident 3 had changes in their skin condition. Resident 2 had dry flaky skin on both hands, itchiness, crust on both palms and Resident 3 had dry flaky skin on the right palm and itchiness. This deficient practice resulted in a delay of medical care and treatment which could have resulted in a negative impact to Resident 2 ' s and Resident 3 ' s well-being. Findings: a. During a review of Resident 2 ' s admission Record indicated the facility originally admitted Resident 2 on 6/8/2022 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems) and pruritis (medical term for itching, or the feeling on the skin that makes you want to scratch). During a review of Resident 2 ' s Minimum Data Set (MDS – a federally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the needed care and services that were resident centered for one of three sampled residents (Resident 1) when on 6/15/2024, Licensed Vocational Nurse 2 (LVN 2) did not endorse (to inform) to Licensed Vocational Nurse 1 (LVN 1) or Registered Nurse Supervisor 1 (RNS 1) that Resident 1 had sustained a fall. This deficient practice placed Resident 1 at risk for a delay in needed care and services. Findings: A review of Resident 1 ' s admission record dated 5/28/2024, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease (when kidneys are damaged and can't filter blood the way they should), anxiety disorder (characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), lack of coordination (loss of muscle control 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.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was provided with activities of daily living (ADL). This deficient practice resulted in a delay in delivering the necessary care and services to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 1/18/2024 with diagnoses that included atrial fibrillation (irregular and often very rapid heart rhythm) and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 1 ' s History and Physical Exam, dated 1/18/2024, indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/19/2024 indicated that Resident 1 had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 1 required setup or clean-up assistance for eating, oral hygiene, toileting hygiene, shower or bathing self,…

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

Based on interview and record review, the facility failed to ensure the physician was notified of medication refusals for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to result in the adverse effects (undesired harmful effect resulting from a medication or other intervention) of hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), have increased depression (feelings of sadness), and to have increased cholesterol (a waxy, fat-like substance that in high amounts in the body can cause heart disease) levels in the body. Findings: A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided a comfortable and homelike environment for seven of 17 sampled residents (Resident 194, 3, 10, 47, 52, 62, and 79) by failing to provide communal dining. This deficient practice had the potential to result in decreased social interactions, decreased psychosocial wellbeing, and weight loss in residents. Findings: a.1 A review of Resident 3's Face Sheet (admission record) indicated the facility admitted the resident on 9/29/2023 and readmitted the resident on 11/20/2023, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 3's History and Physical (H&P - a formal assessment of a patient and their problem) dated 11/20/2023, indicated Resident 3 had capacity to understand and make decisions. A review of Resident 3's Minimum…

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

Based on observation, interview and record review, the facility failed to ensure a resident's orthostatic blood pressure (taking a blood pressure [BP- the pressure of circulating blood against the walls of blood vessels] lying down, sitting up, and standing up) was taken correctly for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to place Resident 87 at risk for developing symptoms of orthostatic hypotension (a form of low blood pressure [the force of the blood pushing on the blood vessel walls is too low] that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting). Findings: A review of Resident 87's Face Sheet (admission record) indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening 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.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one of two sampled residents (Resident 17) investigated during the Medication Storage and Labeling task by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered Resident 17's Ambien (medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) per the physician's orders on 3/14/2024. 2. Ensure the Record of Controlled Substances form (a form completed to document removal of a controlled substance [substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological (related to the mental and emotional state of a person) dependence]) from a bubble pack [packaging in which…

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 Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) was acted upon for four of five sampled residents (Resident 19, 87, 57, and 7) investigated for unnecessary medications by: 1. Failing to conduct an MRR for Resident 19 and 87. 2. Ensure the physician's response to the pharmacy recommendations were carried out for a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose) of mirtazapine for resident 57. 3. Ensure the physician's response to the pharmacy recommendations were clarified and carried out regarding orders for antidepressants (medication used for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere 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.

Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity by failing to ensure the certified nursing assistant sat at eye level while providing feeding assistance for one of four sampled residents (Resident 59) investigated under the Dining Observation Task. This deficient practice had the potential to affect a resident's self-worth and self- esteem. Findings: A review of Resident 59's Face Sheet (admission record) indicated the facility admitted the resident on 12/30/2020 and readmitted the resident on 7/5/2021 with diagnoses that included chronic obstructive pulmonary disease (COPD, progressive lung disease), unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 59's Minimum Data Set (MDS - an assessment and screening too) dated 1/1/2024, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's call light device (device used by residents that when pressed informs facility staff that assistance is being requested) was within reach for two of two sampled residents (Resident 13 and Resident 44). This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: a. A review of Resident 13's Face Sheet (admission record) indicated the facility admitted the resident on 12/28/2023, with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with dyskinesia (uncontrolled, involuntary muscle movement), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 13's Minimum Data Set (MDS- a…

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

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments) for medication refusal for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 87. Findings: A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the resident was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of two medication carts (Medication Cart 1) investigated during the Medication Storage and Labeling task by failing to: 1. Ensure two opened bottles of glucometer (medical device for determining the approximate concentration of glucose [sugar] in the blood) control solution (solutions used to test the glucometer for proper function) were labeled with the open date. 2. Ensure Medication Cart 1 refrigerated emergency medication kit (e-kit- basic emergency medical kit that includes common emergency drugs) was secured after opening and there was documentation indicating what was removed. These deficient practices had the potential to result in inaccurate blood sugar readings, mismanagement of diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]) in residents, and delay in care and services. Findings:…

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

Based on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not willfully falsify entries in Resident 17's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) for one of two sampled residents (Resident 17) investigated for medication storage and labeling by documenting the administration of Ambien (a medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) on 3/14/2024. This resulted in inaccurate documentation in Resident 17's medical chart indicating the resident received Ambien, gabapentin, and simvastatin. 2. Ensure LVN 1 did not willfully falsify entries in the MAR for one of four sampled residents (Resident 18) investigated for medication…

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

Based on observation, interview, and record review, the facility failed to ensure that both the top and bottom small dryers (Dryer Unit 2) inside the laundry room were maintained in good working condition when the thermometer (tool that measures temperature) for each dryer was observed not working on 3/22/2024. This deficient practice had the potential to lead to contamination of resident clothes and may cause a spread of infection. Findings: During a concurrent observation and interview on 3/22/2024 at 8:30 a.m., with the Housekeeping Supervisor (HKS) inside the laundry room, observed the thermometer for both the top and bottom dryer units of Dryer Unit 2 with a temperature reading of 120 degrees Fahrenheit (F-unit of measure). The HKS stated that each dryer should maintain a temperature of 180 degrees F. During a concurrent interview and record review on 3/22/2024 at 8:50 a.m., with the HKS, reviewed the facility's water and dryer temperature log for 3/22/2024. The HKS stated the temperature for both the top and bottom dryer units of Dryer Unit 2 was noted to be 180 degrees F at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act by failing to report an allegation of abuse that occurred on 2/27/2024 for two of two sampled residents (Resident 1 and Resident 2) within two hours of being made aware of the allegation to the State Survey Agency (SSA). This deficient practice had the potential to result in unidentified abuse in the facility and placed residents at risk from further abuse. Findings: A review of Resident 1's admission Record dated 1/26/2024, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included, metabolic encephalopathy (brain dysfunctions due to problems with your metabolism), type 2 diabetes (a disease that occurs when your blood glucose [blood sugar] is too high), chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems),…

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.