Eskaton Village Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the nutritive values of food were conserved during preparation for a census of 33 residents, when [NAME] 1 prepared quiche (an entrée for lunch) without measuring the ingredients and following the recipe. This failure decreased the facility's potential to meet the residents' nutritional needs. Findings: During a concurrent observation and interview on 1/8/25 at 9:45 a.m. with [NAME] 1 in the main kitchen, [NAME] 1 was observed mixing the ingredients when cooking quiche. [NAME] 1 did not follow the recipe and poured unmeasured amounts of liquid eggs and heavy cream in a pot. [NAME] 1 confirmed she did not follow the recipe to cook quiche and stated she did not need to measure the amounts of liquid eggs and heavy cream. [NAME] 1 also stated she was unable to tell the exact numbers of servings to be prepared. A review of the facility's recipe titled, Quiche [NAME] Jour, dated 2024, indicated, one gallon (a unit of measure) plus three…

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 food was stored and prepared in accordance with professional standards for a census of 33 residents, when; 1. Unlabeled, expired, incorrectly dated, and soiled food items were found stored in the ready-to-cook area in the main kitchen; 2. Wet, dirty, and damaged cooking pans were found stored on the ready-to-use rack next to cooking area in the main kitchen; 3. A can-opener was found dirty, ready-to-use, and attached to the kitchen counter in the main kitchen; 4. The interior dispenser of ice machine had black, brown, and white substances on its surfaces in Skilled Nursing Facility (SNF) kitchen; 5. One kitchen staff touched the clean cutting board and knife with soiled gloved hands after touching multiple surfaces in the main kitchen; and 6. Ice buildup was found on the edges and frames of entry doors and on food boxes inside the walk-in freezers in the SNF and main kitchens. These failures decreased the facility's potential to provide sanitary conditions to store and prepare food for its residents.…

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 safely operate the dryer for a census of 33 residents, when the dryer's lint compartment was not cleaned accordingly. This failure decreased the facility's potential to prevent a fire hazard. Findings: During a concurrent observation and interview on 1/8/25 at 11:04 a.m. with Laundry Staff (LS) in the laundry room, the three lint compartments of the dryers were inspected. LS opened the lint compartment, rolled up two thick layers of lint, and discarded it. LS confirmed she did not clean the lint compartment at the beginning of her shift. During a concurrent interview and record review on 1/9/25 at 8:41 a.m. with the Housekeeping Supervisor (HS), the lint compartment log was reviewed. HS expected staff to clean the lint compartment every two hours and stated it would have been a fire hazard if staff did not clean the lint compartment frequently. A review of the facility's Cleaning the Lint Compartments Log for January 2025, indicated morning and evening laundry staff should have cleaned the lint trap every two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of 22 sampled residents (Resident 248), when the light switch behind Resident 248's bed was broken and kept in a non-operational drawer. This failure had the potential to negatively impact Resident 248's psychosocial well-being, ability to read, and access to personal belongings. Findings: A review of Resident 248's Resident Face Sheet indicated she was admitted to the facility on [DATE] with a diagnosis of right femur (the large bone in the upper part of your leg) fracture. A review of Resident 248's Physician Order Report, dated 12/1/24-12/31/24, indicated she had the capacity to understand choices and make health care decisions. During a concurrent observation and interview on 1/6/25 at 10:57 a.m. with Resident 248 in her room, Resident 248's wall light behind her bed was broken and the light's switch was kept in the nightstand's top drawer. Resident 248 stated the nightstand's top drawer was…

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

Based on observation, interview, and record review, the facility failed to develop a person-centered care plan for one of 22 sampled residents (Resident 148), when Resident 148's care plan did not indicate he was receiving oxygen therapy. This failure decreased the facility's potential to meet Resident 148's care needs. Findings: A review of Resident 148's Resident Face Sheet indicated he was admitted to the facility in December 2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dependence on supplemental oxygen. During an observation on 1/6/25 at 2:35 p.m. in Resident 148's room, Resident 148 was observed receiving oxygen at two liters per minute via nasal cannula (a device that gives you additional oxygen through your nose). A review of Resident 148's General Order, dated 1/3/25, indicated Resident 148 was on oxygen at two liters per minute every shift. During concurrent interview and record review on 1/8/25 at 12:16 p.m. with Licensed Nurse 4 (LN 4), Resident 148's care plan was reviewed. LN 4…

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 services according to professional standards of quality for one of 22 sampled residents (Resident 198), when Licensed Nurse 1 (LN 1) prepared a medication for Resident 198 taken from another resident's medication supply. This failure decreased the facility's potential to safely administer medications to residents. Findings: A review of Resident 198's Resident Face Sheet indicated Resident 198 was admitted to the facility in December 2024 with diagnoses including right hip fracture and chronic constipation. A review of Resident 198's Prescription Order, dated 12/22/2024, indicated an order for polyethylene glycol (medication used to treat constipation) once a day. During a concurrent observation and interview on 1/6/25 at 9:17 a.m. with LN 1, LN 1 was observed preparing polyethylene glycol for Resident 198. LN 1 removed the medication from a plastic bag and the bag's label indicated a different resident's name. LN 1 confirmed she prepared Resident 198's medication after taking it from another…

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 adequate assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) for one of 22 sampled residents (Resident 248), when Resident 248 was not offered or given showers as scheduled. This failure had the potential to negatively impact Resident 248's cleanliness, discomfort, and psychosocial well-being. Findings: A review of Resident 248's Resident Face Sheet indicated she was admitted to the facility on [DATE] with a diagnosis of right femur (the large bone in the upper part of your leg) fracture. A review of Resident 248's Physician Order Report, dated 12/1/24-12/31/24, indicated she had the capacity to understand choices and make health care decisions. The report further indicated Resident 248 should have showered twice a week on Monday and Friday. During a concurrent observation and interview on 1/6/25 at 10:57 a.m. with Resident 248 in her room, Resident 248 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safety measures were in place for one of 22 sampled residents (Resident 15), when Resident 15 fell to the floor during transfer and sustained a blunt head injury (when the head hit a hard object or surface without breaking the skull) and a scalp abrasion (cut of the scalp). This failure decreased the facility's potential to prevent Resident 15's fall and injury. Findings: A review of Resident 15's Resident Face Sheet indicated Resident 15 was admitted to the facility in 2019 with a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 15's Physician Order Report, dated [DATE] to [DATE], indicated Resident 15 had no capacity to understand choices and make health care decisions due to dementia (a progressive state of decline in mental abilities). Resident 15 had an order to be up in chair daily as tolerated. A review of Resident 15's John Hopkins Fall Risk Assessment Tool,…

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 food preferences were accommodated to one of 22 sampled residents (Resident 15), when Resident 15's meal ticket did not match with lunch's meal tray. This failure had the potential to negatively impact the resident's nutritional status. Findings: A review of Resident 15's Resident Face Sheet indicated Resident 15 was admitted to the facility in 2019 with a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 15's Physician Order Report, dated 1/1/25 to 1/31/25, indicated Resident 15 had no capacity to understand choices and make health care decisions due to dementia (a progressive state of decline in mental abilities). The report further indicated Resident 15 had fortified diet (food that have nutrients added to them), mechanical soft (food that is easy to eat and does require lots of chewing) chopped, and bit size texture. During a concurrent observation and interview on 1/6/25 at 12:38 p.m. with Certified Nursing Assistant 2 (CNA 2) 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.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for a census of 33 residents, when Certified Nursing Assistant 3 (CNA 3) did not use gown and gloves in an isolation (separation of residents with an infection from residents without an infection) room. This failure had the potential to increase the spread of infection among residents. Findings: A review of Resident 31's Resident Face Sheet, indicated Resident 31 was admitted to the facility in 2023 with a diagnosis of pneumonia (an infection/inflammation in the lungs). During a concurrent observation and interview on 1/6/25 at 9:30 a.m. with CNA 3, Resident 31's room had a contact isolation sign on the door. The sign indicated staff to use gown and gloves when entering the room. CNA 3 went inside Resident 31's room and collected the meal tray from the bedside without using gown and gloves. CNA 3 confirmed she should have used gown and gloves while providing care in an isolation room. During an interview on 1/8/25 at 10:46 a.m. with the Infection Preventionist (IP), IP…

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 rights of one of three sampled residents (Resident 1) when a medication was discontinued without informing the resident. This failure resulted in Resident 1 not being able to have input into decisions regarding her plan of care. Findings: According to Resident 1's admission record, she was admitted in 4/24 with diagnoses including aftercare following joint replacement surgery and Stage 3 chronic kidney disease (mild to moderate loss of kidney function). It also indicated Resident 1 was her own responsible party (RP, medical decision maker). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had no memory impairment. A review of Resident 1's clinical record included the following documents: A General Acute Care Hospital (GACH) Physician's (MD) Order for Admission, dated 4/16/24, indicated the following orders: 1. Hydrochlorothiazide-spironolactone (medication used to treat high blood pressure and fluid retention), 25mg.-25mg. (milligrams, a unit of measurement), 2 tablets,…

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 manage one of three sampled residents (Resident 1's) pain timely when Licensed Nurse (LN) delayed administration of the breakthrough pain medication for the resident. This failure resulted in Resident 1 being in pain, feeling ignored and mistreated. Findings: Review of Resident 1's clinical record, Resident Face Sheet, indicated the resident was admitted to the facility with diagnoses that included chronic pain syndrome, chronic pancreatitis (inflammation of the pancreas) and low blood oxygen. In an interview on 4/30/24 at 12:25 p.m., the Interim Director of Nursing (IDON) at the IDON's office, the IDON stated on 4/22/24 Resident 1 was upset and complained that LN 1, who worked at night shift, did not give her pain medication on time and made excuses that she was busy or that Resident 1 was not her only resident, justifying the delayed pain medication administration. The IDON stated Resident 1 expressed she felt miserable and being mistreated by LN 1 not getting pain medications when she needed. In an interview on 4/30/24…

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 a complete record of controlled drugs' receipt and disposition for a census of 21, when the Director of Nursing (DON) did not sign the facility's Discontinued Narcotic Drug and Disposition Log upon receiving controlled drugs. This failure decreased the facility's potential to safely destroy the residents'-controlled drugs. Findings: During an interview on 2/27/24 at 3:55 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated she's used to verbally counting the controlled drugs with the DON when delivering it for destruction without dating and signing any log. During a concurrent interview and record review on 2/27/24 at 3:45 p.m. with Interim DON (IDON), the facility's Discontinued Narcotic Drug and Disposition Log and untitled logs were reviewed. The untitled logs indicated the destruction dates for controlled substances with pharmacist and DON signatures. The Discontinued Narcotic Drug and Disposition Log indicated no documentation. IDON stated none of the logs indicated the DON's signature and the date she received 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 The facility failed to ensure that recipes were used and followed during meal preparation. This failure had the potential to alter the nutrient content of the meals and to affect the health status of the 3 residents (Resident 13, 14 and 185) out of 21 receiving the Consistent Carbohydrate diet to control blood sugar. Findings: During a return visit to the main kitchen on 2/27/24 at 8:48 a.m., the lunch meal was being prepared. The lunch meal was to include the following options: Chicken Tortilla Soup, Roasted Corn and Vegetable Succotash, Grilled Huli Huli Chicken, Cioppino with Garlic Toast, Quinoa [NAME], Citrus Basil Roast Veggie, Roasted Cauliflower, and Garlic Mashed Potatoes. During a walk through the food production area, no recipes were seen at the various workstations. Chef 1 (C1), who had worked for the facility for approximately 3 weeks, was making Cioppino (fish stew). He added onions, garlic, fennel, oil, and white wine to the tilt skillet to heat. After it boiled, he added tomato sauce and water.…

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 serve food at a safe and appetizing temperature for five out of 21 residents (Residents 8, 9, 84, 186, and 236). This failure had the potential of leading to poor food intake, nutrient deficits, and undesirable weight loss for residents eating facility prepared meals. Findings: During an interview on 2/27/24 at 8:37 a.m., in Resident 9's room, his wife stated that the food was served cold at times. She went on to state that this was particularly problematic when in the previous room that received food from the last meal cart. During an interview on 2/26/24 at 9:24 a.m., Resident 8 stated that the food is a little cold, not very warm. I like warm food to be warm. During an interview on 2/26/24 at 10:17 a.m., Resident 84 stated that sometimes the soup and hot cereal are not hot. During an interview on 2/26/24 at 12:26 p.m., Resident 236 was served lunch. She stated that the fish in the taco was not cooked thoroughly. Resident 236 further stated that this was not the first time and whenever…

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 provide food storage and preparation in accordance with professional standards for food service safety when: 1) Hair and beard nets not used as required; 2) Kitchen surfaces found discolored or rusted; 3) Food products not labeled and/or dated; 4) Fans found with whitish/gray build-up; 5) Food packages left open and/or uncovered; 6) Floor in dry storage found with missing linoleum; 7) Worn equipment not discarded and replaced such as can opener, cutting boards, and fry pan; 8) Moldy bread was not discarded; 9) Kitchen floors, oven, heating element of large kettle, and wire rack found with dark build-up and/or debris; and, 10) Reach-in ice cream dipping cabinet found with ice build-up and discoloration on sides of cabinet. These concerns had the potential to lead to food borne illness for the 21 residents eating facility provided foods. Findings: 1) During initial Assisted Living Unit (ALU) kitchen tour on 2/26/24 at 8:10 a.m., Wait Staff 2 (WS2) was observed walking through the kitchen…

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 infection control practices for four out of 14 sampled residents (Resident 14, Resident 234, Resident 235 and Resident 237) when: 1. Staff did not disinfect vital sign equipment before and after use; 2. A Housekeeper (HK) did not apply the proper Personal Protective Equipment (PPE, gloves, gown, and/or goggles/face shield if risk of splash or spray) while cleaning Resident 234's room; and, 3. Resident 14, Resident 235 and Resident 237 were not assisted or offered to wash their hands before meals. These failures had the potential to spread infection in the facility. Findings: 1. During a concurrent observation and interview on 2/26/24 at 2:45 p.m. and 3:10 p.m., the Certified Nursing Assistant 2 (CNA 2) confirmed she was using the same vital sign equipment for multiples residents in different rooms. She confirmed she did not and should have disinfected the vital sign equipment before and after each use. During an interview 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.

The facility failed to maintain equipment in safe operating condition when: 1) ALU (assisted living unit) walk-in freezer found with ice build-up on ceiling and racks indicating potential temperature changes; 2) Ice machine filter found leaking clear fluid on to the main kitchen floor in cook's work area; and, 3) Sandwich bar not holding food temperature in safe food zone (below 41 degrees Fahrenheit-a unit of measurement). These issues had the potential of leading to food borne illness for the 21 residents eating facility prepared meals, as well as staff injury. Findings: 1) During the initial kitchen tour of the Assisted Living Unit (ALU) on 2/26/24 at 8:45 a.m., the walk-in freezer was observed to have ice buildup on the ceiling (areas of up to 1.5 inches across), as well as an ice drip in left rear corner with a collection of ice of up to 6 inches deep on the racks below. In a subsequent interview at 8:51 a.m. with the Director of Culinary Experience (DCE) he concurred that there was ice buildup. When shown that the freezer gasket was misshapen in the top corner, he stated that…

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 notify the resident of a bed hold upon transfer to the hospital for one of 14 sampled resident (Resident 85). This failure had the potential for Resident 85 not knowing the duration of the bed hold period and not able to exercise the resident's right of returning to the facility. Findings: Review of the Resident Face Sheet, undated, indicated Resident 85 was returned to the facility on 2/26/24 with diagnoses including post-operation of the right hip surgery. Review of the Minimum Data Set (MDS, an assessment tool), dated 2/15/24, indicated Resident 85 had no memory problems. Review of the Progress Note, dated 2/26/24 at 9:57 a.m., indicated Resident 85 was complaining of chest pain and was sent to emergency room for evaluation at 7:52 a.m. Review of the Care Plan, dated 2/26/24, indicated Resident 85 was complaining of chest pain and was sent to acute hospital as physician ordered. During observations on 2/26/24 at 9:21 a.m., 9:56 a.m., 12:44 p.m., 2:23 p.m., Resident 85 was not in the facility. During an…

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 accurately assess four of 14 sampled residents (Resident 4, Resident 234, Resident 235, and Resident 25), when the Minimum Data Set (MDS; an assessment tool) inaccurately indicated: 1. The change in Resident 4's skin condition; 2. Resident 234's Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while sleeping); 3. Resident 235's urinary catheter; and, 4. Resident 25's MDS discharge assessment date. These failures decreased the facility's potential to identify residents' care needs. Findings: 1. A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including right upper arm fracture and readmitted on [DATE] with diagnoses including stage 4 sacral pressure ulcer (skin damage caused by constant pressure. Muscles, bones, and/or tendons may also be visible). A review of Resident 4's Progress Notes, dated 1/11/24, indicated Resident 4 had…

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 follow its own policy and procedure for Baseline Care Plan (BCP, a care plan that identifies resident's care needs upon admission) for one of 14 sampled residents (Resident 14) when Resident 14 was not provided a written summary of her BCP within 48 hours of admission. This failure had the potential to increase Resident 14's risk of not being aware of her plan of care. Findings: According to Resident 14's admission record she was admitted to the facility first week of February with diagnoses including,left ankle charcot (weakening of the bones in foot due to significant nerve damage) revision. With orders for non-weight bearing status due to pins and external fixators (devices used to keep fractured bones stabilized), attached to the left ankle/foot. Alert and oriented with no memory problems. She makes her own healthcare decisions. A review of Resident 14's BCP indicated it was completed on 2/1/24. In an interview on 2/26/24 at 4:33 p.m. with Resident 14, she stated she did not remember having a meeting to talk about 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 develop and/or implement a person-centered care plan for three of 14 sampled residents (Resident 84, Resident 14, and Resident 234) when: 1. There was no care plan for a coccyx (tail bone) wound for Resident 84; 2. There was no care plan for a wedge pillow for Resident 14; and, 3. There was no care plan for a continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while sleeping) machine for Resident 234. These failures had the potential for Resident 84, Resident 14, and Resident 234 to not receive the appropriate care, services, and treatment. Findings: 1. Review of the Resident Face Sheet, undated, indicated Resident 84 was admitted to the facility in 2024 with diagnoses that included falls. Review of the Minimum Data Set (MDS, an assessment tool), dated 2/17/24, indicated Resident 84 had no memory problems. Review of the Physician Order Report, dated 2/11/24 to 2/29/24, indicated Resident 84 had a treatment order for his coccyx wound, cleanse with normal saline,…

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 revise in a timely manner the care plan interventions following a significant change assessment for one of 14 sampled residents (Resident 4), when Resident 4 developed a facility-acquired sacral pressure injury. This failure decreased the facility's potential to provide Resident 4 with a person-centered care plan and evaluate its effectiveness. Findings: A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including right humerus (long bone in upper arm) fracture and readmitted on [DATE] with diagnoses including stage 4 sacral pressure ulcer (skin damage caused by constant pressure) and pressure-induced deep tissue damage of sacral region. A review of Resident 4's Care Plan History, dated 10/17/23, indicated Resident 4 was at risk for impaired skin integrity related to right humerus fracture and limited mobility. A review of Resident 4's Minimum Data Set (MDS; an 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.

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 14 sampled residents (Resident 235), when Resident 235's omeprazole (medication used to treat excess stomach acid) was not administered as indicated in physician's order. This failure decreased the facility's potential to safely follow the physician's orders. Findings: A review of Resident 235's Face Sheet, indicated she was admitted to the facility in February 2024. During an observation on 2/27/24 at 8:24 a.m. in Resident 235's room, Licensed Nurse 3 (LN 3) administered 40 milligrams (mg; a unit of measure) capsule of omeprazole to Resident 235. A review of Resident 235's Administration History, dated 2/28/24, indicated an order of 40 mg of omeprazole capsule to be administered to Resident 235 daily 30 minutes before a meal for excess acid build up in the stomach and LN 3 administered omeprazole on 2/27/24 at 8:37 a.m. During an interview on 2/27/24 at 9:09 a.m. with Resident 235, Resident 235 stated around 8:15 a.m. she had cheerios…

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 and implement a physician's order for one of 14 sampled residents (Resident 14) when a prescribed hip-ankle wedge pillow was not provided as ordered for Resident 14. This failure had the potential to delay the healing of Resident 14's ankle related to improper positioning and alignment. Findings: According to Resident 14's admission record she was admitted to the facility in February 2024 with diagnoses including left ankle charcot (weakening of the bones in foot due to significant nerve damage) revision, with orders for non-weight bearing status due to pins and external fixators (devices used to stabilize fractured bones) attached to the left ankle/foot. Resident 14 was alert and oriented with no memory problems. During a concurrent observation and interview on 2/26/24 at 2:24 p.m., observed Resident 14 lying in bed, with no wedge pillow in use. Resident 14 stated she was not using a wedge pillow because the facility did not have the right kind. The nurses just put pillows behind her hip but she…

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 pressure injury preventative care plan interventions for one of 14 sampled residents (Resident 4), when: 1. The certified nursing assistants (CNAs) did not consistently check Resident 4's skin during routine care for impairments; 2. Resident 4 was not frequently repositioned until 12/1/23; and, 3. A pressure reducing mattress was not applied until 11/27/23. These failures increased Resident 4's potential to develop a facility-acquired pressure injury. Findings: A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility in October 2023 with diagnoses including right humerus (long bone in upper arm) fracture and was readmitted in November 2023 with diagnoses including stage 4 sacral pressure ulcer (skin damage caused by constant pressure where muscle and bone may be exposed) and pressure-induced deep tissue damage of sacral region (between the right and left hip bones). A review of Resident 4's Care Plan History, 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 remove from use one expired medication for a census of 21, when miconazole nitrate cream (used to treat skin infections) was stored in the residents' treatment cart after its expiration date. This failure increased the facility's potential to administer expired medications to residents. Findings: During a concurrent observation and interview on 2/27/24 at 10:30 a.m., with Licensed Nurse 1 (LN 1), one household cream of miconazole nitrate was opened on 1/2/24 and stored in the treatment cart with expiration date 8/23. LN 1 confirmed miconazole cream was expired and stated it should have been removed from the cart. During an interview on 2/27/24 at 3:45 p.m. with Interim Director of Nursing (IDON), IDON stated expired medications should not have been stored in the treatment cart because there was a potential to administer it to residents which could have been unsafe. A review of the facility's policy and procedure titled, Medication Storage, dated 1/21, indicated Outdated, contaminated, discontinued or…

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

Based on interview and record review, the facility failed to complete its abuse and neglect training and dementia in-services (a professional training or staff development effort) for two out of five staff members. This failure had the potential to place the residents at risk for elder abuse. Findings: Review of the personnel record for Licensed Nurse 6 (LN 6) revealed a hire date of 9/1/21. The record did not include any documentation of further dementia training received in 2023. Review of the personnel record for LN 7 revealed a hire date of 2/16/22. The record did not include any documentation of abuse and neglect training and dementia training received in 2023. During a concurrent interview and record review on 2/28/24 at 3:30 p.m., the Infection Preventionist (IP) confirmed there was no dementia care training in 2023 for LN 6. During a concurrent interview and record review on 2/28/24 at 3:49 p.m., the Infection Preventionist (IP) confirmed there was no dementia care training and abuse training in 2023 for LN 7. Review of the facility's policy titled, In-service Training -…

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.