River City Post Acute

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 3 sampled residents (Residents 4 and 104).For Resident 4, a licensed nurse did not administer the resident's multivitamin in accordance with the Physician Orders.For Resident 104, a licensed nurse did not administer the resident's:a. folic acid, an essential vitamin for cell growth and red blood cell formation; andb. calcium, a mineral important for strong bones and overall health, as ordered by the physician.As a result, 3 errors were identified out of 31 opportunities for error during the observation of medication administration; the facility medication error was 9.68%.1. During an observation of medication administration on 3/3/26 at 8:15 a.m., Licensed Nurse (LN) 11 was observed to prepare and administer Resident 4's morning medications which did not include Resident'4 multivitamin-minerals tablet.During an interview on 3/3/26 at 8:25 a.m., LN 11 stated she did not have a bottle of multivitamins on her medication cart to complete Resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedure for a census of 162 when:Three bottles of atropine eye drops, medication used to treat various eye conditions, 1% (percent, unit of measure), requiring room temperature storage, were stored in the refrigerator, creating a potential risk for drug degradation and reduced effectivenessOpened inhalers (used to administer medication by breathing in) in the medication cart were not dated, which put residents at risk of receiving expired or outdated medication1. During a concurrent observation and interview with Licensed Nurse (LN) 13 on [DATE] at 2:25 p.m. in Medication Room Hall 1, three bottles of atropine 1% were stored in the refrigerator at 38 degrees F (Fahrenheit, unit of measure for temperature) per refrigerator thermometer. LN 13 stated, the eye drop bottles needed to be stored at 68-77 degrees F per the bottle's storage requirement.During an interview on [DATE] at 11:10 a.m. with the assistant…

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 food was stored in a sanitary manner when:1. Multiple cups, bowls and a large colander were found stored upright and exposed to the air, dust and splatter in the kitchen and when, 2. The activities refrigerator had no working thermometer, foods were not dated when opened, and chocolate ice cream drippings and debris were observed on the bottom of the freezer.These failures increased the risk for food borne illness. 1.During an initial tour observation on 3/3/26 at 8:19 a.m., two large trays of coffee cups, a nest of 6 mixing bowls and colander were stored upright on a bottom shelf in the kitchen open to air, dust and splatter.During a concurrent observation and interview on 3/3/26 at 8:20 a.m. with Dietary Aid (DA) 2, DA 2 verified two large trays of coffee cups were stored upright, open to the air, dust and splatter and said, They are supposed to be turned upside down to protect them from dust. During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for 8 sampled residents (Resident 95, Resident 56, Resident 54, Resident 17, Resident 153, Resident 126, Resident 133, and Resident 173) and residents who use shower room in hallway 6 and 7 when: 1. Resident 95 had a visibly blood-soiled dressing left on arteriovenous fistula site (AVF; a surgically created connection between an artery and a vein, usually in the arm, that allows easy access to the blood stream for dialysis-a treatment that uses a machine to clean waste and extra fluid from the blood when a person's kidneys were no long able to do it) and 2. There were unsanitary conditions in the showers of hallway 6 and 7, and 3. Resident 56's nebulizer (a machine to convert respiratory medication into a mist for direct entry into the lungs) mask and tubing were not stored properly to maintain cleanliness, and 4. Resident 54's enteral feeding pump (medical device used to deliver…

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 care in an environment that maintained and enhanced residents' dignity and respected their individuality, when a white board at the Nursing Station of Hall 6 identified two residents by their room numbers referring them as FEEDERS.This failure had the potential to compromise residents' dignity by exposing residents' care needs.During an observation on 3/3/26 at 4:05 p.m., a white board on the wall at the Nursing Station of Hall 6 had two resident rooms that were labeled as FEEDERS.During a concurrent observation and interview on 3/4/26 at 3:15 p.m., with Licensed Nurse 3 (LN 3) and LN 4, a whiteboard in Hallway 6 listed two resident rooms as FEEDERS. LN 3 & LN 4 stated, staff wrote important information on white board and updated it daily. When the Department asked LN 3 and LN 4 regarding feeders, LN 4 explained, These are the residents that need to be assisted with feeding, one-on-one. LN 3 and LN 4 did not provide any answer when asked if it was appropriate to label and identify residents as…

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 allow two of 36 sampled residents (Resident 19 & Resident 153) to make choices about aspects of their life in the facility that are significant to them when:The facility did not offer or assist Resident 19 to eat in the dining room for breakfast, andThe facility failed to allow Resident 153 to keep snacks in his room.These failures had the potential to affect Resident 19 and Resident 153's mental health and overall wellbeing. 1.During an observation on 3/3/26, at 9:00 a.m., Resident 19 was sitting in bed with his breakfast tray on his bedside table. During an interview on 3/3/26, at 9:00 a.m., with Resident 19, Resident 19 stated, he ate his breakfast in bed and would rather eat in the dining room. Resident 19 stated, he has asked the facility to eat in there and for assistance wheeling himself with his wheelchair, but they do not assist him and stated they kick me out of the dining room. Resident 19 stated, the people who need help to eat are usually in the dining room. During an observation on 3/6/26, 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 complete a Minimum Data Set (MDS: a federally mandated, standardized, and comprehensive assessment tool used in nursing homes to evaluate the functional, medical, and psychological status of residents) assessment for one of four sampled residents (Resident 142) when Resident 142 was discharged on 9/22/25 and facility staff did not complete the Discharge MDS assessment. During a review of Resident 142's facesheet, facesheet indicated, Resident 142 was admitted on [DATE], and discharged from the facility on 9/22/25.During a concurrent interview and record on 3/5/26, at 1:51 p.m., with MDS Nurse 2 (MDS 2), Resident 142's Medical record was reviewed. The Medical record indicated, Resident 142 did not have a discharge MDS assessment completed. MDS 2 stated, the discharge MDS assessment was not completed, we have 14 days from discharge to complete the discharge MDS assessment, and we missed this one.During a review of the MDS Resident Assessment Instrument…

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 36 sampled residents (Resident 18) received a required mental health evaluation for an identified mental disorder.This failure had the potential to result in Resident 18 not receiving needed mental health care and services.A review of the admission record indicated the facility admitted Resident 18 in 2025 with multiple diagnoses, which included bipolar disorder (a mental health disorder characterized by extreme mood swings, alternating between emotional highs and lows). During a record review of Resident 18's Preadmission Screening and Resident Review [PASRR- a comprehensive evaluation tool used to identify persons with mental illness, intellectual or developmental disabilities] Level 1 Screening Evaluation, dated 12/18/25, indicated Resident 18 had a diagnosed mental disorder for which the resident was prescribed psychotropic medications (drugs that affect a person's mental activity, mood, and behavior.) The screening form indicated that Resident 18's Level I was positive, and a Level II was required to be…

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

Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive care plan for two of thirty-six sampled residents (Resident 46 and Resident 88) when: 1. Resident 46's communication board care plan was not implemented by staff. 2. Resident 88 did not have a Care Plan that indicated he needed to wear a helmet when out of bed. These failures placed Resident 46 at the risk of care needs not being met and Resident 88 at risk of fall and injury. 1. A review of Resident 46's Facesheet, indicated he was admitted to the facility in January 2026, with diagnoses that included: cerebral infarction (blockage of an artery in the brain which lead to tissue death), hemiplegia (severe or complete paralysis on one side of the body), dysphagia (difficulty swallowing), retention of urine (inability to fully or partially empty bladder), schizophrenia (a severe mental disorder). It was noted that Resident 46 was his own responsible party. A review of Resident 46's Care Plans, dated 1/13/2026, indicated, The resident has difficulty communicating verbally…

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 arrange needed services for one of thirty-six sampled residents (Resident 88) when Resident 88 did not receive neurology (physician focused on treating disorders of the nervous system including the brain) or neurosurgical (surgical specialty focused on treating disorders of the nervous system including the brain) follow up services after admission to the facility.This failure placed Resident 88 at risk for increased disability and decreased functional status. A review of Resident 88's admission Record indicated Resident 88 was admitted to the facility in April 2024 with multiple diagnoses including cerebral infarction (blockage of a blood vessel in the brain causing cell death), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and intracerebral hemorrhage (bleeding inside the brain). A review of Resident 88's Minimum Data Set (MDS-federally mandated assessment tool), Cognitive Patterns, dated 12/20/25, indicated Resident 88 had a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of 36 residents (Resident 4), received necessary assistance with tooth brushing and mouth care in accordance with the resident's assessed needs, care plan, and facility policy.This failure resulted in ongoing poor oral hygiene, decayed dentition, and unmet assessed Activity of Daily Living (ADL) needs for Resident 4.A review of Resident 4's admission record indicated Resident 4 was originally admitted to the facility on [DATE]. Resident 4 had a history of transient ischemic attack (when blood flow to part of the brain is temporarily blocked) and cerebral infarction (interruption in the flow of oxygen and nutrients to a specific area of the brain, causing brain cells to die), diabetes mellitus type 2 (a chronic condition in which the body doesn't use insulin properly, causing high blood sugar), chronic kidney disease (kidneys are losing the ability to clean waste and excess fluid from the blood), heart failure, acquired…

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 activities to one of 36 sampled residents (Resident 156) when the facility failed to provide activities meaningful to Resident 156 and according to the activities schedule.This failure had the potential to negatively affect Resident 156's mental health and wellbeing.During an interview on 3/4/26, at 8:42 a.m., with Resident 156, Resident 156 stated, she wishes she could get out of bed earlier so she can attend activities. Resident 156 stated, activitiy staff used to offer coffee at 10 am, but they offer that anymore. Resident 156 stated, look at the schedule posted on the wall and see if they offer those activities. Resident 156 further stated, When the state is here, everything is perfect. During a review of the Activity Schedule whiteboard dated March 2026 in Hallway 1, schedule indicated, Wednesday 3/4 10:00 Coffee Social. During a review of Resident 156's Brief Interview for Mental Status (BIMS: a screening tool used in long-term care to assess cognitive function, specifically orientation and…

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

Based on observation, interview, and record review, the facility failed to provide supervision for one of thirty-six sampled residents (Resident 88) to ensure Resident 88 wore a protective helmet when out of bed.This failure placed Resident 88 at serious risk for injury, including intracranial hemorrhage (bleeding inside the skull) from falls or accidents. A review of Resident 88's admission Record indicated Resident 88 was admitted to the facility in April 2024 with multiple diagnoses including cerebral infarction (blockage of a blood vessel in the brain causing cell death), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and intracerebral hemorrhage (bleeding inside the brain). A review of Resident 88's Minimum Data Set (MDS-federally mandated assessment tool), Cognitive Patterns, dated 12/20/25, indicated Resident 88 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 3 out of 15 that indicated Resident 88 was severely cognitively impaired. Further review of Resident 88's MDS, Functional Abilities,…

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 respiratory equipment was maintained in accordance with professional standards of practice for one of 36 sampled residents (Resident 193) when Resident 193's nasal cannula (NC; a medical device with two prongs that is connected to an oxygen source to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first applied. This failure had the potential to result in unsanitary delivery of oxygen to Resident 193 and an increased risk of infection. A review of Resident 193's Facesheet, indicated he was admitted to the facility in 2025, with diagnoses that included, congestive heart failure (a condition where the heart muscle is too weak or stiff to pump blood efficiently causing blood to back up and fluids to accumulate in the lungs and body), pulmonary edema (excess fluid buildup in the lungs making it difficult to breathe), chronic obstructive pulmonary disease (a progressive long-term lung disease that makes it difficult to breath due to damaged airways). 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 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) were maintained for one of 162 residents when prescription medications were stored in a medication cart without a resident specific prescription label with an increased risk of medication error or drug diversion. Inspection of the medication cart 2 in hall 7 with Licensed Nurse (LN) 11 on 3/4/26 at10:30 a.m. revealed the bottom drawer of the cart contained used prescription medications without resident specific pharmacy label. These medications included two blister packs of apremilast, medication used to help calm body's overactive immune system.During an interview on 3/4/26 10:35 a.m. with LN 11, LN 11 stated, the two blister packs did not have a resident specific pharmacy label.During an interview on 3/5/26 11:18 a.m. with the Assistant Director of Nursing (ADON) 1, ADON 1 stated, the prescription medications needed to be properly labeled within 24 hours after…

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 protect one of three sampled residents (Resident 1) from mental and emotional abuse when Resident 1's visitor/caregiver displayed anger by physical aggression in Resident 1's room and was verbally aggressive to Resident 1. This failure had the potential for Resident 1 to experience mental anguish and psychosocial distress. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March 2025 with multiple diagnoses including neuromuscular dysfunction of the bladder (loss of bladder control due to nerve damage), protein calorie malnutrition (decreased protein and calorie intake causing weight loss and nutritional deficiencies), dysphagia (difficulty swallowing), and congestive heart failure (heart does not pump blood as efficiently as it should). The admission Record indicated Resident 1's visitor/caregiver was his Responsible Party (RP) and healthcare decision maker. A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns,…

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 report suspected abuse for one of three sampled residents (Resident 1) to The Department within the regulatory timeframe, when Resident 1's visitor/ caregiver was reported as abusive and the incident was not reported until two days later. This failure resulted in a delay of an investigation of abuse which had the potential for abuse to continue causing increased emotional distress or mental anguish for Resident 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March 2025 with multiple diagnoses including neuromuscular dysfunction of the bladder (loss of bladder control due to nerve damage), protein calorie malnutrition (decreased protein and calorie intake causing weight loss and nutritional deficiencies), dysphagia (difficulty swallowing), and congestive heart failure (heart does not pump blood as efficiently as it should). The admission Record indicated Resident 1's visitor/caregiver was his Responsible Party (RP) and healthcare decision maker. 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 observation, interview, and record review, the facility failed to maintain infection control practices for two of three sampled residents (Resident 1 and Resident 2) who had indwelling urinary catheters (a soft tube inserted into the bladder to drain urine into bag outside the body) when:CNA 1 removed his gloves, put on a new pair of gloves without washing hands, and then provided care to another resident.CNA 2 adjusted Resident 2's urine drainage bag without wearing gloves. These deficiencies had the potential to result in catheter-associated urinary tract infections (CAUTIs) for Resident 1 and Resident 2.Findings: 1. Resident 1 was admitted to the facility late 2025 with diagnoses which included urinary retention and personal history of infectious disease. During a review of Resident 1's Care Plan Report [CP], dated 1/04/26, the CP indicated, Enhanced standard/barrier precautions for the prevention of transmission of multidrug-resistant organisms with residents with urinary catheter. The interventions included: .g) change gowns and gloves and perform hand hygiene when…

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 observations, interviews and record review, the facility failed to protect one of five sampled residents (Resident 3's) right to be free from verbal abuse when Licensed Nurse 2 (LN 2) cursed and yelled at him.This failure caused Resident 3 to feel humiliated, fearful and intimidated.During a review of Resident 3's admission Record (AR), the AR indicated that Resident 3 was admitted to the facility in December 2025 with diagnoses that included Hemiplegia (severe loss of strength), Hemiparesis (weakness), and Depression (serious mental health condition).During a review of Resident 3's Progress Notes (PR), dated 1/12/26, The PR indicated that Resident 3's Brief Interview for Mental Status (BIMS, tool to assess cognition) score was 13 out of 15 which suggested Resident 3 was cognitively intact.During an interview on 2/2/26 at 9:32 a.m., with the Administrator, the Administrator stated that LN 2 verbally abused Resident 3. The Administrator further stated that Resident 3 was mentally and emotionally affected, as evidenced by Resident 3 deciding to stay in his room and refused to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of five sampled residents, Resident 4's change of condition when: 1.There was no signed documentation of a physician telephone order (TO, verbal orders given by physician over the phone) of naloxone on file for Resident 4 that was given on [DATE], 2. There was no documentation of naloxone administration on Resident 4's Medication Administration Record (MAR), used to document medications taken by patient); and3. The Assistant Director of Nursing (ADON) did not follow the facility's policy and procedures for the administration of Naloxone which included giving repeated doses and calling 911. These failures had the potential to have resulted in a lack of continuity of care and the delay of critical interventions.Findings:During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility in [DATE] with diagnoses that included Hypertension…

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 accommodate the exercise of resident/resident representative's rights for one out of 11 sampled residents (Resident 5) when facility did not respond timely to Resident 5's representative request of Resident 5's personal belongings.This failure resulted in Resident 5 not having access to his personal belongings and had the potential for Resident 5 to experience undignified existence. Findings:A review of Resident 5's clinical record indicated Resident 5 was admitted May of 2025 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).A review of Resident 5's clinical records indicated Resident 5 was discharged from the facility on 9/5/25.During a phone interview on 12/1/25 at 2:17 p.m.…

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 exercise the resident representative's right for one out of five sampled residents (Resident 5) when Resident 5 signed the facility's admission agreement, consent for treatment and release of information, and consents for facility services while Resident 5 was not oriented to person, place, date and time and did not have the capacity to make medical decisions. This failure has the potential to result in Resident 5 and Resident 5's representative to not fully understand the facility's admission agreement, treatment options, and other services that would be provided to Resident 5.Findings:A review of Resident 5's clinical record indicated Resident 5 was admitted May of 2025 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing…

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 out of five sampled residents (Resident 1) was free from significant medication error when Resident 1 did not receive his prescribed antiseizure medications (used to treat epilepsy and other seizure disorders by altering electrical activity in the brain) in accordance with the physician's order and standards of practice.This failure had the potential for Resident 1 to experience seizure activity (a sudden, uncontrolled electrical disturbance in the brain that can cause a range of symptoms, such as muscle stiffening, shaking, or altered sensations) and other seizure related complications which could negatively affect the resident's health.Findings:A review of Resident 1's clinical record indicated Resident 1 was admitted January of 2025 and had diagnoses that included cerebral infarction (damage to a part in the brain due to a disrupted blood flow), cerebrovascular disease (a group of conditions that affects the blood flow and the blood vessels in the brain), hemiplegia (complete loss of the ability to move one…

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

Based on observation, interview, and record review, the facility failed to provide a call light within reach for two of five sampled residents (Resident 1 and Resident 2). This failure had the potential to result in unmet care needs and compromise the residents safety.Findings:Resident 1 was admitted to the facility in June 2025 with multiple medical diagnoses including multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness, and need for assistance with personal care. Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 9 out of 15 which indicated Resident 1 was moderately impaired.Resident 2 was admitted to the facility in May 2022 with multiple medical diagnoses including cerebral infarction (a condition where brain tissue dies due to a lack of blood supply) affecting the left side, muscle weakness, and dysphagia (difficulty or inability to swallow). Resident 2 had a…

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

Based on observation, interview, and record review, the facility failed to implement the proper transmission-based precautions (TBP-additional infection control measures used in healthcare settings to prevent the spread of infectious diseases that are transmitted through specific routes) when there was no correct signage posted on the door for one of three sampled residents (Resident 3) who was observed to be positive for Covid-19 (a respiratory illness caused by the SARS-CoV-2 virus). This failure had the potential to increased risk of infection transmission for a facility census of 167 residents.Findings:Resident 3 was re-admitted to the facility in August 2017 with multiple medical diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). Resident 3 had a BIMS (Brief Interview for Mental Status-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.

Based on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from abuse when Resident 2 spit on Resident 1 in the face during a verbal altercation.This failure had the potential for Resident 1 to experience fear or distress.Findings:During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in July 2025 with diagnoses that included encephalopathy (brain disease that alters brain function or structure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had intact cognition.During a review of Resident 2's admission records, the records indicated Resident 2 was admitted in July 2025 with diagnoses that included sepsis (infection in the blood), depression, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).…

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 staff answered call lights (device used by residents to signal his or her need for assistance from staff) in a timely manner for three of 4 sampled residents (Resident 3, Resident 4, and Resident 1).These failures had the potential to result in resident's care needs not being met and placed residents' safety at risk. Findings: 1a. A review of the admission Record indicated Resident 3 was admitted last week of July 2025 with diagnoses including acute respiratory failure with hypoxia (lungs unable to get enough oxygen into the blood) and protein calorie malnutrition (the body does not get enough protein and energy to function properly).A review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/30/25 indicated Resident 3 was cognitively intact.A review of Resident 3's physician order dated 7/26/25 indicated Resident 3 had the capacity to make healthcare decisions.In a concurrent observation…

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 services provided meet professional standards of quality for one of 4 sampled residents (Resident 1) when:1. Resident 1's order for the immobilizer sling (a device used to restrict arm and shoulder movement to aid in the healing process after an injury) was not followed; and2. Resident 1's order for supplemental oxygen was not followed and updated according to residents' needs. These failures increased the risk for Resident 1 to experience increased pain, worsening of injury and be given supplemental oxygen that was not needed. Findings:A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including fracture of upper of right humerus (upper arm bone), dislocation of right shoulder joint (the head of the upper arm bone comes out of the shoulder socket), and fall.A review of the Nurses Progress Note dated 7/16/25 indicated, New admit.alert and oriented x3-4.initially admitted to the hospital for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for one of 4 sampled residents (Resident 2).This failure had the potential to not meet the needs and placed Resident 2 at risk for safety.Findings: A review of the admission Record indicated Resident 2 was admitted [DATE] with diagnoses including multiple sclerosis (the coating that protects the nerves is damaged which disrupts the communication between the brain and the rest of the body leading to wide range of symptoms) and abnormalities with gait and mobility.A review of Resident 2's Minimum Data Set (MDS- federally mandated resident assessment tool) dated 6/27/25 indicated Resident 2 had moderate cognitive impairment and she was dependent on staff for self-care and bed mobility.A review of Resident 2's care plan initiated 6/26/25 indicated, [Resident 2] is at risk for falls/self-injury r/t [related to] Impaired balance/gait, limited mobility, generalize weakness. The interventions indicated, .Place…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe and protective environment for one of three sampled residents (Resident 1), when Resident 1 was hit on the side of his face by Resident 3. During a record review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was admitted to the facility in early 2025 with diagnoses which included cerebral infarction (condition where a part of the brain is damaged or dies due to a lack of blood supply), hemiplegia (a condition characterized by weakness or paralysis affecting one side of the body), and aphasia (language disorder that affects a person's ability to communicate or speak). During a review of Resident 1's Minimum Data Set (MDS - federally mandated resident assessment tool), dated 7/5/25, the MDS indicated Resident 1 had a moderate cognitive impairment and had difficulty speaking but used a phone for communication. During a record review of Resident 3's FS, the FS indicated Resident 3 was admitted to the facility in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure physician's order was followed in accordance with the professional standards of practice for one of three sampled residents (Resident 3), when the physician was not notified of Resident 3's blood sugar level. This failure had the potential for Resident 3 to receive inaccurate and inadequate care.During a record review of Resident 3's Face Sheet (FS), the FS indicated Resident 3 was admitted to the facility in early 2021 with diagnoses which included diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), dementia (term describing a decline in mental ability severe enough to interfere with daily life), psychotic disturbance (collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 3's…

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

Based on interview and record review, the facility failed to provide adequate monitoring and supervision for one of four sampled residents (Resident 1), when Resident 1 left the facility without notifying staff. This failure resulted in Resident 1 leaving the facility unsupervised and increased her risk for harm and injury. Findings: Resident 1 was admitted to the facility March 2025 with diagnoses which included schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and the need for assistance with personal care. A review of the Minimum Data Set (MDS, an assessment tool), dated 3/31/25, indicated Resident 1 had moderate cognition impairment. Resident 1's family members were listed as the responsible party. During a review of Resident 1's Order Summary Report, order dated 3/28/25, the orders indicated, Resident (DOES NOT HAVE) the capacity to make healthcare decisions. During a review of Resident 1's Order Summary Report, order dated 4/17/25, the orders indicated, Wander Guard/Wander Elopement Device due to poor safety awareness .every shift check…

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 adequate supervision to ensure safety when Resident 1 eloped from the facility for a census of 157. This failure had the potential to result in serious injury or death for Resident 1. Findings: During a review of Resident 1's admission Record, the record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included idiopathic peripheral autonomic neuropathy (damage to the nerves of the autonomic nervous system which controls involuntary functions like heart rate and digestion) and 3rd degree burns involving 10 -19% of body surface. During a review of Resident 1's Nurses Progress Notes dated 6/24/25 at 12:10 p.m., the nurses note indicated Resident has a scheduled medication at 05:00. Per resident normal routine they would come to the nurse's station around 04:00 requesting their medication 1 hour early. RN (registered nurse) noticed they did not come to the nurse's station around 4:55, at this point the RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain acceptable infection control practices when four shower rooms were observed unsanitary for a census of 165. This failure had the potential for the shower rooms to harbor infectious organisms and spread them to the residents. Findings: During an observation and concurrent interview on 6/10/2025 at 11:49 a.m. in Shower room [ROOM NUMBER] for the 600 hall with Licensed Nurse 2 (LN 2), a red drinking cup was found on the shower room sink. LN 2 stated the cup should not be there and it was unsanitary. During a concurrent observation and interview on 6/10/25 at 12:22 p.m. with Certified Nurse Assistant 1 (CNA 1), the Shower room for Hall 1 was observed with dark brown and black mold and mildew on the walls of the shower area and flooring. CNA 1 confirmed the mold and mildew in the shower room and stated it had been going on for several months. During a concurrent observation and interview on 6/10/2025 at 12:42 p.m. with Licensed Nurse 3 (LN 3) 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 follow professional standards of practice when they failed to follow physician orders for two of six sampled residents (Resident 1 and Resident 2). These failures had the potential to result in poor residents ' health outcomes. Findings: 1. A review of Resident 1 ' s clinical record indicated Resident 1 was admitted in early 2025 with multiple diagnoses including diabetes (a disease manifested by high blood sugars and causes slow wound healing). A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated assessment tool), reflected a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 14 out of 15 which indicated Resident 1 was cognitively intact. A review of Resident 1's MDS, Functional Abilities, indicated Resident 1 was dependent on staff for mobility, transfers, and putting on/taking off footwear. During an observation on 6/10/25 at 11:52 a.m. in Resident 1 ' s room, Resident 1 ' s lower extremities were observed at the base of the bed. A dressing was observed 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 ensure interventions consistent with resident needs were implemented for one of three sampled residents (Resident 1) when Resident 1 sustained a fracture of the 4th right finger from a fall and interventions to support and stabilize the finger to prevent worsening were not implemented in a timely manner. This failure resulted in delay in the management of Resident 1 ' s fracture. Findings: During a review of Resident 1 ' s admission records, the records indicated Resident 1 was admitted to the facility in July 2016 with diagnoses that included metabolic encephalopathy (brain disease that alters brain function or structure), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and dementia (a progressive state of decline in mental abilities). Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1…

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 protect the resident ' s right to be free from physical abuse by a resident for one of five sampled residents (Resident 1) when facility staff witnessed Resident 3 hit Resident 1 on the head. This failure resulted in Resident 1 not being free from abuse and had the potential for Resident 1 to be injured. Findings: Resident 1 was admitted [DATE] with diagnoses which included anxiety disorder, dementia (impaired ability to remember, think, or make decisions) and adult failure to thrive. A review of Minimum Data Set (MDS, an assessment tool), dated 2/26/25, indicated Resident 1 had severe cognition impairment. Resident 3 was originally admitted [DATE] with diagnoses which included dementia and personal history of traumatic brain injury. A review of the MDS, dated [DATE], indicated Resident 3 had intact cognition. During an interview on 6/2/25 at 12:56 p.m. with Licensed Nurse 3 (LN 3), LN 3 stated that on 5/23/25 she observed Resident 3 come behind…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy and procedures (P&P) to ensure Resident 1's responsible party received written notification, including the reason for the change, before a room change was initiated for one of two sampled residents (Resident 1). This failure violated Resident 1 and Resident 1's Responsible Party's (RP) right to receive written notice of the room change and had the potential to result in confusion for Resident 1 and dissatisfaction with his living arrangements. Findings: Review of Resident 1's admission Record indicated Resident 1's family member was his responsible party (RP). During a review of Resident 1's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool), dated 5/5/25, indicated Resident 1 was usually able to understand others, usually able to make himself understood and as having a Brief Interview for Mental Status, (BIMs-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status 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 observation, interview and record review the facility failed to ensure resident safety for one resident (Resident 1) out of a census of 158 when Resident 1's care plan was not implemented correctly and consistently, and facility did not know Resident 1's whereabouts. This failure resulted in Resident 1 missing and eloping from the facility and reduced the facility's potential in keeping Resident 1 safe from harm. Findings: Review of Resident 1's admission Record (AR), the AR indicated that Resident 1 was admitted in late February 2023 with diagnosis including schizoaffective disorder (a condition that can affect a person's perception of reality and mood) and other psychoactive substance abuse (a condition where someone struggles to control, and it impairs judgment and may lead to changes in brain structure). Review of Nurse's Progress Note dated 4/13/25 at 6:16 p.m., indicated, .Per charge hall nurse, resident was found missing from [facility] at approximately 4:00 PM hour. Charge hall nurse searched around and, in the facility, and not found. This writer drove down 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 received care which met professional standards for one of three sampled residents (Resident 2) when physician ' s order to apply soft heel lift boots (soft boots used to relieve pressure against the heels) was not implemented. This failure had the potential for the development or worsening of pressure injury (damage to skin and underlying tissues when continuous pressure cuts off blood flow to the area). Findings: During a review of Resident 2's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 2 was admitted to the facility April 2023 with multiple diagnoses which included atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a buildup of plaque in the main heart blood vessel that impairs blood flow and results in chest pain). During a review of Resident 2 ' s physician ' s orders, dated 04/14/24, the physician ' s orders indicated, .elevate heels off bed while in bed or…

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

Based on observation, interview and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for a census of 163, when uncovered disposable razors on top of an overfilled sharps container (used to safely dispose of hypodermic needles and other sharp medical instruments,) inside the residents shower room in nursing station seven was not properly disposed and replaced timely by staff. This failure had the potential to result in transmission, spread of infection, and caused harm for the residents. Findings: During a concurrent observation and interview on 2/15/25 at 11:21 a.m., with License Nurse 1 (LN1), inside the resident's shower room in one of the nursing station, LN 1 confirmed the sharps container was full and multiple uncovered disposable razors were on top it. LN 1 verified the door of the resident's shower room was left open. LN 1 stated, The door should not be left open because the residents can access the sharps and other things inside. LN 1 also stated, Whoever has to touch that has a risk of cutting…

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 professional standard of care was provided for one of three sampled residents (Resident 3), when the physician's order for fluid restriction (a diet which limits the amount of daily fluid consumption) was not followed. This failure placed Resident 3 at risk for dehhdration or fluid overload. Findings: Resident 3 was admitted to the facility in late-2024 with diagnoses which included heart failure and end-stage kidney disease. During a concurrent observation and interview on 4/15/25 at 12:34 p.m., in Resident 3's room with Certified Nurse Assistant (CNA) 3, CNA 3 confirmed there was a pitcher filled with water and ice, a fruit juice in tetra pack, water bottle, and prune juice in a sealed cup were located on Resident 3's bedside and over-bed table, all within the residents reach. CNA 3 was unable determine the amount of fluid found in Resident 3's room and stated it was already there when CNA 3 started his shift. CNA 3 also added there was no fluid restriction warning in Resident 3's room. CNA 3 stated,…

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

Based on observation, interview and record review the facility failed to provide adequate supervision to prevent elopement for one of two sampled residents (Resident 2). This failure had the potential for Resident 2 to be injured or harmed, as he was able to leave the facility without staff being aware. Findings: Review of Resident 2's face sheet (a snapshot of a resident's essential information) indicated the residednt was admitted to the facility with diagnoses of Nontraumatic Intracerebral Hemmorhage ( bleeding in the brain), Alcoholic Cirrhosis of the Liver ( the most advanced stage of alcohol-related liver disease characterized by extensive liver scarring and damage). During an interview with the Certified Nursing Assistant (CNA) on 4/3/25 at 2:35 p.m., she stated Resident 2 was confused. He had a Brand Name, Wander Elopement Device (WED) in place as he wandered around and was an elopement precaution. The Resident got up and would go to the main lobby of the building. The CNA stated she was not working that day when the elopement occurred. The CNA stated that Resident 2's WED…

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 intravenous (IV, the administration of substances directly into a vein) care in accordance with professional standards of quality for two of six sampled resident's (Resident 2 and Resident 3) when Resident 2 and Resident 3 did not have physician orders for IV flushes (used to clear out IV lines after medication is used and to prevent blockages in the line). This failure had the potential for the residents to not receive the full dose of medication ordered, to receive the incorrect type or amount of IV flush and increased the risk for a blockage in the IV line. Findings: Resident 2 was admitted to the facility early 2025 with diagnoses which included bone infection and infection in the hip joint. During an observation on 4/2/25 at 1:07 p.m. of Resident 2, Resident 2 had a Peripherally Inserted Central Cather (PICC, a thin flexible tube inserted into a vein in the upper arm that extends into a large vein near the heart) inserted into his left upper arm. During a review of Resident 2's Order Summary…

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 safe, sanitary care for two of six sampled resident's (Resident 2 and Resident 3) intravenous (IV, the administration of substances directly into a vein) care when the Peripherally Inserted Central Cather (PICC, a thin flexible tube inserted into a vein in the upper arm that extends into a large vein near the heart) dressings were not changed, and IV tubing was not dated. These failures increased the risk of infection. Findings: Resident 2 was admitted to the facility early 2025 with diagnoses which included bone infection and infection in the hip joint. During a review of Resident 2's Order Summary Report [OSR], Active Orders as of 4/2/25, the OSR indicated Resident 2 had three different antibiotics ordered to be administered intravenously. During a review of Resident 2's Care Plan Report [CP], created 3/25/24, the CP indicated, .Change IV site per policy .Change dressing per policy . During an observation on 4/2/25 at 1:07 p.m. of Resident 2's left upper arm, Resident 2 had a clear plastic dressing…

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 residents (Resident 1) were cared for in a manner which promoted their dignity when CNA 1 spoke to Resident 1 with a rude and upset tone while helping during toileting. These failures had the potential to negatively impact residents' psychosocial well-being. Findings: Resident 1 was admitted to the facility February 2025 with multiple diagnoses which included chronic kidney disease, muscle weakness, and need for assistance with personal care. Resident 1's Minimum Data Sheet (MDS - a federally mandated resident assessment tool), dated 2/8/25, indicated Resident 1 had no memory impairment. The MDS further indicated that Resident 1 needed substantial/maximal assist (helper does more than half the effort) for toileting. During a review of Resident 1 ' s progress notes, dated 2/17/25, indicated .resident was wet and needed to be changed. So, resident turned on her call light for assistance. CNA (Certified Nursing Assistant) responded but got upset at the resident why she was on the light . 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.

Based on observation, interview, and record review the facility failed to maintain infection control practices for a census of 171 when: 1. No Enhanced Barrier Precautions (EBP, involves use of gown and gloves during high contact resident care designed to reduce transmission of Multi Drug Resistant Organisms [MDRO, bacteria resistant antibiotics]) were in place for Resident 99, Resident 115, and Resident 31, and, 2.the facility staff failed to sanitize a blood pressure cuff between residents. These failures increased the risk for infections: Findings: 1. Resident 99 was re-admitted to the facility in late 2024 with diagnoses which included acute pyelonephritis (severe bacterial kidney infection), resistance to multiple antimicrobial drugs, and Extended Spectrum Beta Lactamase (ESBL, a bacterial that is resistant to common antibiotics) resistance. During a review of Resident 99's, Order Summary Report [OSR], dated 11/21/24, the OSR indicated, IV [intravenous] central line [a thin flexible tube that is inserted into a large vein near the heart] . During a review of Resident 99's care…

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 comprehensive care plans for two of 37 sampled residents (Resident 87 and Resident 161) that included measurable objectives and timetables to meet the resident's medical and nursing needs. This failure created the potential for inaccurate care. Findings: Review of Resident 87's physician orders contained an order dated 10/29/24 for Clopidogrel Bisulfate (Anticoagulant-blood thinner used to prevent stroke, heart attack and other heart problems) 75 MG (milligram) one time day for DVT (Deep Vein Thrombosis) Prophylaxis (to prevent blood clot in a vein). During a review of Resident 87's clinical record on 11/19/24 revealed no care plan regarding Resident 87 being on an anticoagulant medication. During a concurrent interview and record review the following day on 11/20/24 at 12:09 p.m. with the Director of Nursing (DON) and Regional Clinical Resource Nurse (RCRN) Resident 87's clinical record was reviewed. The DON indicated there was a care plan regarding Resident 87 being on an anticoagulant medication. During a review…

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 care was provided in accordance with professional standards for 1 of 37 sampled residents (Resident 72) when Resident 72 did not receive dialysis as prescribed. This resulted in Resident 72 being transferred to the emergency room (ER). Findings: Review of Resident 72's diagnoses included End Stage Renal Disease (ESRD-permanent kidney failure) and Dependence on Renal Dialysis (process to remove excess water, toxins and waste from the blood). Review of Resident 72's physician orders contained an order dated 3/29/24 for dialysis on Tuesday, Thursday and Saturdays. P/U (pick up) @ 8AM, return around 2 PM Transportation: every day shift every Tue, Thu, Sat. During a review of Resident 72's Progress Note dated 3/12/2024 at 8:27 a.m., Per noc (night) shift resident hasn't had dialysis since Thursday of last week and should be sent to hospital when I spoke to resident he said he feels okay only when he is feeling like he has excess fluid build up and its hard to breath will he ask to go to hospital Called CMEC to update…

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 annual performance evaluations (PEs) for two of two sampled certified nursing assistants (CNA 1 and CNA 2). This failure increased the risk of residents to receive poor-quality care from the CNAs. Findings: During a record review on 11/21/24 at 9:29 a.m. with the Director of Staff Development (DSD), two employee charts were reviewed, CNA 1 and CNA 2. CNA 1 was hired 9/1/07, the last documented PE was completed on 10/19. CNA 2 was hired 1/22/15, the last documented PE was completed on 3/22. During an interview on 11/21/24 at 10:45 a.m. with the Regional Human Resource Manager (RHRM), the RHRM was asked about the annual PE's and stated, Unfortunately we have had some turnover .we have not done the annual performance evaluations .they are important [for CNA's] to get a good sense of feedback . During a review of the facility's policy and procedure (P&P) titled, PERFORMANCE EVALUATIONS, dated 11/23, the P&P indicated, .performance evaluations may be conducted annually, on or around your anniversary date .Performance…

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 infection control practices when the cook failed to wear a beard restraint in the kitchen for a census of 165 Residents when: cook's facial hair was not covered with a beard restraint while preparing food. This deficient practice had the potential to cause the transfer of harmful bacteria and hair into food served to residents living at facility. Findings: During the initial kitchen tour on 11/18/24, at 8:53 a.m., observed the cook preparing food without a beard guard. During a concurrent observation and interview on 11/18/24, at 9:02 a.m., with the Dietary Manager (DM) in the kitchen, the DM confirmed the cook was not wearing a beard restraint. The DM further confirmed the cook must always wear a beard restraint when working in the kitchen .failure to do so may result in foodborne illness and potential hair in the food served to residents. During a review of the facility's policy and procedure (P&P) titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised 11/22, the P&P…

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 the walk-in freezer in safe operating condition when ice buildup was noted on the ceiling and back wall of the freezer. This had the potential to affect the safety and quality of the food served for 165 of the residents eating facility prepared meals. Findings: During a concurrent observation and interview on 11/18/24, at 10:15 a.m., with the Dietary Manager (DM), by the walk-in freezer, the DM confirmed there was ice buildup on the ceiling and the back wall. The DM stated, maintenance takes care of the de-icing of the freezer. During an interview on 11/20/24 at 11:03 am with the Maintenance Director, (MD), the MD confirmed there was ice buildup in the walk-in freezer that could affect food quality. The MD further stated, I have adjusted the door closure mechanism .so it closes more quickly to prevent warm air getting in, leading to more ice buildup. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 12/09, the P&P indicated, .1. The Maintenance…

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 resident bedrooms met the minimum requirement of 80 square feet per resident. There were 13 rooms with three occupants in each room for a census of 171, were below the minimum requirement of 80 square feet per resident. This failure increased the potential for inadequate personal space for the residents in these rooms. During an observation and concurrent interviews conducted on 11/18/24 at 12:03 p.m. rooms [ROOM NUMBER] were observed to be neat, with sufficient space for residents' personal effects. There was ample room for entrance, way out, maneuvering of equipment in and out of the rooms, and access to the bathrooms. No validated issues or concerns regarding the lack of space for delivering care were verbalized by any of the residents in these rooms. During an interview on 11/18/24 at 12:08 p.m. with Resident 135, Resident 135 stated, .The room is small, but we respect each other's space .I like to have stuff, and we keep it…

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 protect one out of four sampled residents' (Resident 4) right to be free from physical abuse by a resident (Resident 1) when Resident 1 yanked, tugged, and shook Resident 4's hair backwards. These failures resulted in Resident 4 getting hurt, being scared, and experienced emotional distress, and had the potential for Resident 4 and all residents in the facility to experience physical and/or psychosocial harm. Findings: A review of Resident 1's clinical record indicated Resident 1 was originally admitted July of 2016 and had diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 7/23/24, indicated Resident 1 had a…

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

Based on observation, interview, and record review, the facility failed to provide a sanitary environment for food preparation and service for a census of 156 residents when rodent droppings were observed in the kitchen and the dry food storage area. This failure had the potential to contaminate food served to residents causing food-borne illness. Findings: A review of the facility's Commercial Service Agreement for pest control services, dated 5/26/23, indicated . [Name of company] agrees to provide service for the following pests .Roaches .Common ants .Rats and mice .Common spiders .Flies .Service means the periodic treatment to help control/combat the Covered Pests .Customer Obligations .The Customer shall extend all reasonably necessary cooperation to ensure satisfaction from pest services, including: availability of premises, appropriate sanitation, and corrective construction measures .Service Schedule [Name of company] service representative shall service the Customer (service frequency) .every other week . A review of the facility's pest control reports, dated 8/26/24 and…

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

Based on observation, interview, and record review, the facility failed to dispose of trash and garbage properly when outside garbage dumpsters were uncovered for a census of 156 residents. This failure had the potential to attract rodents and insect pests resulting in an unsanitary and uncomfortable environment for residents. Findings: During a concurrent observation and interview on 9/24/24 at 3:37 p.m. with the Maintenance Director (MD), observed outside garbage dumpsters. Observed 3 blue dumpsters and 2 of the dumpsters were half covered by lid. Observed 1 large compactor bin open with no cover. Observed compactor machine with no bin underneath. Observed trash and garbage in each uncovered dumpster and in the compactor bin. Observed multiple flying pests around area. The MD acknowledged that the garbage dumpsters and the compactor bin were left uncovered. The MD stated that the garbage service did not cover the bins after emptying. The MD stated that the garbage service did not move the compactor bin back underneath compactor machine, so it was open, and staff had been throwing…

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 necessary means of communication for one of four sampled residents (Resident 1), when staff did not use translation services including phone translation services and Resident 1 was not provided with a communication board (an alternative communication device with symbols and pictures to help people with limited English communicate). This failure had the risk potential for Resident 1's care needs to be unmet leading to inadequate care. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in September 2023 for multiple diagnoses including hemiplegia (paralysis of one side of the body) of right side, diabetes (too much sugar in the blood), and dysphagia (difficulty swallowing). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 7/10/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 9 out…

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

Based on observation, interview, and record review, the facility failed to provide a comfortable and sanitary environment for one of four sampled residents (Resident 1), when Resident 1's privacy curtain had a brown crusted stain on it and the top drawer of the bedside dresser had insect fragments, stains, and solid particle matter on the bottom of the drawer. This failure resulted in an unsanitary and uncomfortable environment for Resident 1 with the risk potential for infection or harm. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in September 2023 for multiple diagnoses including hemiplegia (paralysis of one side of the body) of right side, diabetes (too much sugar in the blood), and dysphagia (difficulty swallowing). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 7/10/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 9 out of 15 which indicated Resident 1 was moderately cognitively impaired. A review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to revise the Care Plan for one of four sampled residents (Resident 1), when Resident 1's Care Plan did not accurately reflect the feeding assistance provided. This failure had the potential for Resident 1 to receive incorrect feeding assistance not in accordance with her wishes. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in September 2023 for multiple diagnoses including hemiplegia (paralysis of one side of the body) of right side, diabetes (too much sugar in the blood), and dysphagia (difficulty swallowing). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 7/10/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 9 out of 15 which indicated Resident 1 was moderately cognitively impaired. A review of Resident 1's MDS, Functional Abilities and Goals, dated 7/10/24, indicated Resident 1 was independent with eating. A review of Resident 1's Order Summary…

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 two of three sampled residents (Resident 1) and (Resident 2), were free from abuse, when Resident 2 was seen hitting Resident 1 on the arm, afterwhich Resident 1 turned and threw his coffee on Resident 2. This failure increased the potential for physical and psychosocial injury. Findings: Resident 1 was admitted to the facility in mid-2024 with diagnoses which included sepsis (infection throughout the body), pneumonia (lung infection) and schizophrenia (mental disorder of the thought processes). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/3/24, the MDS indicated Resident 1 had moderately impaired memory. Resident 2 was admitted to the facility in mid-2024 with diagnoses which included disease of the spinal cord, hypertension (high blood pressure), diabetes (inability of body to properly regulate blood sugar), and brain injury. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident…

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

Based on observation, interview and record review, the facility failed to maintain one of three sampled resident's (Resident 1) assistive devices in working condition when the resident's hearing aids were inoperable. This failure resulted in Resident 1 being unable to communicate and feeling frustrated. Findings: Review of Resident 1's medical record, admission RECORD indicated the resident was a long term resident in the facility with diagnoses that included lung problems and depression. In a concurrent observation and interview on 7/17/24 at 10:35 a.m. in Resident 1's room, Resident 1 was observed lying in bed talking with staff next to her bed both in loud voices. Staff stated the resident was hard of hearing and advised me to speak up and be close to the resident so she could hear. The resident did not wear hearing aids. Resident 1 reported she used to have hearing aids but did not know what happened to them and stated, I can't hear, or I can't make out what they are saying to me .very frustrating. During the interview, the resident was observed to be cupping her left ear 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 and interview the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. Dietary aide (DA) 1 used her non-sterile, gloved index finger and thumb to prepare the food thermometer for insertion into the food. 2. Trash can not covered near food, a glove laying on the floor, a small sink next to the prepared food not clean. 3. Resident 2's breakfast tray was taken out of the dirty tray cabinet and given to Resident 2. These failures had the potential for residents receiving food from the facility kitchen, in a census of 167, to be exposed to food-borne illness. Findings: 1. During a concurrent observation and interview on 7/2/24 at 7:40 a.m., with Dietary Assistance (DA) 1, DA 1 was observed preparing the food thermometer for insertion into the food by using her non-sterile, gloved index finger and thumb to slide the thermometer between them. DA 1 stated, We put it in the cold water to calibrate it and then wipe it with our hands, then put it into the food. During an interview on 7/2/24 at 9:30…

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 meals at a safe and appetizing temperature for three out of three random residents (Residents 1, Resident 2, and Resident 3) when, meals were served cold. This failure had the potential for poor food intake, nutrient deficits, and undesirable weight loss for residents eating facility prepared meals. Findings: During an interview with the Administrator (ADM) on 6/13/24 at 10:31 a.m., the ADM stated, Residents have complained of cold food. The ADM further stated, This has been an ongoing problem. During a concurrent observation and interview with the Registered Dietician (RD) on 6/13/24 at 12:21 p.m., the RD measured the food temperatures from the food cart delivered to Hall 6. The RD stated, The hot entrée and starch should be at a temperature of 120 degrees or greater. The food items tested for temperature were: >Country fried steak (hot entrée) - 108.1 degrees Fahrenheit >Mashed potatoes (starch) - 99.1 degrees Fahrenheit During an interview with the RD on 6/13/24 at 12:39 p.m., the RD confirmed 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 follow proper infection prevention and control practices for one of four sampled residents (Resident 3) when staff stored five unlabeled bedpans (a device used as a receptacle for urine and/or feces) and one unlabeled, uncleaned bedside commode bucket (a device used as a receptacle for urine and/or feces) under the sink in Resident 3's bathroom. This failure had the potential to increase the spread of infection. Findings: Resident 3 was admitted to the facility on [DATE], with diagnoses that included: epilepsy (a disorder of the brain resulting in seizures), hemiplegia (the loss of the ability to move and/or feel in parts of the body), and muscle weakness. During a review of Resident 3's care plan (CP), dated 9/5/23, the CP indicated, .an ADL [activities of daily living] Performance Deficit r/t [related to] Stroke [injury caused by a lack of blood flow to the brain], Limited ROM [range of motion], Hemiplegia, Limited Mobility, Weakness,…

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 documentation review, the facility failed to provide food at an appetizing temperature when three residents (Resident 3, Resident 4, and Resident 5) complained that hot foods were consistently served cold, staff were aware of the complaints, and residents brought up the food temperature issue during the resident council meeting and yet unresolved for a census of 165. This failure resulted in the residents' preference consistently not being honored, therefore, Resident 5 feeling disrespected and Resident 3 and Resident 4 settling for having hot food cold. Findings: In a telephone interview on 5/8/24 at 4:01 p.m., Resident 1's family member voiced that the facility served the hot food cold for the resident. In an interview on 5/9/24 at 11:18 a.m., Resident 3 was in the wheelchair in the hallway and complained, Food comes cold. Resident 3 stated, I am kind of settling for having cold food. But I like to have hot food hot, like eggs in the morning. In an interview on 5/9/24 at 11:24 a.m., Resident 4 was in her wheelchair in her room. The resident stated, Food is…

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

Based on observation, interview and documentation review, the facility failed to provide a functioning call light system for two of three sampled residents (Resident 1 and Resident 2) when neither the light above their room nor the call light panel at the nursing station were working when the residents put the call lights on. This failure compromised the major communication link for staff to meet the needs of the residents and placed the residents at risk for safety. Findings: Resident 1 was a long-term resident in the facility with diagnoses that included right side weakness and the need for assistance with personal care. In a concurrent observation and interview on 5/9/24 at 10:40 a.m., with Licensed Nurse (LN 1), Resident 1's call light was tested and noted the light above the resident's room in the hallway did not turn on. Resident 2, Resident 1's roommate, pushed her call button on and no light lit up, either. LN 1 stated when the resident put a call light on, it also beeped at the nursing station with flashing lights. The call light monitoring panel at the nursing station 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 interview and record review the facility failed to ensure one of four residents (Resident 1) was free from abuse when facility staff witnessed Resident 2 punch Resident 1 in the face. This failure resulted in Resident 1 to sustain a laceration and bruising under his left eye. Findings: Resident 1 was admitted to the facility early 2024 with multiple diagnoses which included hemiplegia (loss of ability to move one side of the body), dysarthria (difficulty speaking) and muscle weakness. A review of Minimum Data Set (MDS, an assessment tool), dated 3/6/24, indicated Resident 1 was cognitively intact. Resident 2 was admitted to the facility April 2024 with multiple diagnoses which included pulmonary embolism (a blood clot in the lung) and seizures. Review of MDS, dated [DATE] indicated, Resident 2 had moderately impaired cognition. During a review of Resident 1's Progress Note, dated 4/18/24, at 9:16 a.m., indicated, at 910 am resident [Resident 1] was physically attacked by roommate .began to punch…

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 comprehensive care plans (plans that summarize specific care needs and treatments) were developed for one of four sampled residents (Resident 1), when the facility identified Resident 1 as exit seeking. Care plans were not created until after Resident 1 eloped (run away secretly) from the building.This failure resulted in no written interventions being available for staff to follow which could have reduced the risk of Resident 1 leaving the building and being lost for eight hours. Findings: Resident 1 admitted to the facility early 2024 with diagnoses which included metabolic encephalopathy (a problem in the brain), alcohol abuse with perceptual disturbance (misinterpreting the environment, hallucinations), dementia (memory problems). Resident 1's family member was listed as the responsible party. During a review of Resident 1's PHYSICIAN'S ORDERS FOR admission ., dated 3/29/24, the orders indicated, .Lacks capacity to understand and sign admission contract, participate in plan of care or make health care decisions…

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

Based on interview and record review, the facility failed to provide adequate monitoring and supervision for one of four sampled residents (Resident 1), when Resident 1 left the facility without notifying staff. This failure caused Resident 1 to be lost for eight hours and increased the risk for harm. Findings: Resident 1 admitted to the facility early 2024 with diagnoses which included metabolic encephalopathy (a problem in the brain), alcohol abuse with perceptual disturbance (misinterpreting the environment, hallucinations), dementia (memory problems). Resident 1's family member was listed as the responsible party. During a review of Resident 1's PHYSICIAN'S ORDERS FOR admission ., dated 3/29/24, the orders indicated, .Lacks capacity to understand and sign admission contract, participate in plan of care, or make health care decisions . During a review of Resident 1's Progress Notes (PN), dated 3/30/24 at 11:54 a.m. the PN indicated, resident has been very confused today has packed his bags twice tried to walk out of the facility stating he was just going to go out to his truck or…

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

Based on observation, interview, clinical record and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) had access to his motorized wheelchair (MWC) when they failed to provide a place to store it within the facility premise. This failure resulted in Resident 1 not being able to have mobility within the facility or outside the facility. Findings: Resident 1 was admitted to the facility in 2023 with diagnoses that included severe morbid obesity (a condition of being severely overweight) and muscle weakness. A review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive Patterns, dated 12/30/23, indicated Resident 1 had a Brief Interview for Mental Status (a tool to assess cognition) score of 15 out of 15 which indicated Resident 1 was cognitively intact. A further review of Resident 1's MDS, under the functional abilities and goals section indicated Resident 1 required full assistance when using a manual wheelchair. During an interview with the Director of Nursing (DON) on 2/21/24 at 10 a.m., the DON stated, 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 observations, interview and record review, the facility failed to ensure a homelike environment was provided for two of 31 sampled residents (Residents 12 and 39) when there was no running hot water in their bathroom. This failure resulted in resident 12 and 39 not having access to hot water to wash their hands. Findings: Resident 12 was admitted to the facility in August 2022 with diagnoses which included Cerebral Infarction (lack of blood supply to brain cells that cause parts of the brain to die off), muscle weakness, Type II Diabetes (chronic condition that affects the way the body processes blood sugar). During a review of Resident 12's Minimum Data Set (MDS, an assessment tool), dated 9/25/23, the MDS indicated Resident 12 had severe cognitive impairment. Resident 39 was admitted to the facility in June 2022 with diagnoses which included anxiety, high blood pressure, and chronic obstructive pulmonary disease (COPD, a disease that causes difficulty or discomfort in breathing). 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 observation, interview and record review, the facility failed to employ staff with appropriate competencies for a census of 157 when: 1. [NAME] 1 was unable to demonstrate knowledge of fire safety measures; and 2. [NAME] 1 did not know how to calibrate the thermometer used to check the temperature of cooked food. This failure had the potential to cause a fire that could result in serious injury or substantial property loss, and inaccurate temperature readings of food that may cause rapid growth of pathogenic microorganisms (an organism causing disease to a person), resulting in foodborne illness (infection caused by bacteria, viruses and parasites). Findings: During a concurrent observation and interview with [NAME] 1 on 12/13/23 at 10:40 a.m., [NAME] 1 stated, he did not know what to do if there was a fire in the kitchen. When asked to demonstrate how to properly calibrate the thermometer, [NAME] 1 replied, I don't know how to calibrate the thermometer, I only know how to check the temperature of the food. During an interview with the Registered Dietician Regional (RDR 1)…

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 serve meals at a safe and appetizing temperature for 10 out of 31 sampled residents (Resident 99, Resident 7, Resident 92, Resident 139, Resident 64, Resident 22, Resident 209, Resident 74, Resident 150 and Resident 50) whose meals were delivered and served cold. This failure had the potential for decreased meal intake which could potentially result in weight loss due to lack of proper nourishment that could negatively impact the resident's quality of life. Findings: During an interview with Resident 74 on 12/11/23 at 9:10 a.m., Resident 74 stated the food was always cold. During an interview with Resident 99 on 12/11/23 at 09:15 a.m., Resident 99 stated, eggs are cold, food that is supposed to be hot are cold. During an interview with Resident 139 on 12/11/23 at 10:32 a.m., Resident 139 stated, the food is always cold, Eggs and sausage for breakfast is always cold. I have not had a warm breakfast, lunch or dinner ever since I came here. During an interview with Resident 92 on 12/11/23 at 10:38 a.m., Resident…

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

Based on observation, interview, and record review, the facility failed to ensure that nutritional supplements on two of four inspected medication carts (med cart 1 and med cart 2) were labeled with a date and time when opened and kept at proper temperatures. This failure decreased the potential for residents to receive the full nutritive value of their supplements. Findings: During a concurrent observation and interview on 12/13/23 at 11:15 a.m., with the Director of Nursing (DON) in Hall 1, on cart 1, a Med-PASS® (a nutritional supplement) box was observed without a time labeled on it when it was opened. It was labeled with the date 12/13, and kept in a thick-walled plastic bin called a cold bin. On touch, both the Med-PASS® box and cold bin were at room temperature. The DON stated, Med-PASS® box is kept in a cold bin to maintain the refrigerator temperatures. The DON also acknowledged that the Med-PASS® box was not labeled with the time when it was opened. The DON verified that the Med-PASS® box and cold bin were not cold to touch and were at room temperature. The DON also…

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 facility document review, the facility failed to provide 80 square feet of space per resident in rooms 26, 34, 35, 42, 43, 44, 46, 47, 48, 49, 50, 51, and 53. This failure increased the potential for inadequate personal space for the residents in these rooms for a census of 157. Findings: During an observation and concurrent interviews conducted on 12/11/23 beginning at 9:01 a.m., room numbers 26, 34, 44, 49, and 51 were observed to be uncluttered with sufficient space for the personal effects of residents. There was ample room for entrance, egress (going out) and maneuvering of equipment in and out of the rooms and access to the bathrooms. There were no validated issues or concerns regarding lack of space for the delivery of care verbalized by any of the residents in these rooms. During an interview on 12/11/23 at 11:04 a.m. with Resident 2, Resident 2 stated room size was ok. During an interview on 12/11/23 at 11:16 a.m. with Resident 14, Resident 14 stated, The room could be bigger .[it's]fine .[I] make do. During an interview with 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 one of 31 sampled residents (Resident 129) was provided with an appropriate call light system to call staff when she needed assistance. This failure had the potential for the resident's needs not being met. Findings: Resident 129 was admitted to the facility January 2023 with multiple diagnoses which included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), hemiplegia (severe loss of strength on one side of the body), and hemiparesis (partial loss of strength on one side of the body). During a review of Resident 129's care plan, dated on 1/23/23, indicated, The resident has limited physical mobility r/t [related to] bilateral lower extremities contracture (contracture, a condition of shortening and hardening of muscles, tendons, and other tissue leading to deformity and rigidity of joints) and upper extremity contracture. During a concurrent observation and interview on 12/11/23, at 10:14 a.m., Resident 129 was lying in bed with both hands contracted and wrapped in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure the intravenous (IV) tubing was labeled with the date and time for 1 of 31 sampled residents (Resident 208). This failure had the potential to result in an infection for Resident 208. Findings: A review of the skilled nursing, admission Record indicated, Resident 208 was admitted to the facility on [DATE], with a diagnoses including, Methicillin Resistant Staphylococcus Aureus infection (a type of infection resistant to antibiotics). During a concurrent observation and interview with Licensed Nurse 4 (LN 4) on 12/11/23 at 8:49 a.m., LN 4 verified the IV tubing was not labeled with the date and time. LN 4 stated, The IV tubing should be labeled with the date and time. A review of Resident 208's physician orders, dated 12/8/23, indicated an order for Vancomycin (an antibiotic) 1.25 grams IV every 12 hours at a rate of 125 milliliters (ml) per hour related to Methicillin Resistant Staphylococcus Aureus (MRSA)…

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 infection prevention and control program guidelines and practices were maintained for one of four sampled residents (Resident 1), when the isolation contact precautions cart was set up with no personal protective equipment (PPE) available for staff use. This failure had the potential to result in transmission and spread of infection for a vulnerable population. Findings: Resident 1 was admitted in late 2023 with diagnoses which included herpes zoster (shingles, a highly contagious viral infection with lesion requires airborne or contact isolation). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/3/23, the MDS indicated Resident 1 had mild memory impairment. Resident 2 was admitted in late 2022 with diagnoses which included herpes zoster. During a review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 9/22/23, the MDS indicated Resident 2 had no memory impairment. During a review of Resident 1's Nursing Care Plan (NCP), dated 11/1/23, the NCP…

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 protect one of 4 sampled residents (Resident 1) from verbal and physical abuse when Resident 2 physically assaulted Resident 1 and caused multiple injuries and used derogatory language towards him. Additionally, Resident 2 had in the recent past assaulted two other residents (Resident 3 and Resident 4). This failure resulted in Resident 1 sustaining injuries to his left ear, left side of face, left eyebrow and right 3rd finger, and had increased the potential to negatively impact Resident 1's psychosocial well-being. Findings: According to the admission Record, the facility admitted Resident 1 over 3 years ago with multiple diagnoses which included fracture of unspecified vertebra (small bones) of the lower back and recurrent depression. Resident' s most recent Minimum Data Set (MDS, an assessment tool) indicated he scored 10 out of 15 in a Brief interview for Mental Status (a cognitive test) which indicated he had moderate cognitive impairment. The MDS further indicated the resident had no physical or verbal…

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 protect one of 3 sampled residents (Resident 1) from verbal and physical abuse when Resident 2 physically assaulted him and used derogatory language towards him. This failure resulted in Resident 1 having a headache and had the risk potential to negatively impact his psychosocial well-being. Findings: According to the 'admission Record' the facility admitted Resident 1 recently with multiple diagnoses which included diabetes, right below knee amputation and schizophrenia (mental illness) manifested with auditory hallucinations (hearing voices or noises that don't exist in reality). Resident 1 scored 15 out of 15 in a Brief Interview for Mental Status (BIMS, tests memory and recall), dated 10/3/23, which indicated he was cognitively intact. Resident 1's physician 'Order Summary Report' indicated he was taking medication for schizophrenia and being monitored for auditory hallucinations every shift. According to the 'admission Record' the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean environment was maintained for a census of 164 residents, when facility shower rooms were observed to be unsanitary. These failures had the potential to compromise the health, safety, and dignity of residents by increasing the risk of transmission-based infection in an unsanitary and uncomfortable environment. Findings: During an interview on 8/25/23 at 1 p.m. with Resident 3, Resident 3 indicated, It's not ok for us to be exposed to shit, it's unsanitary. The common areas that we all use, and share should be clean .it's gross [when it's dirty]. During an interview on 8/25/23 at 1:15 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, we must go to the nurses' station and beg for the cleaning wipes, they are not always available in the shower rooms. During a concurrent observation and interview on 8/25/23 at 1:22 p.m. with the Director of Nursing (DON), shower room tiles were worn, stained, scratched, and black…

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, clinical record review, and facility document review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) received a medication in accordance with professional standards of practice when Licensed Nurse (LN) 1, gave Certified Nursing Assistant (CNA) 1 a narcotic medication, to give to Resident 1. This failure could have resulted in drug diversion and inaccurate care. Findings: A review of the facility's investigation report indicated Resident 1 reported that on 7/23/23 or 7/24/23 around 2 a.m., Licensed Nurse (LN) 1 gave Certified Nursing Assistant (CNA) 1 a narcotic medication, to give to Resident 1 and LN 1 did not watch Resident 1 take the medication. Resident 1 stated she asked CNA 1 where the nurse was and CNA 1 replied, He didn't want to put a mask on, so he asked me to give it to you. Review of the facility's investigation report indicated on 7/25/23, LN 1 was interviewed. LN 1 stated on 7/23/23 at 11 p.m., he was passing medications when he entered Resident 1's room and realized he wasn't wearing a mask. LN 1 walked out of the room and as…

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 Minimum Data Set (MDS- a resident assessment tool used to guide care) was accurate for one of four sampled residents (Resident 3) when the Behavior section did not reflect that Resident 3 exhibited multiple aggressive behaviors. This failure had the potential to result in Resident 3 not receiving appropriate care and interventions. Findings: A review of Resident 3's clinical record indicated Resident 3 was admitted January of 2023 and had diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and dementia (memory loss that interferes with daily functions). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, Assessment Reference Date (ARD)/Target date (last day of the observation or look back period that the assessment covers for the resident) of 7/22/23, indicated, Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out…

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.