River Pointe Post-Acute

Based on observation, interview, and record review, the facility failed to ensure call lights were available to use for two of 31 sampled residents (Resident 113 and Resident 121), when:1. Resident 113's call light was not within reach and not suitable to be used; and2. Resident 121's call light was not within reach.These failures decreased the facility's potential to assist residents in a timely manner when needed.Findings: 1. A review of Resident 113's admission Record, dated 3/17/26, indicated Resident 113 was admitted to the facility in July 2025 with diagnoses including multiple sclerosis (MS-a chronic, progressive disease damaging the nerve cells in the brain and spinal cord) and glaucoma (a group of eye diseases causing vision loss and blindness). During a concurrent observation and interview on 3/10/26 at 8:15 a.m. with Certified Nursing Assistant (CNA) 2 and Resident 113, Resident 113 was in bed and a regular call light was observed tied to the left bed rail. Resident 113 was unable to find the call light. Resident 113 explained left hand weakness, partial right hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow proper infection control practices for one of six sampled residents (Resident 1) when a contracted staff member provided care to Resident 1 without wearing a gown. This failure had the potential to increase the spread of infection for a census of 112. Findings:Resident 1 was admitted to the facility in February of 2026 with diagnoses that included Methicillin Resistant Staphylococcus Aureus Infection (MRSA, an infection caused by antibiotic resistant bacteria). A review of Resident 1's Physician Orders (PO), dated 2/9/26, indicated, CONTACT PRECAUTIONS [infection-control measures used in healthcare settings to prevent the spread of germs transmitted by direct or indirect contact with a patient or their environment. They require wearing gloves and a gown for all room interactions, dedicated equipment usage, and strict hand hygiene] SECONDARY TO DX: Saccral Wound Infection (MRSA) every shift.During a concurrent observation and interview on 2/19/26 at 8:46 a.m. with the Contract Phlebotomist (CP, a…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received adequate assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), when showers were not provided as scheduled. This failure had the potential to result in Resident 2 not attaining his highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 2's admission record (AR), the AR indicated Resident 2 was admitted in late winter 2026 with diagnoses which included walking and mobility abnormalities, need for assistance with personal care, and heart failure. A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/26/26, indicated Resident 2 had no memory impairment and was totally dependent on shower transfer (getting in and out of shower/tub). A review of Resident 2's ADL care plan, initiated 1/28/26, indicated [Resident 2] has an ADL selfcare performance, and [Resident 2]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food allergies were honored for one of four sampled residents (Resident 1) when during the lunch meal on 12/21/2025 Resident 1 was served Banana Pie that contained a known allergen.This failure resulted in Resident 1 to have a potentially life-threatening allergic reaction.Findings:During a review of Resident 1's clinical record, Resident 1 was admitted in December 2025 with diagnoses that included chronic respiratory failure (a long-term condition where the lungs can't get enough oxygen in or remove enough carbon dioxide), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), and oxygen dependence. Resident 1's allergies included banana causing anaphylaxis (severe, potentially life-threatening allergic reaction). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/8/25, Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated 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.

Based on observation, interview, and record review, the facility failed to ensure assistance with the use of dentures was provided for one of three sampled residents (Resident 1).This failure increased the potential for Resident 1 to refuse meals and lose weight.A review of the admission Record indicated Resident 1 was admitted early December 2025 with diagnosis including generalized muscle weakness. Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/10/25 indicated Resident 1 was cognitively intact, had impairment on both upper extremities and required substantial or maximal assistance (helper does more than half the effort) for oral hygiene which included ability to insert and remove dentures into and from the mouth. Further review of Resident 1's clinical records indicated the following:-Care plan, initiated 12/4/25 indicated, Resident 1 had Activities of Daily Living (ADL) self care performance deficit and at risk for ADL decline related to generalized weakness, carpal tunnel syndrome (a pinched nerve of the wrist causing numbness, pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication was stored in a safe manner for one of three sampled residents (Resident 1).This failure had the potential for diversion or unauthorized use of medication not being securely stored. A review of the admission Record indicated Resident 1 was admitted early December 2025 with diagnosis including generalized muscle weakness. Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) dated 12/10/25 indicated Resident 1 was cognitively intact with a score of 15. During a concurrent observation and interview on 12/19/25 at 11:16 a.m., three unlabeled medication cups with white cream were observed inside a white plastic rectangular container on top of Resident 1's dresser. Resident 1 stated the little cups were lidocaine cream (topical cream used to relieve pain) brought in by the nurse, and the cream was applied to her hands twice a day. During a concurrent observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision, per care plan, for a 1:1 sitter (responsible to ensure resident safety with constant supervision) for one of three sampled residents (Resident 1) when Resident 1 was left unattended in his room.This failure had the potential to put Resident 1 at risk for falls, injuries and elopement while being unsupervised. Findings: Resident 1 is a [AGE] year old resident that was admitted to the facility in October 2025 with multiple diagnoses that included encephalopathy (disorder affecting brain function or structure, leading to confusion, memory loss, or coma), hemiplegia (severe weakness on one side of the body), hemiparesis following cerebral infarction (weakness on one side of the body, affecting the arm, leg, and sometimes face, often due to brain injury following a stroke) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS, an assessment tool), dated 10/10/25, indicated…

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

Based on observations, interviews and record reviews, the facility failed to ensure that the call light system was fully functional and properly maintained for one of three sampled residents (Resident 1) when Resident 1 pressed the call light button and activated the call light above the resident's room door, the corridor call lights located on the wall and above the double door failed to illuminate.This incomplete functionality of the call light system had potential to delay staff response to Resident 1's needs and impede Resident 1's ability to effectively communicate for assistance when required.Findings:Resident 1 was admitted to the facility in early Winter of 2025 with diagnoses which included respiratory and heart failure.A review of Resident 1's Order Summary Report (ORS) indicated, Resident is capable of making his own health decisions.A review of Resident 1's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 12/8/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognitive function.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of abuse when an incident involving two of five sampled residents (Resident 1 and Resident 3) was not reported to the Department .This failure had the potential to place residents at risk for continued or escalating abuse.Findings:Resident 1 was admitted to the facility in July of 2025 with diagnoses that included violent behavior, restlessness, and agitation.Resident 3 was admitted to the facility in August of 2021 with diagnoses that included dementia. A review of Licensed Nurse 1 (LN 1)'s Nurses Notes (NN), dated 7/29/25, indicated, [Resident 1] was observed striking roommates [Resident 3] in the room and being verbally abusive.During an interview on 8/12/25 at 10:57 a.m. with LN 1, LN 1 stated, [Resident 1] started taking all of [Resident 3]'s things from [Resident 3]'s closet. [Resident 3] saw her [Resident 1] and tried to take her things back and [Resident 1] started to hit her. I don't think it was reported to the state.I turned the corner and saw them tugging back and forth. [Resident 1] was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 107 when: Staff did not wear appropriate personal protective equipment (PPE) for residents on isolation precaution (measures to reduce transmission of diseases) for COVID-19 (a contagious disease caused by the coronavirus [a type of virus]); and,Licensed Nurse 3 (LN 3) was observed eating by the cart in the hallway.These failures decreased the facility's potential in preventing transmission of diseases among residents and staff.Findings:1. During an observation on 7/22/25 at 10:35 a.m. in room [ROOM NUMBER], Novel Respiratory Isolation [measures to reduce transmission of COVID-19] signage was observed by the door of the room, which indicated one or all the residents in the room had tested positive for COVID-19. Housekeeping Staff (HS) was observed inside the room, holding an empty can of soda and cleaning the room. HS was observed wearing a surgical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing care staff meet certification requirements defined under State law and regulation for one of four sampled staff (Certified Nursing Assistant 4 [CNA 4]) when CNA 4 was scheduled to work with expired CNA certification.This failure had the potential to result in residents not receiving appropriate care based on professional standards of practice.Findings:During a review of CNA 4's employee file, the employee file indicated CNA 4's certification expired on [DATE].During an interview on [DATE] at 3:14 p.m. with the Director of Staff Development (DSD), the DSD verified CNA 4's certification expired from [DATE] and CNA 4 last worked on [DATE]. When asked about the expired certification, the DSD stated, .I know I messed up, certification not renewed.Somebody can get harmed, it affects everybody.During an interview on [DATE] at 3:27 p.m. with the Director of Nursing, the DON stated, Expectation is that the DSD maintains a spreadsheet or tracker…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 COVID-19 (a contagious disease caused by the coronavirus [a type of virus]) vaccinations were offered to residents and staff when one of four sampled residents (Resident 1), and one out of four sampled staff (CNA 4), had no documented evidence of their COVID-19 vaccination status.This failure had the potential to result in Resident 1 and CNA 4 not to be aware of the risk and benefits of the vaccination and increased their risk of acquiring COVID-19.Findings:1a. During a review of Resident 1's admission record, the record indicated Resident 1 was admitted in the facility in May 2025 with diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had severe cognitive impairment.During a review of Resident 1's care plan, initiated on 7/15/25, the care plan indicated, Novel respiratory precautions [COVID-19 isolation] r/t [related to] COVID positive test results.During a…

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

Based on interview and record review, the facility failed to ensure professional standards of practice were followed for three of six sampled residents (Resident 1, Resident 2, and Resident 3), when: 1. Resident 1 ' s Permethrin (a medication used to treat scabies - a very itchy rash caused by a parasitic mite that burrows in the skin surface) was not given per physician ' s order and Resident 1 ' s Ivermectin (used for infections caused by parasites) order was not carried out as ordered; 2. Resident 2 ' s Permethrin order was not followed as ordered; and 3. Resident 3 ' s Permethrin order was not carried out timely. These failures had the potential to result in Resident 1, Resident 2, and Resident 3 not having the desired effects of the medications. Findings: 1. During a review of Resident 1 ' s admission records, the records indicated Resident 1 was admitted in February 2025 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought). Resident 1 ' s Minimum Data Set (MDS, a federally mandated assessment tool) indicated 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.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one of six sampled residents (Resident 1) when Resident 1 ' s contact precaution (isolation measures used to prevent the spread of infections transmitted through direct contact or indirect contact) was removed before Resident 1 received treatment for scabies (a very itchy rash caused by a parasitic mite that burrows in the skin surface). This failure decreased the facility ' s potential in preventing transmission of diseases among residents and staff. Findings: During a review of Resident 1 ' s admission records, the records indicated Resident 1 was admitted in February 2025 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought). Resident 1 ' s Minimum Data Set (MDS, a federally mandated assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1 ' s physician order, dated 5/14/25, the order indicated, CONTACT ISOLATION. Check in with…

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

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2 hit Resident 1 on the left hand. This failure resulted in a bruise on Resident 1's left hand and had the potential for Resident 1 to feel unsafe in the facility. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in June 2024 with multiple diagnoses including stage 4 pressure ulcer (injury to the skin with full thickness tissue loss with exposed bone, tendon or muscle due to prolonged pressure) of the sacral (base of the spine) region, dementia (loss of memory and thinking skills) and diabetes (too much sugar in the blood). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 12/5/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 14 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's SBAR [Situation, Background, Assessment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper infection control practices for one of seven sampled residents (Resident 1) when a Certified Nursing Assistant (CNA) did not put on a protective gown when performing resident care. This failure had the potential to increase the spread of infection. Findings: Resident 1 was admitted to the facility in November of 2024 with diagnoses that included skin infection. A review of Resident 1 ' s Order Details, dated 12/2/24, indicated, Enhanced Barrier Precautions [EBP, precautions taken by healthcare staff to prevent the spread of infection] during high contact time secondary to indwelling Foley Catheter [a flexible plastic tube inserted into the bladder to provide continuous urinary drainage]. Review of the facility ' s policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised 8/22, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) [bacteria that are resistant to certain commonly used antibiotics] 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.

Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. The ice machine was not clean; and 2. Kitchenware was stacked and stored while wet in the clean and ready-to-use storage area; and 3. Fry pans stored in the clean and ready-to-use storage area were not clean; and 4. Food in open packages was not covered and open food items lacked complete label; and 5. Expired food was available for use; and 6. Food thawing processes were not followed; and 7. Outdated resident food brought from the outside was not discarded; and 8. One dietary staff did not have hair fully covered; and 9. Two dietary personnel were not able to demonstrate and verbalize correct concentration testing and concentration range of dishwasher sanitizer; and 10. Two dietary personnel were not able to verbalize the correct manual dishwashing process. These failures had the potential to result in food contamination which could cause illness in the 105 of 105 residents…

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

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed of properly when two of the two outside dumpsters were not adequately closed, and the surrounding area was littered with debris for a census of 108. This failure had the potential to expose the residents, visitors, and staff to pests, odor, or disease. Findings: During a concurrent observation and interview on 11/5/24 at 10:49 a.m. with the Dietary Supervisor (DS), the lid of facility garbage dumpster containing bags of trash was not tightly closed. Urinal with brown and yellow liquid observed on ground next to the garbage bin. DS confirmed lid was open and should be tightly closed. During a follow-up observation on 11/6/24 at 7:45 a.m., gate to dumpster area was open, and hatch doors on top of both garbage dumpster and recycling dumpster were open. During a follow-up observation on 11/6/24 at 4:45 p.m., both garbage dumpster and recycling dumpster lids were open. During a concurrent observation and interview on 11/7/24 at 7:55 a.m. with the Environmental Services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Dietary Services Supervisor (DS) failed to demonstrate the appropriate competencies and oversight to carry out the functions of the food and nutrition services. These deficient practices had the potential to cause food borne illness for 105 of 108 of the highly susceptible residents who consumed food from the kitchen of the facility as evidenced by: 1. DS was unable the verbalize the proper procedure of thawing meats by using the refrigeration method (cross refer to F812, #6); 2. DS did not have proper knowledge about the correct concentration of the sanitizer for the dishwashing machine (cross refer to F812, #9), and 3. DS did not have knowledge about the proper process for manual dishwashing by the three-compartment sink (cross refer to F812, #10) 4. DS did not have hair fully covered by hair restraint (cross refer to F812, #8) Findings: 1. During an observation of the walk-in refrigerator on 11/5/24, at 9:55 a.m., there was a three-level carts with boxes of foods and the boxes were wet and observed liquid was leaking out 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 Dietary Aide (DA 1) had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. DA 1 was unable to demonstrate and verbalized the correct use of the test strip and the correct concentration of the sanitizer (Chlorine) for the dishwashing when using the dishwashing machine, and 2. DA 1 was unable to verbalize the correct process of manual dishwashing with three-compartment sink. These failures had the potential to place 105 out of 108 highly susceptible residents who consumed food from the facility at risk for food borne illness. Findings: 1. During a concurrent observation and interview on 11/5/24, at 10:33 a.m. with DA 1 and Dietary Services Supervisor (DS), DA 1 demonstrated and verbalized the process of dishwashing with dishwashing machine. She stated to check the effectiveness of the sanitizer (Chlorine) was to use the test strip to check the concentration and it should be 200 ppm (parts per million - a measurement unit for…

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

Based on observation, interview, and record review, the facility failed to ensure the planned menu was followed for lunch on 11/6/24 when: 1. Two of four residents (Resident 25 and Resident 38) with large portion diets received incorrect portions of meatballs (5 counts of meatballs instead of 6 counts.) 2. Four of four residents (Resident 6, 29, 38, and 40) with Renal or CKD5 diets (diets for people managing chronic kidney disease) received tapioca pudding instead of cookie as dessert. 3. Three of three residents (Resident 10, 24, and 100) with low fat and low cholesterol (a type of fat, LFLC) diets received whole milk and margarine with wheat roll instead fat free milk and no margarine with wheat roll. 4. Two of two residents (Resident 64 and Resident 81) with finger food diets received rice and tapioca pudding instead of diced/sliced potato and pudding on graham crackers 5. 105 of 105 residents did not receive garnish with parsley for their meals. These deficient practices had the potential to result in residents having meals which would not meet their nutritional needs. Findings:…

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

Based on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for two of 22 sampled residents (Resident 11 and Resident 5) when: 1.Resident 11's medications were left on the bedside table unattended. 2. Resident 5's oxygen tubing was left unconnected to the oxygen machine. These failures decreased the facility's potential to safely follow physician's order and cause health complications. Findings: 1. During a review of Resident 11's admission Record, it indicated that Resident 11 was admitted in Fall of 2022 with multiple diagnosis that included acute and chronic respiratory hypoxia (condition that can cause decreased oxygen through the body) and Type 2 Diabetes with polyneuropathy (condition that causes problems with blood sugar control with nerve ending damage. During a concurrent observation and interview on 11/6/24 at 8:28 a.m. with Resident 11, Resident 11 was lying in bed and a medication cup contianing several medications was on the bedside table unattended. Resident 11 stated the nurses leaves 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 that the residents remained free of accident hazards for a census of 108 when: 1) The facility did not have a smoking policy and procedure and failed to supervise residents (Resident 27 and Resident 61) smoking on facility premises. 2) The facility did not have a smoking care plan for a resident (Resident 61) non-compliant with care. These failures had the potential to result in accidents including resident injury and fire. Findings: 1) During a review of Resident 27's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 27 was admitted to the facility January 2021 with multiple diagnoses which included asthma (a chronic lung disease that causes inflammation in the airways, making it difficult to breathe) and nicotine dependence (a chronic disease that occurs when someone's body and mind become used to having nicotine in their system). During a review of Resident 27's Smoking Assessment, dated 9/21/24, the Smoking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had a 20.69% error rate when six medication errors out of 29 opportunities were observed during a medication pass for one of five Residents (Residents 88). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: During a concurrent medication pass observation and interview on 11/5/24 at 8:15 a.m. with Licensed Nurse 3 (LN 3), LN 3 was observed preparing Resident 88's medications for administration. LN 3 placed 5 ml (ml- a unit of measurement) of liquid docusate sodium (a medication to help treat constipation) 50 mg (milligram, a unit of measurement)/ml in a 15 ml medication cup. LN 3 placed 10 ml of liquid levetiracetam (a medication to prevent seizures) 100mg/ml in a separate 15 ml medication cup. LN 3 did not dilute the liquid docusate sodium or liquid levetiracetam. LN 3 placed omeprazole (a medication to treat acid reflux) 20 mg delayed release tablet, aspirin (a medication to prevent blood clots) 81 mg chewable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 22 sampled residents (Resident 88) was free of a significant medication errors when he received omeprazole (a medication to treat acid reflux) in crushed pill form instead of the physician ordered liquid suspension through his percutaneous endoscopic gastrostomy (PEG - a feeding tube that's inserted through the abdomen wall and into the stomach) tube. This deficient practice had the potential for ineffective use of omeprazole resulting in a blocked PEG tube and decreased absorption of the medication. Findings: During a review of Resident 88's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 88 was admitted to the facility February 2024 with multiple diagnoses which included cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) and gastro-esophageal reflux disease (GERD- a chronic condition that occurs when stomach contents leak into the esophagus). During a review of Resident 88'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 store discontinued medications and destroyed medications in locked compartments and permit only authorized personnel to have access to the keys in two medication rooms for a resident census of 108. These failures had the potential for medication loss and diversion or misuse of medications from not being securely stored. Findings: During an concurrent observation and interview on 11/5/24 at 9:30 a.m. with Licensed Nurse 1 ( LN1) of Medication room [ROOM NUMBER] drug storage, there was a cabinet with a single door that had a metal latch on it. The cabinet was unlocked with no padlock on the latch. Observations of the cabinet opened revealed multiple packets of medications, bottles of pills and liquid medications. LN 1 stated that this cabinet is not locked and is kept unlocked. During an observation on 11/5/24 at 10:08 a.m. with LN 1 of Medication room [ROOM NUMBER], a double door cabinet with 2 metal latches connecting the 2 doors together…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement action plans in their Quality Assurance and Performance Improvement (QAPI) program for an identified infection control issue for a census of 108 residents. This failure had the potential to affect infection prevention in the facility. Findings: During a review of the facility's system for their QAPI program, it was noted that a Performance Improvement Project (PIP) dated 8/16/24 was identified for an infection control issue. It had review dates for 9/16/24, 10/16/24, and planned complete date of 11/16/24. No documented evidence the following tasks were done: 1) In-Service to all nursing department .2) 100% Competency skills check for current Full Time Employees and upcoming new hires CNAs and LNs . 3) 100% Skin Sweep Weekly x 6 weeks and 4) Findings of the audits in #1, 2 and 3 will be reported in the QAA(quality assessment and assurance) Monthly Meeting. There was no further documented evidence that the facility had follow up reviews or meetings in September 2024 or October 2024 as required per the PIP. 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 follow and maintain an effective infection prevention and control program for a census of 108 residents when: 1. Staff failed to properly store Resident 1's personal items found on the floor 2. Facility staff provided care without wearing all the required personal protective equipment (PPE) for Resident 21 who was on Enhanced Barrier Precaution (EBP) (EBP - infection control intervention designed to reduce transmission of multidrug-resistant organisms, MDROs- bacteria that resist treatment with more than one antibiotic] that requires gown and glove use) 3. Resident 80 and Resident 66 urinals (a hand-held bottle for urination) were not labeled with a resident identifier and the date it was initially used; 4. A blood pressure cuff was not cleaned and sanitized in between resident use; and 5. Linens and a soiled incontinence (involuntary leakage of urine or feces) pad were observed on the floor of Resident 56's room. These failures had the potential to result in the spread of infection in the facility. Findings:…

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

Based on observation, interview, and record review the facility failed to provide a safe and sanitary environment for one of 22 sampled residents (Resident 66) when: 1. Electrical devices were not checked and safe for use 2. Oxygen tubing was found lying on the floor 3. Power strip and scattered electrical cords were found on the floor and not secured 4. A medical device was plugged into a power strip; and 5. Unclean floors These failures had the potential for Resident 66 to experience a preventable fall, unsafe and unsanitary living conditions. A review of Resident 66's admission Record indicated Resident 66 was admitted late 2023 with multiple diagnosis of obstructive sleep apnea (a disorder that causes you to stop breathing while asleep), acute respiratory failure and history of falling. During an observation on 11/6/24 at 1:37 p.m. in Resident 66 room, Resident 66 was lying in bed with CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) machine, a personal fan, and a laptop…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rights of the residents were maintained for three of six sampled residents (Resident 2, Resident 5 and Resident 6) when four facility employees did not wear identification badges (ID). This failure had the potential to cause residents to feel vulnerable and did not promote safety and security measures for all the residents in the facility. Findings: A review of Resident 2's clinical record indicated Resident 2 was admitted October of 2024 and had diagnoses that included ulcer (open sore) on both legs, heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), abnormalities of gait and mobility, and muscle weakness. A review of Resident 2's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/19/24, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 2 had a moderately impaired cognition. During an interview on 10/28/24 at 12:26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 1's physician's order for moisture associated skin damage (MASD) treatment was not followed. This failure had the potential for Resident 1's wound to worsen and for Resident 1 to not achieve their highest practicable well-being. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted October of 2024 and had diagnoses that included osteomyelitis of vertebra (a serious infection of the backbone), diabetes mellitus (a chronic condition causing too much sugar in the blood which inhibits the body's natural wound-healing capabilities), muscle weakness, and severe obesity. A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/19/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident call system in the toilet and bathing area for one of seven sampled residents (Resident 7) when Resident 7 did not have a functional call system in the bathroom. This failure had the potential to jeopardize Resident 7's health and safety when using the bathroom and requring assistance within their room. Findings: A review of Resident 7's clinical record indicated Resident 7 was admitted October of 2024 and had diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and muscle weakness. A review of Resident 7's active physician's orders, dated 10/23/24, indicated, Resident [Resident 7] is capable of making her own health decisions. During an observation on 10/28/24 at 12:06 p.m. of Resident 7's room, Resident 7's call light was on. During a concurrent observation and interview on 10/28/24 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.

Based on interview and record review, the facility failed to notify Resident 1's (Res 1) representative (RP) regarding Res 1's room change. This failure had the potential to cause psychosocial distress to Res 1 as well as concern to Res 1's RP due to the lack of notification of a room change. Findings: In a review of the Resident Face Sheet, Res 1 was admitted mid 2024 with diagnoses including gangrene (a condition that causes tissue to die) and Parkinson's Disease (a brain disorder that negatively affects the nervous system). During a phone interview on 6/3/24 at 11:47 A.M., with the RP, she stated that Res 1 was moved to another room without being informed which made her upset and concerned that she didn't receive a reason why. During a concurrent interview and record review on 6/4/24, at 1:34 p.m., with the Director of Nursing (DON), the DON stated that she could not find any documentation in Res 1's chart that indicated the reason for the room change or that the RP was notified. The DON stated it is her expectation is that the RP is to be notified regarding room changes. During…

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

Based on interview and record review, the facility failed to protect one of their residents, Resident 1 (Res 1), from neglect by not providing showers as scheduled. This failure had the potential to cause physical and psychosocial harm to the resident and caused emotional distress to Res 1's representative (RP). Findings: In a review of the Resident Face Sheet, Res 1 was admitted mid 2024 with diagnoses including gangrene (a condition that causes tissue to die) and Parkinson's Disease (a brain disorder that negatively affects the nervous system). During a phone interview on 6/3/24, at 11:47 AM, with Res 1's RP, the RP stated that when she went to visit Res 1, he would appear dirty, and on one occasion his hair was messy and was covered in food. She further stated .he appeared like he looked homeless. During a concurrent interview and record review on 6/4/24 at 1:34 p.m. with the Director of Nursing (DON), the bathing tasks and showers sheets of Res 1 were reviewed from 5/12/24/-5/19/24. The DON stated that she could not find documentation that Res 1 had been offered, received, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide showers or grooming for one of four sampled residents (Resident 4), when Resident 4 did not have a shower or bath within the month of October 2023. This deficient practice had the potential to result in body odor, skin irritations and infections. Findings: During a review of the clinical record for Resident 4, the admission record indicated Resident 4 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction (also called stroke), and mild cognitive impairment (problems with mental abilities such as memory or thinking). A review of the Resident's Minimum Data Set (MDS-assessment tool used to guide care), Resident 4's Brief Interview for Mental Status (BIMS), section C, Cognitive Patterns, dated 8/3/23, indicated, BIMS could not be conducted because Resident 4 is rarely/never understood, and with short and long-term memory problems. Section G, Functional Status, dated 8/3/23, indicated, .Bathing - Total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to ensure 2 (Resident #86 and Resident #89) of 8 continent residents reviewed for sharing a bathroom with residents of the opposite gender were treated with respect and dignity. Specifically, Resident #86 verbalized concerns related to a resident of the opposite gender walking in on them while using the commode. Also, the facility failed to ensure 1 (Resident #39) of 3 residents who were dependent on staff for eating was treated with dignity. Specifically, Certified Nurse Assistant (CNA) #1 placed a meal tray in front of Resident #39, left the room, and continued to deliver trays to other residents before returning to feed Resident #39. Additionally, CNA #1 and CNA #2 referred to Resident #39 as a feeder. Findings included: 1. Review of a facility policy titled, Quality of Life - Dignity, revised February 2020, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth 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, record review, and facility policy review, the facility failed to ensure the baseline care plan addressed continuous positive airway pressure (CPAP) therapy and the care/services necessary related to the use of a CPAP machine for 1 (Resident #362) of 5 residents reviewed for baseline care plans. Findings included: Review of a facility policy titled, Care Plans - Baseline, dated December 2016, revealed, 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g. [for example] dietary needs, medications, routine treatments, etc. [et cetera]) and implement a baseline care plan to meet the resident's immediate care needs included but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR [pre-admission screening and resident review] recommendation, if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, record review, and facility policy review, the facility failed to ensure a resident who required continuous positive airway pressure (CPAP) therapy had physician's orders for CPAP therapy, CPAP settings, and the necessary care and services related to CPAP use for 1 of 1 (Resident #362) resident reviewed for respiratory services. Findings included: Review of a facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, dated March 2015, revealed, Preparation 1. Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. 2. Review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory, and gastrointestinal status. 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP [positive end-expiratory pressure] pressure (CPAP, IPAP [inspiratory positive airway pressure] and EPAP [expiratory positive airway pressure]) for the machine. A review of an admission Record…

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

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a continuous positive airway pressure (CPAP) mask was cleaned and stored to prevent infection for 1 (Resident #362) of 1 resident reviewed for respiratory services. Findings included: Review of a facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, dated March 2015, specified, Purpose 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. A review of an admission Record indicated the facility admitted Resident #362 on 10/03/2023 with diagnoses that included hypertension and edema. The admission Minimum Data Set (MDS) assessment for Resident #362 had not been completed at the time of the survey. Review of Resident #362's plan of care initiated on 10/04/2023 revealed the resident was 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.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to ensure staff donned all necessary personal protective equipment (PPE) before entering the room of a COVID-19 positive resident in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 2 (Resident #356 and Resident #357) of 2 COVID-19 positive residents reviewed for transmission-based precautions (TBP). Findings included: Review of a facility policy titled, Isolation - Categories of Transmission-Based Precautions, dated 07/17/2023, revealed, 2. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne. The policy also indicated, Droplet Precautions 1. Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets…

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