Whitney Oaks Care Center

Based on observation, interview, and record review, the facility failed to ensure the planned menu was followed for the therapeutic diets during lunch on 5/21/25 when: 1. Six residents (Resident 1, 11, 70, 85, 88, and 108) with small portion diets received three ounces (oz.) of meat instead of two oz.; 2. Six residents (Resident 16, 23, 49, 81, 82, and 112) with fortified diets did not receive planned fortified food; and, 3. 57 out of 113 residents who received lunch meals did not receive garnishes with their lunch meals. These failures had the potential to result in compromising the medical and nutrition status of residents who received meals from the facility kitchen. Findings: During the lunch meal distribution on 5/21/25 beginning at 11:49 a.m., it was noted as follows: 1. During both interviews with [NAME] (CK) 1 and CK 2 on 5/21/25 at 11:55 a.m. and 12:35 p.m., CK 1 and CK 2 confirmed and stated all the regular roast beef they prepared were three oz. per serving (slice). During the meal distribution, it was noted six residents (Resident 1, 11, 70, 85, 88, and 108) with small…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective infection prevention and control program when: 1. The licensed nurse (LN) did not perform hand hygiene (HH, washing hands with soap and water or use of an alcohol-based sanitizer) in accordance with standards of practice during medication pass for Resident 6 and Resident 23; and, 2. Residents were not offered to clean their hands by staff prior to consuming their lunches in the dining room. These failures had the potential to result in transmission of infection to residents in the facility. Findings: 1. During a medication pass observation on 5/20/25 at 8:40 a.m. with LN 2, LN 2 prepared medications for Resident 6 without wearing gloves or handwashing prior to preparation and administration. When asked if she wore gloves during the medication pass, LN 2 stated she could not remember. During a medication pass observation on 5/20/25 at 12:12 p.m., LN 1 picked up Resident 23's partially eaten meal tray from on top of a trash can without wearing gloves and left the room. LN 1 then returned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote dignity and respect for Resident 61 when Licensed Nurse 3 (LN 3) did not provide privacy to body after leaving Resident 61's room, and did not communicate with Resident 61 while providing care. These failures decreased the facility's ability to provide care in a dignified and respectful manner for Resident 61. Findings: A review of Resident 61's admission record indicated he was originally admitted in November 2020 with diagnoses including dementia (a progressive state of decline in mental abilities), and functional quadriplegia (inability to move legs and arms due to physical weakness). A review of Resident 61's Minimum Data Set (MDS- a federally mandated assessment tool), dated 3/3/25, indicated Resident 61's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 0 out of 15 with an inability to express ideas and make decisions. A review of Resident 61's Activity of Daily Living (ADL-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately complete the quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of 24 sampled residents (Resident 64). Failure to accurately assess Resident 64's Multi-Drug Resistant Organism (MDRO, an organism that is resistant to multiple antibiotics) status resulted in an inaccurate record. Findings: A review of Resident 64's admission Record, dated 5/23/25, indicated, Resident 64 was admitted to the facility in January 2024 with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and Resistance to Multiple Antimicrobial Drugs. During a review of Resident 64's MDS, dated [DATE], the MDS indicated the presence of MDRO as an active diagnosis. During a review of Resident 64's Health Care Facility Transfer Form, 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 administer a medication according to professional standards of quality for one of 34 sampled residents (Resident 23) when his insulin lispro (a fast acting insulin, medication to treat diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing)) according to the physician's order. This failure had the potential to cause poor glycemic (blood sugar) control which could lead to heart disease, nerve damage, kidney disease, vision loss, and foot problems. Findings: A review of Resident 23's medical record indicated he was admitted to the facility Fall 2022 with diagnosis which included diabetes. A review of Resident 170's clinical record included a physician's order dated 5/20/25, for insulin lispro 100 unit/milliliter (a unit of measurment) inject 8 unit subcutaneously (under skin) before meals for DMII (typle 2 diabetes). During a medication pass observation on 5/20/25 at 7:55 a.m. with Licensed Nurse 1(LN1), LN 1 was observed preparing 10 medications for Resident 23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communication needs were met for one of 34 sampled residents (Resident 51) when communication materials were not available for use by the resident. This failure had the potential to impede Resident 51 from maintaining or reaching the highest practicable well-being. Findings: Resident 51 was admitted to the facility in April 2025 with diagnoses which included right femur fracture, and muscle weakness. Resident 51's Minimum Data Set (MDS, an assessment tool) dated 4/28/25 indicated memory was severely impaired. The MDS also indicated Resident 51's preferred language was other than English. During a review of activities care plan for Resident 51 initiated 4/28/25, indicated Provide activity calendar in room .Provide activity materials like books, magazines, TV, radio, arts and crafts .in accordance with interests. During a review of Resident 51's Comprehensive Skilled Review Note dated 5/15/25, indicated .Language barrier-Russian speaking only. During a concurrent observation and interview on 5/20/25 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 observation, interview, and record review, the facility failed to ensure two (2) of 34 sampled residents (Resident 27 and Resident 220) received services to maintain nail care, good grooming, and personal hygiene for the use of neck brace device. This failure decreased the facility's ability to promote healthy nail growth and enhanced residents' appearance, overall well-being and to prevent skin irritation and potential infections. Findings: A review of Resident 27's admission Record (AR) indicated she was admitted on [DATE] with diagnoses which included depression (serious medical illness that can significantly impact how a person feels, thinks, and acts), left sided body weakness and cognitive impairment. A review of Resident 27's Physician's Order (PO) dated 2/19/25, the PO indicated, Resident's Consult - Podiatry As Needed For Mycotic/Hypertrophic Nails And/Or Keratotic Lesions. During a concurrent observation and interview on 5/20/25 at 4:18 p.m., Resident 27's right fingernails were long, jagged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 31) out of 34 sampled residents was provided nail care. This failure resulted in Resident 31's overgrown toenails and the potential to develop an infection or injury. Findings: A review of Resident 31's admission record indicated Resident 31 was admitted to the facility in July 2024 with diagnoses which included respiratory failure (inadequate gas exchange by the respiratory system) and chronic obstructive pulmonary disease (COPD). During a concurrent observation and interview on 5/20/25 at 8:33 a.m. in Resident 31's room, Resident 31 indicated she had stated her toenails needed to be trimmed. An observation of Resident 31's toenails showed her toenails were long, past the edge of her toes. Resident 31 stated her toenails kept getting caught on her bed linens and was worried about scratching herself. During a concurrent observation and interview on 5/22/25 at 11:06 a.m. with Licensed Nurse (LN) 6, in Resident 31's room, LN 6 observed Resident 31's toenails and acknowledged they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 102) indwelling catheter (IC, a type of urinary catheter designed to remain in place for an extended period to drain urine from the bladder) tubing was free from accumulated urine sediments. This failure decreased the facility's ability to prevent obstruction of the catheter's lumen, leading to reduced urine flow or complete blockage. Findings: A review of Resident 102's admission Record (AR) indicated he was admitted on [DATE] with diagnoses which included urine retention and enlarged prostate (gland that produces some of the fluid) with lower urinary tract symptoms. A review of Resident 102's Physician's Order (PO) dated 5/12/25, the PO indicated: Indwelling [Brand Name] Catheter . # 18F [FR: French; catheter size]/10 ml [milliliter, metric unit of measurement] for diagnoses of obstructive and reflux uropathy; monitor every shift; cleanse with warm soap and water, rinse and pat dry; irrigate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 220) incentive spirometer (IS, a handheld medical device used to help patients practice taking deep breath, encouraging lung expansion to prevent respiratory complications) was available and provided as ordered. This failure decreased the facility's ability to help Resident 220's exercise his lungs to expand, strengthen, inflate, and clear mucus and other secretions after surgery. Findings: A review of Resident 220's admission Record (AR) indicated he was admitted on [DATE] with diagnoses which included cervical spinal fusion (a surgery that joins two or more vertebrae in the neck to create a stable, solid piece of bone). A review of Resident 220's Physician's Order (PO) dated 5/13/25, the PO indicated, Incentive Spirometer: three times per day for 10 days due to pulmonary dysfunction related to: PNEUMONIA [PNA, a lung infection where the air sacs (alveoli) fill with fluid or pus, making 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 observation, interview and record review, the facility failed to ensure: 1. Destruction prescription medications according to facility policy and procedure (P&P); and, 2. The narcotic emergency kit (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced according to facility P&P after use. These failures had the potential for abuse or misuse of medications and for emergency medications to be unavailable when needed. Findings: During an observation and interview on 5/20/25 at 8:52 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated there was not a drug buster (a container to safely hold disposed drugs) available on her cart. LN 2 placed amiodarone (medication primarily used to treat heart rhythm problems) and another unidentified loose pill she found in the medication drawer inside a used latex glove and stored it inside the med cart. LN 2 confirmed there was not a drug buster located in her medication cart. LN 2 stated proper disposal of medications should be immediately in a drug buster and not in glove. 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's consultant pharmacist (CP) failed to identify drug-related issues on one of 34 sampled residents (Resident 170). This failure had the potential for unsafe medication use for all residents in the facility. Findings: A review of Resident 170's admission record indicated she was admitted in Spring 2025 diagnoses including anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression, diabetes mellitus II (disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (having too much fat, like cholesterol or triglycerides in the blood) A review of Resident 170's clinical record included a physician's order dated 5/20/25, for quetiapine (an antipsychotic) 25 milligram (mg, a unit of measure), 1 tablet by mouth 12 hours as needed for agitation. A review of Resident 170's medical 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, interview, and record review, the facility failed to ensure opened multi-dose medications and biologicals were dated with an open and discard date, expired medications were not available for resident use, and single resident over-the-counter (OTC) products were appropriately labeled . These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications or biologicals from inadequate temperature monitoring and storage. Findings: During a concurrent observation and interview on 5/20/25 at 12:29 p.m. alongside Licensed Nurse (LN) 3, an inspection of Medication Cart 100 (Med Cart 1) identified two bottles of nitroglycerine (a medication used to treat chest pain). LN 3 confirmed the two bottles of nitroglycerine were not labeled with a pharmacy label. During a concurrent observation and interview on 5/20/25 at 12:40 p.m. with LN 4, an inspection of Medication Cart 300 (Med Cart 3) identified one medication…

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

Based on observations, interviews and record review the facility failed to ensure resident safety for three residents (Resident 56, 76, and 114) out of 34 sampled residents when the call lights were out of reach. This failure had the potential for the residents to be unable to notify staff if there was an emergency. Findings: A review of Resident 114's admission record indicated he was admitted to the facility in December 2024 with diagnoses which included hemiplegia (muscle weakness to one side of the body) and diabetes mellitus (high blood glucose). During a concurrent observation and interview on 5/20/25 at 7:48 a.m. in Resident 114's room, Resident 114 could not locate his call light. Resident 114's call light was observed hanging over the right-side bed rail and laying under the bed, out of reach. Resident 114 confirmed he would not be able to notify staff if there was an emergency. A review of Resident 56's admission record indicated he was admitted to the facility in February 2025 with diagnoses which included quadriplegia (partial or complete loss of function in all four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean and sanitary environment for the residents who used the dining area and residents who ate facility prepared meals when a bird cage containing 4 birds was not kept clean and sanitary, and was placed next to the walkway of the two (2) kitchen doors where food carts carrying resident meals pass through for a census of 118 residents. This failure had the potential to result in cross-contamination of facility prepared resident meals and could spread infection and/or other bird-related diseases to residents, facility staff, and visitors. Findings: During a telephone interview on 8/7/24 at 12:35 p.m. with Responsible Party (RP) 1, RP 1 stated, .They [facility] have birds in the dining area, near the kitchen door, and it's [bird cage] dirty. It's [bird cage] not clean, those [dirt] might get into their [residents] food . During an observation on 8/8/24 at 12:12 p.m., at the dining area during lunch mealtime, a black metal birdcage containing 4 birds was observed on the north side wall of the dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 1), when the dose of Resident 1's Seroquel (Quetiapine Fumarate, a medication used to treat mental/mood disorders) was not given per physician's order. This failure had the potential to result in Resident 1 not having the desired effects of the medication. Findings: During a review of Resident 1's admission record, the record indicated Resident 1 was admitted in July 2024 with diagnoses that included bipolar disorder (a disorder that causes intense changes in mood, energy levels and behavior). Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had intact cognition. During a review of Resident 1's physician order, dated 7/2/24, the order indicated, Quetiapine Fumarate Oral [by mouth] 400 MG (milligrams, a unit of measurement) .Give 2 tablets by mouth at bedtime for BIPOLAR DISORDER M/B [manifested by] rapid mood cycling from pleasant to extreme anger. During a review of Resident 1's care plan…

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

Based on observation, interview, and record review, the facility failed to ensure food preferences were honored for one of three sampled residents (Resident 2), when Resident 2 disliked broccoli but he was served broccoli during the lunch meal. This failure resulted in Resident 2's food preferences not being honored, and Resident 2 not receiving options for food of similar nutritive value. Findings: During a review of Resident 2's admission record, the record indicated Resident 2 was admitted in June 2024 with diagnoses that included transient ischemic attack (a temporary blockage of blood flow to the brain) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Resident 2's Minimum Data Set (MDS, an assessment tool) indicated Resident 2 had intact cognition. During a review of Resident 2's document titled, DIETARY INTERVIEW/PRE-SCREEN -V3.0, dated 7/12/24, the document indicated, IV. FOOD LIKES/DISLIKES .CHECK DISLIKES. ITEMS LEFT UNCHECKED INDICATE FOOD LIKES. The document further indicated broccoli and cabbage were checked under F.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility garbage dumpsters were not accessible to insects and vermin when the dumpster lids were not kept closed. This failure had the potential to harbor pests and other types of vermin capable of spreading disease for a census of 123. Findings: On 6/21/24 at 7:45 a.m., an observation of the facility's two (2) outside blue colored garbage dumpsters and 1 green colored recycling bin dumpster were found to be over filled. The two (2) blue colored garbage dumpster lids were not closed and sealed because it was overfilled with garbage. The recycling dumpster lid was also observed not closed because it was overfilled with cardboard boxes. The surrounding ground area around the garbage dumpsters were observed to be littered. During an interview with the Housekeeping Manager (HM) on 6/24/24 at 8 a.m., the HM was shown the two (2) blue colored garbage dumpsters and one (1) green colored recycling dumpster. The HM confirmed the lids were not covering the tops of the dumpsters because the dumpster were over…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient supply of linens were available for staff to use during residents daily care for a census of 123. This failure decreased the facility's ability to provide care and services to enhance the self-esteem and self-worth of the residents. Findings: During the initial tour observation and interview with residents, on 6/18/24 at 10:19 a.m., one Resident stated that during the provision of care, there was linen shortage pretty much everyday that staff talked about. The Resident stated, she was worried how the facility was being ran. During a concurrent observation and interview, on 6/18/24 at 12:17 p.m., with Certified Nurse Assistant 7 (CNA 7), CNA 7 opened the linen storage #1 and heaved a heavy sigh and shook her head and she said nothing. CNA 7 stated linens will be filled out once delivered, but right now, there were no linens to use for the residents. Linen storage room [ROOM NUMBER] was observed to be empty. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop baseline care plans for three out of 29 sampled residents (Resident 364, 366, and resident 320) when: 1. Care plans were not developed for the use of indwelling urinary catheters (flexible tube used to empty the bladder and collect urine in a drainage bag) for Resident 364 and 366; and, 2. Care plan for the use of a Bilevel Positive Airway Pressure machine (BiPAP, a device assisting in breathing) was not initiated withing 48 hours of admission. These failures had the potential for residents to not receive appropriate and timely care and treatment. Findings: 1. During a review of Resident 366's admission record, the record indicated Resident 366 was admitted to the facility on [DATE] with diagnoses including severe chronic kidney disease (severe loss of kidney function) and benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty). During an observation on 6/18/24 at 9:57 a.m. in Resident 366'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 develop comprehensive, person-centered care plans for eight out of 29 sampled residents (Resident 48, 62, 94, 102, 103, 361, 364 and 366) when care plans were not developed for the use of indwelling urinary catheters (flexible tube used to empty the bladder and collect urine in a drainage bag), psychotropic medications and EBP (Enhanced Barrier Precautions). These failures had the potential for residents to not receive appropriate, adequate timely care and treatment. Findings: During a review of Resident 366's admission record, the record indicated Resident 366 was admitted to the facility on [DATE] with diagnoses including severe chronic kidney disease (severe loss of kidney function) and benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty). During an observation on 6/18/24 at 9:57 a.m. in Resident 366's room, Resident 366 was observed lying in bed with a urinary catheter bag hooked to the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revise the activities care plan for 5 of 29 sampled residents (Resident 11, Resident 42, Resident 52, Resident 67, and, Resident 76) to reflect current person-centered interventions/tasks for a census of 123. These failures decreased the facility's ability to evaluate the effectiveness of the interventions to improve the residents' physical and social well-being. Findings: 1. During a record review of Resident 11's Face Sheet (FS), the FS indicated Resident 11 had diagnoses which included depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic respiratory failure (CRF, a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a record review of Resident 11's physician's order (PO), dated 2/14/24, the PO indicated Resident 11 was admitted to hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to provide proper respiratory care services for three residents (Resident 320, Resident 81, and Resident 42) of 29 sampled residents consistent with the professional standards of quality, the person- centered care plan, and the residents' choices when: 1. Resident 320's Bilevel Positive Airway Pressure machine (BiPAP, a device assisting in breathing) order did not provide specific pressure parameters and staff providing care were not trained in handling BiPAP equipment; 2. A respiratory care order and care plan was not followed for Resident 81; and, 3. Resident 42's order to use an incentive spirometer (a handheld medical device used to help patients, to take slow and deep breaths, facilitates lung expansion and strengthening) every waking hour was not implemented. These failures reduced the facility's potential to provide proper respiratory care services to Resident 320, Resident 81, and Resident 42, and increased the residents' risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately document and replace emergency medications (E-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) for a census of 123. These failures resulted in the facility not having accurate accountability of emergency medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: During an inspection on 6/18/24 at 10:33 a.m. of Medication Storage room [ROOM NUMBER], alongside Infection Preventionist (IP), a First Dose Emergency Kit Oral Medications was observed sealed with a red plastic tie indicating it had been opened by nursing staff. Inside the kit were six E-kit logs (a document completed by nursing staff whenever a medication is removed from the emergency supply), with the earliest entry into the kit documented on 6/9/24. One of the six logs was…

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

Based on observation, interview, and record review, the facility had a 24.14% error rate when seven medication errors out of 29 opportunities were observed during a medication pass for three of four Residents (Residents 39, 43, and 96). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: 1. During a medication pass observation on 6/18/24 at 8:03 a.m. with Licensed Nurse 6 (LN 6), LN 6 was observed entering Resident 43's room to measure her blood sugar level. Resident 43 stated she had already eaten breakfast as LVN 6 performed the blood sugar test. LVN 6 then went to prepare eight medications, including Novolog (a rapid-acting insulin to treat diabetes), amlodipine (a medication to treat high blood pressure), and potassium chloride (a potassium supplement) extended release (ER, a long-acting formulation) for Resident 43. LN 6 looked inside the medication cart and stated she could not locate the Novolog and would follow up with the pharmacy. She placed Resident 43's prepared…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 57) was free of a significant medication error when he received Lantus (a long-acting insulin, medication to lower blood sugar level) two times (doses) past the expiration date. This deficient practice had the potential for ineffective use of insulin, resulting in uncontrolled high blood sugar for the resident. Findings: During an inspection of Medication Cart 1 on [DATE] at 1:24 p.m. alongside Licensed Nurse 5 (LN 5), one vial Lantus for Resident 57 labeled with an opened date of [DATE] was identified. LN 5 confirmed the finding and stated Lantus expired 28 days after opening and confirmed it had expired on [DATE]. A review of Resident 57's medical record indicated a physician's order, dated [DATE], for insulin glargine (brand name: Lantus) 100 units/milliliter (units/mL, a unit of measurement), inject 10 units SQ (subcutaneous, under the skin) at bedtime for DM II (Diabetes type II, 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: 1. Prepared medications were properly stored and administered at the time of preparation; 2. Expired and discontinued medications were not available for resident use; and, 3. Refrigerated medications were stored in accordance with facility policy & procedure (P&P). The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being securely stored. Findings: 1. During a medication pass observation on 6/18/24 at 8:45 a.m. with Licensed Nurse 6 (LN 6), LN 6 was observed administering ClearLax (a medication to treat constipation) to Resident 39. Resident 39 drank approximately half the ClearLax solution when LN 6 left the resident unattended with the remainder of the medication on her bedside table and moved onto preparing medications for the next resident. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, prepare, and serve food in accordance with professional standards for food service safety when: a) Food packages in the freezer were not tightly closed after use, leaving food exposed to the air; b) A red sanitizer bucket was found with insufficient sanitizing concentration only 2 hours after setting up, and several hours before the second shift staff would conduct the next check; c) Dietary staff were unable to correctly describe the 3-compartment sink set-up for manual dishwashing; d) Kitchen walls and ceiling had missing and/or peeling paint; and, e) Resident refrigerator had expired yogurt available for resident 86, and grapes kept for an unnamed resident, and the resident in that room was on a pureed diet. These failures had the potential of leading to food borne illness for the 125 residents eating facility provided meals. Findings: a) During the initial kitchen observation and concurrent interview on 6/18/24 at 8:12 a.m. in…

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

Based on observation, interview, and record review, the facility failed to provide staff with the needed equipment to assist residents in safely accessing and consuming outside food when staff were unable to heat foods to correct serving temperatures. This failure had the potential of limiting food intake leading to malnutrition and/or weight loss, and/or leading to food borne illness for the 125 residents eating facility prepared meals. Findings: During an observation and concurrent interview with Licensed Nurse 8 (LN8) on 6/19/24 at 9:40 a.m. at the Nursing Unit 2 resident refrigerator, LN8 stated that the resident microwave had been removed a while ago. When asked how staff would heat resident food, LN8 stated she was unsure how staff would do this, though believed some staff had used the staff microwaves in the breakroom. During an observation and concurrent interview of Register Nurse Supervisor (RNS) at Nursing Station 1 on 6/19/24 at 11:01 a.m., RNS verified that there was no microwave at the nursing station to warm resident food. When asked about heating resident food, 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, interviews, and record reviews the facility failed to ensure: 1. Nursing staff maintained nails and performed hand hygiene (cleaning hands to prevent the spread of infectious disease) in accordance with nationally accepted standards of practice and facility policy and procedure (P&P); 2. Enhanced Barrier Precautions (EBPs) were utilized for seven residents (Residents 48, 62, 102, 103, 361, 364 and 366) out of 29 sampled residents when staff did not follow infection prevention and control interventions; 3. Staff performed handwashing after handling soiled lenin; 4. Infection Prevention trainings and/or inservices were provided to staff after repetitive cases of urinary tract and upper respiratory infections were identified during infections surveillance; and, 5. The facility's Infection Prevention and Control Program (IPCP) was reviewed annually. These failures had the potential to increase residents' risk of infection and the spread of multi-drug resistant organisms (MDRO's) for census of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate assessments were performed for two residents (Resident 33 and Resident 23) of 29 sampled residents when: 1.Resident 33's vision assessment was inaccurate; and, 2. Resident 23 did not have a change of condition assessment completed. These failures resulted in Resident 33 and Resident 23 not receiving accurate assessments reflective of their medical status and reduced the facility's potential to identify strengths to maintain or improve functional abilities. Findings: 1. A review of Resident 33's admission RECORD indicated she was admitted to the facility on [DATE] with multiple diagnoses which included legal blindness, presence of artificial eye, hearing loss, dementia (memory problems), and osteoporosis (bone disease that can lead to decrease in bone strength and increase the risk of fractures). During a concurrent observation and interview on 6/18/24 at 9:52 a.m., in Resident 33's room, with Certified Nursing Assistant 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record reviews, the facility failed to provide resident centered care for one resident (Resident 368) of 29 sampled residents when the facility did not ensure Resident 368's pressure relief heel boots were put on per comprehensive assessment, plan of care, physician's order, and Resident 368's choices. This failure decreased the potential for Resident 368 to receive effective treatment and necessary care. Findings: A review of Resident 386's admission RECORD indicated he was re-admitted to the facility on [DATE] with multiple diagnoses which included cellulitis (a deep infection of the skin caused by bacteria) of left lower limb, type 2 diabetes (high blood sugar) with skin ulcer, chronic embolism and thrombosis of unspecified deep veins (blood clot in the vein) of unspecified lower extremity, Charcot's joint (bone and joint fragmentation of the foot and ankle) unspecified ankle and foot, and localized edema (swelling). A review of Resident 368's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record reviews, the facility failed to provide appropriate care to maintain good foot health for one resident (Resident 261) of 29 sampled residents when Resident 261's toenails were dirty, long, and untrimmed. This failure reduced to facility's potential to provide appropriate foot care for Resident 261. Findings: A review of Resident 261's admission RECORD indicated he was admitted to the facility on [DATE] with multiple diagnoses which included diabetes, Alzheimer's Disease (memory problems), altered mental status, malnutrition, abnormal gait and mobility, and peripheral vascular disease (narrowed blood vessels reducing blood flow to the limbs). During a concurrent observation and interview on 6/19/24 at 8:35 a.m., Resident 261 was in bed and bilateral (both; in this instance, feet) toenails were observed to be dirty, long, and were untrimmed. Resident 261's conversation was incomprehensible, laughing without reason, and not able to provide meaningful conversation. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record reviews, the facility failed to ensure the resident's bed rails were properly installed for one resident (Resident 13) when there was no informed consent and no physician order for bedside rail use. This failure had the potential to result in negative outcomes including accident hazards, physical restraint, decline in Activities of Daily Living and function, and psychosocial outcome. Findings: A review of Resident 13's admission RECORD indicated she was re-admitted to the facility on [DATE] with multiple diagnoses which included pain in left and right shoulders, fracture of upper end of right and left arms, and hemiplegia affecting left nondominant side (muscle weakness or partial paralysis on one side of the body that can affect arms, legs or facial muscles). Resident 13's Minimum Data Set (MDS, a comprehensive assessment tool), dated 4/23/24 indicated Resident 13 had no memory problems. During a concurrent observation and interview on 6/18/24 at 9:02 a.m., 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 and record review, the facility failed to have the Medical Doctor's (MD) notes signed. This failure had the potential for Resident 99 to received confusing, inaccurate, and inadequate care for a census of 123. Findings: Resident 99 was admitted to the facility with diagnoses of Unspecified Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Major Depressive disorder, Disorientation. Review of Client 99's clinical records indicated the resident was readmitted to the facility on [DATE] at 5:45 p.m. from the Acute Hospital. The Primary Medical Doctor (PMD) notes History and Physical (H/P) by the MD, indicated Resident 99 was seen by the MD on 3/21/23. There were no other MD notes for the months of April or May for review. During an interview with the Medical Records Director (MRD) on 6/21/24 at 10:15 a.m. the MRD confirmed there were no other MD notes from the computerized records that indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a newly admitted resident (Resident 99) was seen by the Medical Doctor (MD) once every 30 days for the first 90 days upon admission. This failure had the potential for Resident 99 to received inadequate and inaccurate care and assessment for a facility census of 123. Findings: Resident 99 was admitted to the facility with diagnoses of Unspecified Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Major Depressive disorder, Disorientation. Review of Resident 99's clinical records indicated the resident was readmitted to the facility on [DATE] at 5:45 p.m. from the Acute Hospital. The clinical records indicated the Primary Medical Doctor (PMD) notes History and Physical (H/P) by the MD, indicated Resident 99 was seen by the MD on 3/21/24. There were no other MD notes for the months of April or May to indicate Resident 99 was seen by the MD. 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 one resident (Resident 94) out of 29 sampled residents was free from unnecessary psychotropic medications when Resident 94 was prescribed an order for buspirone (a psychotropic medication that affects the brain associated with mental processes and behavior) as needed for 14 weeks. This failure had the potential to cause medication interactions, confusion, and falls. Findings: During a review of Resident 94's admission record, Resident 94 was admitted to the facility in February 2024 with diagnoses including right femur (thigh bone) fracture and muscle weakness. A review of Resident 94's order summary, indicated the following medication order buspirone with a start date of 3/18/24, to be given every eight hours as needed for anxiety for 14 weeks, manifested by restlessness. During a review of the Consultant Pharmacist's Medication Regimen Review, dated March 2024, the consultant pharmacist indicated Resident 94's order for buspirone needed a 14 day stop date for the as needed order. During a concurrent interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to promote dignity when one of three sampled residents (Resident 1) stated she had been pinned down and hit during care by two Certified Nurse Assistants (CNA 3 and CNA 4). This failure caused Resident 1 to be fearful and to feel she was being bullied and had the potential to affect the resident's self-esteem, self-worth, and diminish her quality of life. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (weakness or paralysis on one side of the body), muscle weakness, and right and left shoulder pain. A review of Resident 1's most recent quarterly Minimum Data Set (MDS, an assessment tool) indicated Resident 1 scored a 15 out of 15 on a Brief Interview for Mental Status (BIMS, a screening tool that aids in identifying cognitive ability), indicating she was cognitively intact. During an interview on 11/7/23 at 12 p.m. with Resident 1, Resident 1 stated, I needed to have my brief (underwear) changed . 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) for one of three sampled residents (Resident 1) when staff did not timely report an allegation that a staff member hit a Resident. This failure resulted in Resident 1 not receiving an immediate assessment and interventions to ensure safety. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (weakness or paralysis on one side of the body), muscle weakness, and right and left shoulder pain. A review of Resident 1's most recent quarterly Minimum Data Set (MDS, an assessment tool) indicated Resident 1 scored a 15 out of 15 on a Brief Interview for Mental Status (BIMS, a screening tool that aids in identifying cognitive ability), indicating she was cognitively intact. During an interview on 11/7/23 at 12 p.m. with Resident 1, Resident 1 stated, I needed to have my brief (underwear) changed . it was last week . around 4 in the morning while being cared for by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, when the facility failed to thoroughly investigate an allegation of physical and verbal abuse towards one of three sampled residents (Resident 1) by a certified nursing assistant (CNA 3). Resident 1 alleged CNA 3 yelled at her, punched her, and hit her with a cane. This failure had the potential to expose Resident 1 and other residents to abuse. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (weakness or paralysis on one side of the body), muscle weakness, and right and left shoulder pain. A review of Resident 1's most recent quarterly Minimum Data Set (MDS, an assessment tool) indicated Resident 1 scored a 15 out of 15 on a Brief Interview for Mental Status (BIMS, a screening tool that aids in identifying cognitive ability), indicating she 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 an environment free of accident hazards, when one of four sampled residents (Resident 1) had an ordered fall mat that was not on the floor. This failure had the potential for Resident 1 to sustain a fall with injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted on [DATE], with diagnoses including but not limited to vascular dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents), dated 10/9/23, the MDS indicated Resident 1 had a Brief Interview for Mental Status - BIMS, score of 3 (The BIMS test is used to get a quick snapshot of how well a resident is functioning cognitively at the moment and ranges from 0 - 15. A score of 3 indicates severe cognitive impact). 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 interview and record review, the facility failed to provide written bed-hold information to a resident and resident representative for one of three sampled residents (Resident 1) in a census of 116 when Resident 1 was sent to a general acute care hospital (GACH) and did not have any documentation they were given bed-hold information. This failure had the potential to decrease Resident 1's right to return to the facility. Findings: A review of the Resident Face Sheet, on 10/4/23, indicated Resident 1 was admitted to the facility in May 2022 and indicated Resident 1 was discharged to the emergency department one week after admission to the facility. During the initial tour of the facility on 10/4/23 starting at 11 a.m., Resident 1 was not observed residing in the facility. Review of the facility's census, dated 10/4/23, indicated Resident 1 was not listed as present in the facility. During a concurrent interview and record review on 10/4/23 at 2:05 p.m., the Director of Nursing (DON) confirmed she was not able to find documentation of the bed-hold information given 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 interview and record review, the facility failed to ensure the health, safety and security of one of three residents (Resident 1) when the facility failed to report an alleged harm. This failure had the potential to endanger the health and well-being of all 117 residents in the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in the winter of 2023 with diagnoses which included strain of muscle, fascia and tendon of lower back, contusion of left shoulder(bruising) and bladder neck obstruction (blockage of the urinary tubes). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/6/23, the MDS indicated the BIMS (Brief Interview for Mental Status, an assessment tool), was 7, which reflected a severe knowledge and memory impairment. During a review of Resident 1's Occupational Therapy Progress Note (OTPG) 2/14/23 at 11:59, the OTPG indicated Resident [Resident 1] reported that the blonde OT hurt her arm earlier. Resident described performing bed mobility 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 document review, resident privacy was compromised when tray tickets were thrown into the kitchen garbage. This failure had the potential of compromising resident information for 107 residents receiving facility provided meals for a census of 111. Findings: During the initial kitchen tour on 7/19/22 at approximately 9:30 a.m., Dietary Aide 1 (DA 1) was washing the breakfast dishes. She removed the trays from the transport carts and threw food and resident meal tickets into the garbage which would later be emptied into the outside dumpster. The DA 1 stated nursing will usually destroy the tickets, but if they did not, she was to put them into a box under her manager's desk for shredding. The DA 1 also stated this was done to maintain resident privacy. In a subsequent interview on 7/19/22 at 9:40 a.m., the Certified Dietary Manager (CDM) concurred tray tickets were not to be thrown in the garbage and should be shredded for privacy. During an interview on 7/21/22 at 8:51 a.m., the Assistant Director of Nursing (ADON) stated the Certified Nursing…

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

Based on observation, interview and record review, the facility failed to ensure food preferences were honored for five residents (Resident 10, Resident 20, Resident 45, Resident 52, and Resident 160) for a census of 111. These failures had the potential to lead to poor intake, inadequate nutrition, and/or weight loss. Findings: During an observation of the lunch preparation on 7/20/22 at 10 a.m., [NAME] 1 made a taco casserole by adding onion and white beans to cooked ground beef. This was followed by mixing in tomato sauce and seasonings (chili powder, cumin and garlic). Once finished, it was put into a large pan, covered with flour tortillas and cheese to be baked. The lunch menu for 7/20/22 consisted of Taco Casserole, Zucchini, Fiesta Salad (containing beans and corn), and Fresh Fruit (containing honeydew and cantaloupe). Plain ground meat as well as breaded chicken were prepared as alternatives for this meal. During the observation of meal plating on 7/20/22 at 11:55 a.m. the following occurred: 1. Resident 52, who had spicy food listed as a dislike, was given pureed taco…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility, for a census of 111, failed to ensure: 1. Opened, refrigerated foods were properly labeled with open date and used by date; and, 2. Food preparation equipment were properly cleaned and dried before storing for next use; and, 3. Foods brought in by resident's family were labeled properly inside the resident refrigerator. These failures had the potential of causing food borne illness for the 107 residents who ate at the facility. Findings: 1. During the Initial kitchen tour with the Certified Dietary Manager (CDM) and Registered Dietitian (RD) on 7/19/2022 at 8:30 a.m., two large, opened bottles of salad dressings (1 Italian and 1 Caesar) and a large bottle of Teriyaki sauce were found unlabeled and undated in the walk-in refrigerator. Neither the CDM nor RD could state if they were still safe to use. During an interview with the CDM on 7/21/22 at 10:11 a.m., she stated it was important to monitor use by dates as, the age of the product will affect the safety of the food as well as the nutrient value. A review of the…

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

Based on observation, interview and record review, the facility failed to ensure proper infection control practices were performed for 11 residents (Resident 5, Resident 7, Resident 26, Resident 36, Resident 47, Resident 86, Resident 103, Resident 156, Resident 158, Resident 160, Resident 354) of 24 sampled residents, when: 1. The Director of Nursing (DON) and Certified Nurse Aide 3 (CNA 3) entered resident rooms without wearing proper Personal Protective Equipment (PPE) according to posted signs on the door; 2. Staff did not follow the manufacturer's instruction on disinfectant contact time; 3. Hand hygiene was not performed between glove change, and staff donned PPE improperly; and, 4. Hand hygiene was not initiated before meals for two residents. These failures reduced the facility's potential to prevent a spread of infection. Findings: 1. During a concurrent observation and interview on 7/19/22 at 10:10 a.m., the Director of Nursing (DON) entered Resident 7 and Resident 47's room without a gown and face shield. Outside the rooms a posted sign indicated the rooms were yellow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 91) received regular insulin (a medication used to treat high blood sugar levels in the body) as ordered by the physician. This failure increased Resident 91's risk of complications of diabetes (a chronic long-lasting health condition that affects how your body turns food into energy). The facility census was 111. Findings: A review of an admission record indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM, a disorder that causes blood sugar levels to be abnormally high and requires insulin to lower the blood sugar level) with chronic kidney disease, diabetic neuropathy (a diabetes complication which could lead to weakness, numbness, and pain in the feet), and diabetic retinopathy (a diabetes complication which affects vision). A review of Resident 91's physician's order dated 4/12/22 indicated, .insulin regular human .per sliding scale .If blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 91) was free from significant medication errors when regular insulin (an injectable medication used to treat high blood sugar levels in the body) was administered late. This failure to administer the medication on time increased Resident 91's risk of complications from diabetes (a chronic long-lasting health condition that affects how your body turns food into energy). The facility census was 111. Findings: A review of an admission record indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM, a disorder that causes blood sugar levels to be abnormally high and requires insulin to lower the blood sugar level) with chronic kidney disease, diabetic neuropathy (a diabetes complication which could lead to weakness, numbness, and pain in the feet), and diabetic retinopathy (a diabetes complication which affects vision). A review of Resident 91's physician's order…

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