Pilgrim Place Health Services Center

Based on interview, and record review, the facility failed to develop and/or implement an individualized, person-centered comprehensive care plan (CP) that included measurable objectives, defined time frames, and specific interventions that addressed a diagnosis of dementia (a group of conditions, progressive state of decline in mental ability that interfere with daily activities) for 1 of 1 sampled resident (Resident 9).This deficient practice had the potential to result in Resident 9's cognitive (ability to understand and process information), behavioral, and safety needs not being properly identified, monitored, or addressed, which could lead to inadequate treatment, unmet needs, and a decline in Resident 9's overall well-being.Findings:During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on 9/4/2024, with diagnoses including dementia, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a natural feeling of worry, fear, or unease about future events) disorder. 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 observation, interview, and record review, the facility failed to provide education of a new prescribed pain medication for one of five sampled residents (Resident 99) during medication administration on 12/4/2025.This deficient practice resulted in Resident 99 being uninformed regarding Resident 99's pain treatment and had the potential to result in medication errors to Resident 99.Findings:During a review of Resident 99's admission Record (AR), the AR indicated the facility admitted Resident 99 on 4/22/2021, with diagnoses that included wedge compression fracture of the second lumbar vertebrae (a break in the lower back bone), wedge compression fracture of T11-T12 (a break in the upper back bone).During a review of Resident 99's History and Physical (H&P), dated 12/5/2025, the H&P indicated Resident 99 had capacity to make decisions.During a concurrent observation and interview on 12/4/2025 at 8:33 AM, with Licensed Vocational Nurse (LVN) 2 and with Resident 99, LVN 2 administered Tramadol (medication used for the relieve moderate to severe pain) to Resident 99, LVN 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 11) received treatment and care in accordance with the facility's policy and procedure (P&P) titled, Intravenous Therapy, by failing to ensure Resident 11's need for a peripheral saline lock (S/L - a type of catheter placed intravenously [IV - within a vein] to administer medication or fluid into the bloodstream) access was assessed on 12/2/2025 and when Resident 11 had a PICC (Peripherally Inserted Central Catheter - a long thin tube inserted into a vein in the upper arm and threaded to a large central vein near the heart, used for long term IV fluids, medications, nutrition, blood transfusion and drawing blood avoiding repeated needle sticks). Additionally, the facility failed to ensure Resident 11's S/L site remained clean and Resident 11's PICC was dated.This deficient practice resulted in redness in Resident 11's S/L site on Resident 11's right wrist and Resident 11 complaining of pain 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 care and services to treat the skin and itching for one of seven sampled residents (Resident 2) in accordance with the facility's policies and procedures (P&P) titled, Wound Assessment and Treatment and Skin Assessment by failing to ensure: 1. Resident 2 was given diphenhydramine (medication used to treat allergies, sneezing, runny nose, and itching) for itching according to the physician's orders. Resident 2 had multiple open skin scratches all over the body from itching. 2. Resident 2's Medical Doctor/Primary Care Provider (MD) 1 was notified on 10/6/2025 that Resident 2 continued to have itching and had multiple open scratches all over the body even after being treated with hydrocortisone cream (medication used to relieve inflammation, itching, and redness caused by various skin conditions) from 8/7/2025 to 8/21/2025 and from 9/22/2025 to 10/6/2025. 3. Licensed Nurses assessed Resident 2's skin weekly to monitor Resident 2's wounds for signs of infection and to evaluate how Resident 2 responded to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses accurately assessed and documented one of five sampled resident's (Resident 2's) skin condition weekly in Resident 2's medical record between 8/30/2025 and 10/15/2025. Resident 2 had multiple open skin scratches all over the body from itching. This failure had the potential for Resident 2 to receive inappropriate treatment for itching and put Resident 2 at risk for delayed treatment of infection when Resident 2's multiple skin scratches were not assessed and monitored. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/3/2023 with diagnoses that included unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), unspecified abnormalities of gait and other mobility (inability to walk normally due to injuries or underlying conditions), and muscle wasting and atrophy (thinning of muscle…

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 that one of three residents (Resident 3) received the correct medications at discharge. The discharge nurse provided Resident 3 with blister packs containing medications belonging to two other residents.This failure resulted in Resident 3 ingesting one of the incorrect medications, experiencing nausea, headache, and requiring hospital evaluation.During a review of Resident 3's admission Record (Face Sheet), the facility admitted Resident 3 on 7/17/2025, with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated).During a review of Resident 3's History and Physical (H&P), dated 7/18/2025 indicated Resident 3 had the mental capacity to make medical decisions.During a telephone interview on 9/12/2025 at 11:12 AM with Resident 3, Resident 3 stated she took one of the medications provided by the…

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

Based on interview and record review, the facility failed to follow its own policy and procedure by not documenting physician's communications, not documenting a Change of Condition (COC), and not documenting a reassessment after pain medication was given for one of three sampled residents (Resident 1). This failure had the potential to delay care, reduce clinical oversight, and negatively affect Resident 1's health and comfort.Findings:During a review of Resident 1's admission Record (Face Sheet), the admission record indicated the facility admitted Resident 1 on 6/9/2025 , with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/10/2025, the MDS indicated the cognitive (the ability to think and process information) skills for daily decision making was intact,…

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 report an allegation of abuse for one of one resident (Resident 1). This deficient practice violated Resident 1's right and had the potential for delay in abuse investigation. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/14/24, with diagnoses that included myocardial infarction (heart attack), hemiplegia and hemiparesis (total paralysis and weakness of the arm, leg, and trunk on the same side of the body). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 9/16/24, the MDS indicated Resident 1 was able to express ideas and wants and was able to understand verbal content. The MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with bed mobility including rolling left and right, sit to lying and lying to sitting.…

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 two sampled residents (Resident 1) did not develop pressure ulcers-injury [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against the others]) as indicated in the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention and Management, by failing to ensure: 1.A comprehensive care plan (CP) was developed to address the risk for PIs after Resident 1's readmission to the facility on [DATE]. 2.A pressure injury wound risk assessment was conducted for Resident 1 upon readmission on [DATE]. 3. Resident 1's physician order that indicated the use of a low air loss (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress for Resident 1 included a mattress setting.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 9 and Resident 47) and/or their legal representative (RP) were informed and/or provided written information about Advance Directives (AD, legal document, which specifies the health-related actions in accordance with the resident's wishes, that is actuated when the resident is no longer able to make decisions for himself/herself due to illness or incapacity). These failures violated Resident 9 and Resident 47's right to formulate an AD and had the potential to receive inappropriate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment. Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated, Resident 9 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke, result of disruptive blood flow to the brain) affecting left…

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 revise/update the care plan for two of two sampled residents (Residents 2 and 39) who were assessed as at risk for fall (coming to rest on the ground or lower-level surface). These deficient practices had the potential for the residents not to receive care specific to their needs and placed the residents at risk for further falls and complications. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions), metabolic encephalopathy (impaired brain function) and abnormal gait and mobility (abnormal walking pattern). During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/18/2024, the MDS indicated Resident 2 was cognitively impaired and needed moderate (helper…

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 safe food storage and food handling practices for one of one kitchen (Kitchen 1) and one of one snack/nourishment refrigerator (Refrigerator 1) in accordance with professional standards for food service safety and the facility's policies and procedures (P&P) by failing to: 1. Label/date food items in the kitchen and in the snack/nourishment refrigerator on the unit. 2. Maintain acceptable chemical sanitizing solution (used to sanitize food contact surfaces) concentration in the kitchen. 3. Maintain proper temperatures of the snack/nourishment refrigerator on the unit. 4. Discard expired foods in the snack/nourishment refrigerator on the unit and Resident 8's food that was brought from home. These deficient practices put the residents in the facility at risk for food borne illness (illness caused by the ingestion of contaminated food or beverage), contamination of food and/or affect the palatability of the food for the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for five of five sampled residents (Residents 14, 159, 208, 209 and 214) by failing to: a. Ensure the blood pressure (BP, the force of the blood pushing against the walls of the arteries) monitor was cleaned and disinfected (remove dirt or stains and apply a chemical to a surface in order to destroy germs) after using it with Resident 209 and before using it for Resident 214. b. Ensure Resident 208's urinal was properly labeled with initials, room number, and bed number. c. Ensure a used 8 oz (ounce) [NAME] (brand name) Perineal & Skin Cleanser Rinse-Free (a gentle, specially formulated product that cleans the perineum [area between the anus and genitals] and removes skin irritants) was not kept on top of the toilet tank cover in Resident 14 and Resident 159's restroom. d. Ensure food items and personal belongings from staff were not kept in the clean Linen Closet open shelving cabinet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) for one of two sampled residents (Resident 43) was completed accurately in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 43 to receive inappropriate care and services based on Resident 43's preferences, goals of care, functional and health status, strengths, and needs. Findings: During a review of Resident 43's admission Record (AR), the AR indicated, Resident 43 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including dysphagia (swallowing difficulties), oropharyngeal (middle part of the throat behind the mouth) phase, encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube through the abdomen and into the stomach) and essential (primary) hypertension (high blood pressure). During a concurrent 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 interview and record review, the facility failed to complete and transmit the quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment in a timely manner for two of two sampled residents (Residents 28 and Resident 30) as indicated in the Centers for Medicare & Medicaid Services (CMS - a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual. a. For Resident 28, the MDS was not transmitted within 14 days after discharge from the facility. b. For Resident 30, the MDS was not transmitted within 14 days after admission and discharge. These deficient practices resulted to a late completion and transmission of MDS assessment to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. This had the potential to affect the facility's quality monitoring data. Findings: a. 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 ensure one of three sampled residents (Resident 42) who was admitted with a suprapubic catheter (a type of medical device tube that helps drain urine from your bladder) had a baseline care plan (CP provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) developed and implemented within forty eight (48) hours of admission in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 42 not receiving continuity of care and the lack of communication among staff which could lead to decrease in Resident 42's safety and safeguard against adverse events. Findings: During a review of Resident 42 admission Record (AR), the AR indicated, Resident 42 was originally admitted on [DATE] and last readmitted on [DATE] with multiple…

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 or implement an individualized person-centered care plan for one of one sampled resident(Resident 2) who was at risk for elopement (run away without permission) and had a history of elopement. This failure had the potential to result in unmet individual needs and the potential to affect the resident's safety and well-being. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions), metabolic encephalopathy (impaired brain function) and abnormal gait and mobility (abnormal walking pattern). During a review of Resident 2's Risk of Elopement/Wandering Review (RE/WR) dated 3/15/2024, and 6/17/2024, the RE/WR indicated the resident was at risk for elopement and had a history of leaving the facility without need 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 one of 5 sampled residents (Resident 48), who was assessed as a high risk to develop pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) and was admitted without pressure ulcers, received the necessary care and services to prevent a development of a pressure ulcer. As a result, on 10/1/2024, Resident 48 was identified with a stage 2 pressure injury (an open wound that occurs when the skin breaks, wears away, or forms an ulcer) to the left buttock. Findings: A review of the admission record indicated Resident 48 was admitted to the facility on [DATE], with diagnosis including but not limited to, end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), endocarditis (a life-threatening inflammation…

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 one sampled resident (Resident 35) receiving oxygen therapy was provided respiratory care and resident safety in accordance with the facility's policy and procedure titled Oxygen Administration, and professional standards of practice. There was no sign posted on the resident's door indicating oxygen in use. This deficient practice placed Resident 35's safety at risk regarding oxygen usage. Findings: During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and repeated falls. During a review of Resident 35's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/22/2024, the MDS indicated Resident 35 had impaired cognition (mental action or process of acquiring knowledge and understanding) 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 interview and record review, the facility failed to have a full time Director of Nursing (DON) five (5) days a week, 8 hours a day beginning 3/6/24 up to the present (10/17/24). This deficient practice had the potential to significantly impact the quality of care, overall patient experience and nursing workforce operations in the facility. Findings: During the entrance conference on 10/15/24 at 8:20 am, the Administrator (ADM) stated the facility had an interim/acting Director of Nursing (DON) and was actively looking to hire a fulltime DON. During a review of the facility's medical leave letter of the previous Director of Nursing (DON 1) dated 3/18/24, the medical leave letter indicated DON 1 would be on leave starting 3/6/24. During a review of DON 1's resignation letter, the letter indicated DON 1's last date of employment was on 8/23/24. During an interview on 10/17/24 at 2:53 PM, with the acting (ADON), the ADON stated there had not been an active fulltime DON for approximately 8 months. The ADON stated as the ADON she was responsible for the oversight of the unit and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility was free of a medication error rate of 5 percent (%) or greater during the medication pass observation for one of four sampled residents (Resident 109). The facility had 26 opportunities of medication administration (the act of giving a treatment) observed and three of the 26 medications administered were not in accordance with the physician's orders, resulting in a medication error rate of 11.54%. The medication errors consisted of: a. Resident 109's Eliquis (blood thinner) and Multiple Vitamin were not administered as ordered by the physician. b. Resident 109's tear duct was not held with gentle pressure for one minute after administration of Brimonidine Tartrate Ophthalmic Solution 0.2% (eye drops to lower pressure in the eye) These deficient practices placed Resident 109 at risk for adverse consequences and complications. Cross Reference with F760 Findings: During a review of Resident 109's admission Record (AR),…

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 four sampled residents (Resident 109) observed during medication pass was free of significant medication errors by failing to ensure Resident 109's medication Eliquis (blood thinner) was administered as ordered by the physician. This failure had the potential to increase the risk of blood clot for Resident 109 that may cause embolism (a block in an artery caused by blood clot) leading to serious medical complications. Findings: During a review of Resident 109's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included long term use of an anticoagulant (blood thinner), repeated falls, and displaced intertrochanteric fracture of the right femur (a broken right hip). During a review of Resident 109's care plan titled Anticoagulant (medication that prevents or reduces clotting of the blood) dated 10/12/2024, the care plan indicated to administer medications as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was within reach for one of two sampled residents (Resident 25), as indicated on Resident 25's care plans (CP [provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) and in accordance with the facility's policy and procedure (P&P). This failure had the potential to result in Resident 25 not having Resident 25's needs met in a timely manner and/or Resident 25 to experience harm if Resident 25 was unable to alert staff during an emergency. Findings: During a review of Resident 25's admission Record (AR), the AR indicated, Resident 25 was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness (generalized), difficulty in walking, not elsewhere…

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 interviews and record review, the facility failed to ensure two of two facility staff (the Director of Nursing [DON] and the Registered Nurse Supervisor [RNS]) had Infection Prevention (IP) certificates and had completed specialized training in infection prevention and control while covering the Infection Control Preventionist (ICP) role. This failure had the potential to result in the spread of infections throughout the facility. Findings: On 8/2/24 a visit was made to the facility to investigate a facility reported incident regarding a Covid-19 (minor to severe respiratory illness caused by a new virus and spread from person to person) outbreak (a higher-than-expected number of occurrences of a disease in a specific location and time). During an interview with the Administrator (ADM), on 8/2/24 at 11:12 am, the ADM stated the facility's ICP was on medical leave and the acting ICP role was shared between the DON and the RNS. During an interview with the DON, on 8/2/24 at 3:07 pm, the DON stated the DON was the acting ICP at the facility for several months (did not remember…

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 home like environment for 53 of 53 residents by failing to ensure residents meal trays were in good condition. This failure had the potential to result in a non-home like environment for the residents which could affect the residents' quality of life. Findings: During a concurrent observation and interview on 7/3/2024 at 11:30 a.m. with Director of Nursing (DON) and Kitchen Supervisor (KS) in the kitchen area, there were ten trays observed with cracks and peeling materials. The DON stated the trays were not appropriate and safe for residents to be served meals. The KS stated the broken trays were not appropriate for residents, and the facility should not be using broken, cracked, and/or peeling trays. The KS stated the trays needed to be disposed. The KS stated the facility's policy indicated the facility would provide a homelike environment, and serving meals in broken trays was not a homelike environment. During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike…

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 treat six of six sampled residents (Resident 6, Resident 18, Resident 19, Resident 22, Resident 28, and Resident 155) with respect and dignity when: a - d. Resident 6, Resident 18, Resident 22, and Resident 19's call lights (a visual cue that a patient needs assistance) were not answered in a timely manner. e. - f. Resident 28 and Resident 155's urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bags were left exposed. These deficient practices resulted in Resident's 6, 18, and 19 to feel bad, terrible, and panicky. For Resident's 28 and 155, the deficient practice had the potential to result in feelings of humiliation and embarrassment due to urine being visible to staff and other residents. Findings: a.During a review of a Record of Admission (admission Record, AR), the AR indicated Resident 6 was re-admitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames the air…

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 necessary care and services were provided for two of two sampled residents (Resident 55, and Resident 12) when: a. For resident 53, the facility failed to notify the physician Resident 53's arteriovenous fistula (AVF, a connection that's made between an artery and a vein for dialysis access) was clotted (blocked) and that Resident 53 was not hemodialyzed (dialysis [treatment to remove extra fluid and waste products from the body when the kidneys can no longer perform these functions naturally]) on 7/27/23. b. Resident 12 did not wear heel protectors while lying in bed. These failures had the potential to result in physical harm and decline for Resident 53 due to Resident 53 not receiving scheduled hemodialysis. For Resident 12, the failure had the potential to result in pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break…

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 interviews and record review, the facility failed to ensure six of six sampled residents (Residents 4, 5, 17, 18, 28, and 36) received necessary restorative nursing program (RNP, nursing interventions to promote resident's mobility and functioning as safely as possible) care and services to improve mobility, maintain and prevent further decline in range of motion (ROM, full movement potential of a joint) by failing to: a. Provide RNP services for ambulation and active-assisted ROM (AAROM, joint receives partial assistance from an outside force) exercises for both shoulders to Resident 4 five times per week from 9/1/2023 to 9/30/2023 as ordered by the physician. b. Provide RNP services for Nu-Step exercise (low-impact, full workout of arms and legs with the use of an equipment) to Resident 5 from 9/1/2023 to 9/30/2023 as ordered by the physician. c. Provide RNP services for AAROM exercises to Resident 17's right lower extremity (RLE) from 9/1/2023 to 9/30/2023 as ordered by the physician. d. Provide RNP…

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 interviews and record review, the facility failed to ensure sufficient nursing staff and Restorative Nursing Aides (RNA, nursing aide program that helps residents to maintain their function and joint mobility) were assigned to provide care to all the residents in accordance with the facility's Facility Assessment Tool for four of 10 randomly selected dates for the months of September and October 2023 (9/7/2023, 9/8/2023, 9/10/2023, and 9/11/2023). This failure had the potential to result in compromised quality of care, contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints) to the residents who had orders for RNA and did not receive such services, and a decline in the residents' overall physical and psychosocial well-being. Cross Reference with F688 Findings: During an interview on 10/4/2023 at 10:14 a.m., the Assistant Director of Nursing (ADON) stated the facility has a shortage of licensed and unlicensed nursing staff. The ADON stated the facility has utilized Registry staff, but the quality 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: a. label wheat rolls with a use by date and to label prepared food in the refrigerator. b. store resident's food at a temperature at or below 41 degrees Fahrenheit (F, unit of measurement) in the Nourishment Room refrigerator. These failures had the potential to result in food-borne illnesses (illness caused by consuming contaminated food or beverages). Findings: a. During a concurrent observation and interview on 10/3/23 at 10:27 a.m. with the Executive Chef (EC) in the facility's kitchen Walk in Cooler #2, a clear container of tofu (a soy-based food) was unlabeled. The EC stated the tofu should be labeled to indicate what it is and when it was opened. The EC stated the tofu should be labeled to ensure it is used before it expired. The EC stated if the tofu was given past expiration date, then residents could experience food borne illnesses. The EC stated the tofu should be labeled indicating what it is, so residents who have allergies to soy are not given the tofu. During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices to prevent and control the spread of infections in the facility, when two of two staff (Certified Nursing Assistant [CNA] 1 and CNA 2) entered resident rooms without wearing proper Personal Protective Equipment (PPE, protective clothing or equipment, designed to protect the wearer from the spread of infection or illness), as indicated in the facility's Policy and Procedure (P&P) and national health guidelines. These failures had the potential to result in the spread of infections throughout the facility and illness to the residents and staff. Findings: During a review of Resident 18's Record of admission (admission Record, AR), the AR indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 18's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 8/28/2023, the MDS indicated Resident 18's active…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide one of five sampled residents (Resident 33) or Resident 33's family member/representative with information regarding the right to formulate an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated). This deficient practice had the potential for Resident 33 and Resident 33's family member/representative to receive inaccurate or unnecessary care and/or treatment services regarding life-sustaining treatment. Findings: During a review of Resident 33's Record of admission (admission Record, AR), the AR indicated, Resident 33 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 33's History and Physical Examination (H&P), dated 9/22/23, the H&P indicated, Resident 33 had multiple diagnoses including pulmonary embolism (a blood clot from…

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 facility staff notified the primary care physician regarding a change in condition, for one of one sampled resident (Resident 17), in August 2023. This failure had the potential to result in physical or psychosocial well-being decline for Resident 17 due to a possible delay in obtaining physician orders necessary for Resident 17's treatments and/or services. Findings: During a review of Resident 17's Record of admission (AR), the AR indicated the facility admitted Resident 17 on 6/20/2019 with multiple diagnoses including atherosclerotic heart disease (damaged heart blood vessels due to fat deposits), type 2 diabetes mellitus (long standing condition where the body does not produce enough or resists insulin [hormone that helps the body use sugar for energy]), and major depressive disorder (mental health disorder, a persistent low mood with symptoms like lack of energy, sleep disturbances, or appetite changes). During a review of Resident 17's History and Physical Examination (H&P), dated 8/18/2022, 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 interview and record review, the facility failed to transmit a Minimum Data Set (MDS- a standardized assessment and screening tool) within 14 days after a resident was discharged from the facility for one of one sampled resident (Resident 30). Resident 30's MDS exceeded 120 days due for transmission. This failure had the potential to result in inaccurate assessments of the facility's quality indicators and/or care area concerns for Resident 30. Findings: During a review of Resident 30's Record of admission (admission Record, AR), dated 10/5/23, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection (UTI, an infection in any part of the urinary system), difficulty in walking, and metabolic encephalopathy (brain disease that alters brain function or structure). Resident 30's Record of Admission indicated Resident 30 was discharged from the facility on 6/5/2023. During an interview on 10/4/23 at 2:53 p.m. with the MDS Coordinator (MDSC), the…

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

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one of one sampled resident (Residents 39). Resident 39's MDS incorrectly indicated she had physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body). This failure had the potential to result in Resident 39 not to receive appropriate treatment and/or services. Findings: During a review of Resident 39's Record of admission (admission Record, AR), dated 7/25/23, the AR indicated Resident 39 was admitted to facility on 5/27/23 with diagnoses including multiple falls, presence of left artificial hip joint, and syncope (fainting or passing out) and collapse. During a review of Resident 39's MDS, dated 8/29/23, the MDS indicated Resident 39 had no impairment in cognitive skills (the ability to make daily decisions). Resident 39 required…

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

Based on observation, interview, and record review, the facility failed to develop and implement a care plan for one of one sampled resident (Resident 17) that addressed Resident 17's sleeping patterns and the level of assistance required for Resident 17's activities of daily living (ADL, term used in healthcare that refers to self-care activities) in accordance with Resident 17's preferences and needs. This failure had the potential to result in diminished quality of life and a decline in Resident 17's physical and psychosocial well-being. Findings: During a review of Resident 17's Record of admission (admission Record, AR), the AR indicated the facility admitted Resident 17 on 6/20/2019 with multiple diagnoses including atherosclerotic heart disease (damaged heart blood vessels due to fat deposits), type 2 diabetes mellitus (long standing condition where the body does not produce enough or resists insulin [hormone that helps the body use sugar for energy]), and major depressive disorder (mental health disorder, a persistent low mood with symptoms like lack of energy, sleep…

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 assess the intravenous (IV, administered into veins) site promptly and ensure the site was secured and free of any complications for one of one sampled resident (Resident 18) in accordance with Resident 18's care plan, the facility's Policy and Procedure (P&P), and standards of practice. This failure had the potential to negatively affect Resident 18's physical and psychosocial well-being due to complications of IV therapy. Findings: During a review of Resident 18's Record of admission (admission Record, AR), the AR indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 18's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 8/28/2023, the MDS indicated Resident 18's active diagnoses included coronary artery disease (CAD, buildup of fat deposits in the wall of the arteries supplying blood to the heart), diabetes mellitus (metabolic…

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 three of 12 sampled residents (Residents 28, 33 and 155) received assistance from staff for activities of daily living (ADLs) including nail grooming. Residents 28, 33, and 155's fingernails were long and jagged. These deficient practices had the potential for Residents 28, 33 and 155 to hurt themselves and dirt and germs to get under the fingernails. Findings: a. During a review of Resident 28's Record of admission (admission Record, AR), the AR indicated, Resident 28 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 28's History and Physical Examination (H&P), dated 8/23/23, the H&P indicated, Resident 28 had multiple diagnoses including subdural hemorrhage (SDH, a type of bleed inside your head) and prostate cancer. The H&P indicated, Resident 28 had the capacity to make own decisions. During a review of Resident 28's Minimum Data Set (MDS, an assessment and screening tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess one of one sampled resident (Resident 19) for risks for falling upon admission to the facility on 9/5/23 and implement care and services to prevent falls in according to the facility's Policy and Procedure (P&P). Resident 19, who had a history of falls (to move downwards from higher to a lower level), sustained a fall on 9/7/23, two days after being admitted to the facility. This failure had the potential to result in Resident 19 to develop injury and/or harm to herself. Findings: During a review of Resident 19's Record of admission (admission Record, AR), dated 9/5/23, the AR indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's Client Diagnosis Report, dated 9/14/23, the Client Diagnosis Report indicated, Resident 19 was admitted to the facility with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system), acute respiratory failure (when the lungs can't get…

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 three sampled residents (Resident 36) was provided appropriate treatment and services for care of a clinically-justified indwelling urinary catheter (a flexible tube which is inserted into the bladder to drain urine). Resident 36's indwelling catheter was not kept anchored and secured. This deficient practice had the potential to cause complications such as excessive tension on the catheter, which can lead to urethral (urethra, part of the body that is a tube that carries urine from the bladder to outside the body) tears and/or discomfort, dislodging the catheter, impeding flow of urine, and kinking of the catheter tubing. Findings: During a review of Resident 36's Record of admission (admission Record, AR), the AR indicated, Resident 36 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 36's History and Physical Examination (H&P), dated 5/24/23, the H&P indicated, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 48) received the necessary oxygen (O2) care as ordered. a. Resident 48 had an order of O2 at 2 liters (L, unit of measurement) per minute and was observed with 2.5 liters per minute via (through) nasal cannula (N/C, a tube used to deliver oxygen to help with breathing) on 10/3/23 at 12:54 p.m. b. Resident 48 had only one prong of the N/C in one of Resident 48's nostrils on 10/3/23 at 12:54 p.m. These deficient practices had the potential to result in untoward reaction to Resident 48. Findings: During a review of Resident 48's Record of admission (admission Record, AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including fracture of right femur (broken bone of the leg), repeated falls, and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 48's Physician Orders, dated 9/15/23, 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 record review and interview, the facility failed to report the results of an investigation of an allegation of abuse to two of three sampled residents (Resident 1 and 2) within five working days of the incident to the State Survey Agency for a resident to resident abuse allegation, for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential that the facility would not do a thorough investigation and take appropriate corrective actions to prevent further abuse between Resident 1 and 2. Findings: During a review of Resident 1's Record of admission indicated the facility admitted Resident 1 on 8/9/23. Resident 1 ' s medical diagnoses included type 2 diabetes [a disease in which the body's ability to produce or respond to the hormone insulin (hormone regulates the amount of glucose/sugar in the blood) was impaired], urinary tract infection (UTI- is an infection in any part of the urinary system), and high blood pressure. During a review of Resident 1's Minimum Data Set (MDS- an assessment and screening tool) dated 8/15/23, indicated Resident…

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