Morning Star Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services which met professional standards of practice for two of the five sampled residents (Resident 1, and Resident 5) when Resident 1 and Resident 5's medications were not available, and the license nurse did not notify the physician the medications were not administered. This failure had the potential risk for Resident 1 and Resident 5 to experience worsening of existing health conditions and delayed medical response. During a record review on 8/7/25 at 11:47 a.m. with the Licensed Vocational Nurse (LVN) at the nurses' station, Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/7/25 was reviewed. The AR indicated Resident 1 was admitted [DATE] with diagnoses of left knee osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), asthma (a chronic lung disease caused by 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 interview and record review, the facility failed to follow professional standards practice and the facility's policy and procedure for one of four sampled residents (Resident 1) when Resident 1 was not administered medications as ordered by the physician on 5/23/25. This failure had the potential for Resident 1 to experienced worsening chronic conditions, health deterioration, re-hospitalization and or death. Findings: During a concurrent interview and record review on 6/12/25 at 3:33 p.m. with Licensed Vocational Nurse (LVN 2) at the nursing station, Resident 1's Medication Administration Record (MAR) and Progress Notes dated 5/23/25 were reviewed. The MAR, dated 5/23/25 at 9 a.m. indicated Resident 1 did not receive Allopurinol for gout (a type of inflammatory arthritis that causes pain and swelling in your joints, usually as flares that last for a week or two, and then resolve) , Duloxetine for depression (feelings of sadness don't go away and can get in the way of your everyday life), Empagliflozin…

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 safe and sanitary food preparation and storage practices in the kitchen according to facility policy and procedures and the FDA (Food and Drug Administration-is a government agency responsible for protecting the public health) Food Code when: 1. There was brown, grey, and black debris observed in several areas in the kitchen, including one ventilator fan in the milk refrigerator, two vents above the dishwasher area, one vent in front of the milk refrigerator and one vent in front of the food warming table. 2. There was black and brown debris found on the cabinet shelves next to the stored clean bowls. 3. There was brown debris on every shelf inside of one food cart. 4. There was brown debris on top of the toaster and brown particles found inside the toaster. 5. There was a beef roast inside a plastic bag covered in ice stored in the meat freezer. These failures had potential for cross contamination (when harmful bacteria accidentally moves from one food item to another) and exposure of microorganisms…

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 an effective infection prevention and control program for 54 of 54 sampled residents when: 1. The facility's Water Management Program (WMP) was not implemented since 4/8/22 to reduce the risk of Legionella (waterborne bacteria which can cause life threatening pneumonia - a lung infection) and other waterborne pathogens (germs that cause disease) in accordance with the facility's WMP. This failure placed the residents at risk for cross contamination (when harmful bacteria accidentally move from one food item to another), infection and had the potential for not identifying the risk of waterborne illnesses such as Legionella. 2. Resident 13 and Resident 30's oxygen nasal cannula (a small thin flexible tube with two prongs that fit into the nostrils and connects to an oxygen source) was on the floor. These failures placed Resident 13 and Resident 30 at risk for cross contamination which could result in infections and illness. 3.…

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 residents were treated with dignity and respect for nine of 13 sampled residents (Residents' 2, 4, 6, 9, 14, 21, 26, 29, 31, 34, and 106) when: 1. Licensed Vocational Nurse (LVN) 1 checked Resident 106's blood sugar level (BS-amount of sugar in the blood) without closing the privacy curtain or the door. 2. LVN 3 checked Resident 34's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry throughout the body]) and did not provide privacy. 3. LVN 3 administered medications to Residents' 2, 4, 6, 9, 21, 26, 29, 31, and 34 without closing the privacy curtain. These failures resulted in Resident 2, 4, 6, 9, 21, 26, 29, 31, 34, and 106 not provided respect and dignity during care which could potentially impact residents' well-being leading to vulnerability, decreased dignity, anxiety, stress and depression. Findings: 1. During a concurrent observation and interview on 12/5/24…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of 54 residents residing in the facility when the contracted pharmacist did not check the expiration date of the lorazepam (medication used to treat anxiety and seizure- [a burst of uncontrolled electrical activity in the brain]) medication stored in the emergency kit (E-kit-contains medications provided to residents during emergency situations). This failure placed residents at potential risk for taking expired medications which could lead to serious consequences including reduced effectiveness in treating resident's condition in an event of an emergency and potential adverse reaction. Findings: During a concurrent observation, interview and record review on 12/6/24 at 12:25 p.m. with the Director of Nursing (DON) in the medication room, the refrigerator e-Kit which contained two vials of lorazepam 2MG/ML (milligram-unit of measurement/milliliter-unit of measurement), with an expiration date…

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 medications were stored and labeled in accordance with the facility's Administering Medications, Discontinued Medications, and Storage of Medications policy and procedure when: 1. Treatment cart was left unlocked and unsupervised in front of the nursing station. This failure had the potential for residents and staff to access medicated ointments inside the cart and used which could lead to serious health condition. 2. Resident 14's two inhalers (a device used to give medications in the form of a spray that is breathed in through the mouth) did not have an open date or expiration date on the medication. 3. Resident 14's nasal spray (a devised used to give medications in the form of spray through the nose) did not have an on date or expiration date on the medication. 4. Resident 18's inhaler did not have an open date or expiration date on the medication. These failures had the potential for the medications to be given to 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 and staff interview during the survey period from 12/3/24 through 12/10/24, the facility failed to ensure each bedroom accommodated no more than four residents in (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]). Findings: Throughout the survey period from 12/3/24 through 12/10/24 three resident bedrooms had more than four residents in each bedroom. rooms [ROOM NUMBER] had eight residents per room. Although the bedrooms accommodated more than four residents, each room met the required needs of the residents, as well as the required square footage. The residents had a reasonable amount of privacy, and closet and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for the mobility of the residents. Wheelchairs, devices, and toilet facilities were accessible. The health and safety of the residents will not be adversely affected by the continuance of this waiver. Room Number: Number of Beds: 11 8 12 8 14 8 Recommend waiver…

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 call light was within reach for three of 14 sampled (Residents' 104, 19 and 30) when: 1. Resident 104's call light was under his bed and not within his reach. 2. Resident 19 and Resident 30's call lights were on the floor and not within their reach. This failures resulted in the potential harm of Resident 19, Resident 30 and Resident 104 to not be able to call for assistance by using the call light in the event of an emergency. Findings: 1. During an observation on 12/3/24 at 7:50 a.m. in Resident 104's room, Resident 104 was sitting up in bed with breakfast tray on top of the overbed table in front of Resident 104. Resident 104 did not answer questions asked, but repeatedly requested for coffee. Call light was not within Resident 104's reach, it was on the floor under Resident 104's bed. During a review of Resident 104's clinical record titled, admission Record, (AR-document containing resident personal information) dated 12/10/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services which met the professional standards of practice of care for one of 13 sampled residents (Resident 14) when Licensed Vocational Nurse (LVN) 2 allowed Resident 14 to self-administer her two inhaler (a device used to give medications in the form of a spray that is breathed in through the mouth) not following their own policy and procedure of self-administration of medication. This failure had the potential for Resident 14 to not received the correct medication dose as ordered by the physician. Findings: During a review of Resident 14's clinical record titled admission Record (AR-a medical document which contains resident's medical history, current health status, diagnosis, medications, and legal documents), dated 12/6/24, indicated Resident 14 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty breathing) and asthma…

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 residents who were unable to carry out activities of daily living (ADLs-routine tasks/activities a person perform daily to care for themselves) were provided assistance to maintain personal hygiene and grooming for one of seven sampled residents (Resident 22) when Resident 22's fingernails were long, jagged, with dark colored particles under the nails and his mouth and in between her teeth had food particles. These failures resulted in Resident 22's poor personal hygiene and had the potential to result in serious health condition. Findings: 1. During a concurrent observation and interview on 12/3/24 at 8:58 a.m. in west wing hallway, Resident 22 was lying in bed with eyes closed. Resident 22 stated she had been in the facility for a long time. Resident had long, jagged, and dirty nails with dark colored particles underneath the nails. Resident 22 stated staff would help her trim her fingernails but did not remember when the last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. [NAME] 2 was unable to properly calibrate the thermometer. This failure had the potential to cause foodborne illness for 50 out of 51 sampled residents who received foods from the kitchen. 2. [NAME] 2 did not follow manufacturer's guideline time length for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces). This failure had the potential to cause foodborne illness for 50 out of 51 sampled residents who received foods from the kitchen. 3. [NAME] 1 did not follow the Cooks spreadsheet (the menu document used to guide dietary staff on food items, portions, texture of foods and therapeutic diet) portion size to make pureed chicken during the noon meal on 11/7/23. This failure had the potential risk of compromised residents' nutrition status for four of 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 maintain a sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: 1. The 3-compartment sink did not have an air gap (is vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). 2. [NAME] debris was observed on the wall next to the milk refrigerator, cook freezer, above the steam table, door frame of the dry storage door and a black fan located next to clean water pitchers. 3. Milk refrigerator and produce refrigerator shelves had chipped paint. 4. Two floor holes observed underneath the ice machine. 5. The inside of two microwaves, one located by the hand wash station and the other next to the three-compartment sink had brown sticky substance. 6. The Dietary aide (DA) had exposed facial hair and [NAME] (CK) 2 had exposed hair during meal preparation. These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object…

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 and maintain an effective infection prevention and control program to prevent the transmission of infections when: 1. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene during medication administration to Resident 51. 2. The clean linen room door was left open to the hallway, and the room was unoccupied. 3. The linen cart located in the east hallway containing clean gowns was left open and a crumpled paper tissue was left on the bottom shelf of the cart. 4. The north shower room had washcloth hanging on the soap holder and the handheld shower head was left on the floor. These deficient practices placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During a concurrent observation and interview on 11/7/23 at 12:15 p.m., with LVN 1 in room [ROOM NUMBER], LVN 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide written notification before a room change for three of 53 sampled residents (Resident 31, Resident 27, and Resident 307) when the residents were moved to another room without a written notification including the reason for the move provided to residents and responsible representative (an individual chosen to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications). This failure violated the right of Resident 31, Resident 27, and Resident 307 to receive a written notice explaining the reason for the move before the room changed. Findings: During an interview on 11/7/23, at 9:22 a.m. in Resident 31's room, Resident 31 stated, she would like to be in a room with four persons. Resident 31 stated, It's noisy here. During a review of Resident 31's admission Record (AR), dated 11/8/23, the AR 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 53 sampled residents (Resident 27, Resident 8, and Resident 6) when: 1. Resident 27 and Resident 8 did not have a comprehensive care plan for atrial fibrillation (a-fib- an abnormal heartbeat which reduces the heart's ability to pump properly and increases risk of blood clots) and the use of anticoagulation medication (medication that helps prevent blood clot formation). These failures placed Resident 27 and Resident 8 at risk for signs and symptoms of a-fib and bleeding complications from the used of anticoagulant to go unmonitored. 2. Resident 6's weight loss care plan intervention for weekly weights were not done. This failure placed Resident 6 at risk for delayed identification, reporting, and timely management for weight loss. Findings: During a concurrent interview and record review on 11/8/23 at 11:40 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 27's…

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

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs for four of four sampled residents (Residents 1, 18, 34, and 309) was met for lunch on 11/7/23 when the meal was not plated in accordance with menu guidance for purred diet portion size for purred meat. This failure had the potential to result in under nutrition further compromising the medical status of Residents 1, 18, 34, and 309 who received pureed meat from the kitchen. Findings: During a concurrent observation and interview on 11/7/23 at 9:41 a.m., with [NAME] (CK)1 in the kitchen, CK 1 pour a bowl of dice chicken into blender to make pureed meat. CK 1 stated he weighed the dice chicken and was 6 ounces (oz- a unit of measurement). CK 1 stated he put 6 oz of dice chicken in the blender to make 5 portions of pureed meat for lunch meal. During a concurrent interview and record review on 11/7/23 at 3:13 p.m., with the Registered Dietitian (RD), the Cooks Spreadsheet Fall Menus dated 11/7/23 was reviewed. The Cooks Spreadsheet Fall Menus indicated, 1 portion of Lemon Chicken…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for six of six residents (Resident 33, Resident 45, Resident 1, Resident 18, Resident 34, and Resident 309) when: 1. [NAME] 2 served Resident 33 and Resident 45 a regular textured Brussels sprouts for lunch instead of the physician ordered mechanical soft diet (a diet with food texture of chopped and ground designed for residents who have trouble chewing and swallowing). 2. [NAME] 1 served Resident 1, Resident 18, Resident 34, and Resident 309 chunks of chicken for lunch instead of the physician ordered puree diet (a diet with food texture of soft pudding-like consistency). These failures placed Residents at risk for aspiration (accidentally inhaling food or liquid into the lungs) and choking. Findings: 1. During a review on 11/6/23 at 12:00 p.m. of Resident 45 & Resident 33's Meal Tray Ticket (menu based on the resident's diet physician order and food preference), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, during the survey period of 11/6/23 through 11/9/23, the facility failed to ensure each bedroom accommodated no more than four residents in three of 16 rooms (rooms 11, 12 and 14). This failure had the potential for residents to not have reasonable privacy or adequate space. Findings: During a concurrent observation and interview on 11/7/23 at 9:55 a.m. with Resident 23 in room [ROOM NUMBER], Resident 23 was lying in bed watching television. Resident 23 had a dresser within her curtained area and had personal belongings within reach. Resident 23 stated she had her own area in the room and 8 residents in the room did not affect her privacy. During a concurrent observation and interview on 11/07/23 at 10:05 a.m. with the Director of Maintenance (DOM) in rooms 11, 12 and 14, 8 resident beds were observed in each room. The DOM stated the facility needed a waiver if there were more than 4 residents per room. There was adequate closet and storage space observed for each resident 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 provide a safe, functional, and sanitary environment for (19 of 51 residents (1, 2, 4, 6, 7, 8, 10, 18, 24, 25, 29, 31, 32, 34, 36, 38, 46, 51, and 307) when: 1. Two resident shower rooms had black residue on the tile floors and walls, gaps in between the tiles and the call light pull cords had pink and black substance. 2. Oscillating (rotating) fan with a plastic packaging wrapped at the end of the electrical cord was plugged into a four-socket wall and the plastic packaging was touching the outlet. 3. The shower room in the north hallway had darkened areas on the tile grout. These failure placed residents in a unsanitary environment which could lead to potential health problems and created a fire hazard. Findings: 1. During an observation on 11/6/23 at 9:55 a.m. in room [ROOM NUMBER]'s bathroom, the shower room had areas of a black substance on the tile and in between the tiles on the floor. The shower walls had areas gap spaces 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 maintain an effective pest control program to ensure the facility remained free of pests when two winged bugs were found in a resident's shower. This failure had the potential for bacteria to spread from flies which could cause illness in a medically vulnerable population of residents. Findings: During an observation on 11/6/23, at 9:55 a.m. in room [ROOM NUMBER]'s bathroom, the shower room had two black winged bugs on the wall. During a concurrent observation and interview on 11/6/23, at 10:25 a.m. with Certified Nursing Assistant (CNA) 5 in room [ROOM NUMBER]'s bathroom, CNA 5 confirmed the two black winged bugs were on the shower wall. CNA 5 stated the two black winged bugs on the wall were moths. During a concurrent observation and interview on 11/6/23, at 10:27 a.m. with CNA 2 in room [ROOM NUMBER]'s bathroom, CNA 2 confirmed the two black winged bugs were on the shower wall. CNA 2 stated the two black bugs on the wall were fruit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided meet professional standards of practice for one of three sampled residents (Resident 6) when Resident 6's Physician order for weekly weights was not done on 7/17/23, 7/24/23, 8/7/23, 8/14/23, 8/21/23, 9/4/23, 9/11/23, 9/18/23, 9/25/23, 10/9/23, 10/16/23, and 10/23/23. This failure resulted in Resident 6 unmonitored weight loss. During a concurrent observation and interview on 11/7/23 at 11:57 a.m. with Resident 6 at the bedside, Resident 6 was lying in bed with the noon meal tray in front of her. Resident 6 took a bite of pasta and stated she likes to eat steak and thought she was in her grandparents' home. During an interview on 11/8/23 at 9:15 a.m. with Resident 6 at Resident 6's bedside. Resident 6 stated her appetite was not good, and she preferred liquid foods for breakfast. During a review of Resident 6's admission Face Sheet (a document containing resident profile information which includes patient identification, past…

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 monitor the effectiveness of nutrition interventions and recommend interventions to maintain acceptable parameters of nutritional status for one of three sampled Residents (Resident 6), during which time weight loss continued. These failures resulted in Resident 6 experiencing an unhealthy, unplanned, and undesired severe weight loss of 33 pounds (lb) or 15 percent in six months and a 54 lb weight loss of 22.5 percent in eight months, which placed Resident 6 at risk for further health status decline. Findings: During a concurrent observation and interview on 11/7/23 at 11:57 a.m. with Resident 6 at the bedside, Resident 6 was lying in bed with the noon meal tray in front of her. Resident 6 took a bite of pasta and stated she likes to eat steak and thought she was in her grandparents' home. During an interview on 11/7/23 at 12:09 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 6 had about 25 % meal intake most 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of 53 residents (Resident 2) when Resident 2 was making loud noise and yell during nighttime and was assess for pain by the License Vocational Nurses (LVNs) using the numerical pain scale (a pain assessment tool in which the resident picks or draw a circle around the number that best describes their pain, 0 no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain) which was the wrong pain assessment tool because Resident 2's had severe cognitive impairment. This failure resulted in Resident 2's experienced of pain not accurately assess and manage which could have resulted for Resident 2's increased in making loud noise and yelling during nighttime. Findings: During a record review of Resident 2's admission Record (AR), dated 11/8/23, the AR indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of Unspecified…

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 policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met when one of three sampled residents (Resident 307) did not have documentation of completed post-dialysis weight assessments on multiple dates. This failure placed Resident 307 at risk for delayed identification, reporting, and management of complications from dialysis. Findings: During a review of Resident 307's admission Record, undated, the admission record indicated, Resident 307 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, diabetes mellitus type 2, fluid overload, end stage renal disease and dependence on renal dialysis. During a concurrent observation and interview on 11/6/23 at 9:22 a.m. with Resident 307 in room [ROOM NUMBER], Resident 307 had a sign hanging above his bed which indicated, .no BP (blood pressures), Sticks (blood withdrawals)…

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 expired medications were discarded and not available for use when a stool softener was stored and available for use in one of one medication cart. This failure had the potential to result in the administration of expired medication that may have lost their potency and may be ineffective. Findings: During a concurrent observation and interview on 11/8/23 at 10:05 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 identified one bottle of a stool softener medication with an expiration date of 8/2023. LVN 1 stated the expired stool softener medication should have been discarded to avoid giving the expired medications to residents. LVN 1 stated expired medications had the potential to lose its efficacy. During an interview on 11/8/23 at 10:18 a.m., with Registered Nurse (RN) 1, RN 1 stated, . checking the expiration date of medication is important because medication can lose it's efficacy and possibly cause unwanted side effects . During an interview on 11/8/23 at 10:28 a.m., with Director of Nurses (DON),…

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 dispose of garbage under sanitary condition when the facility's trash dumpster was left uncovered and overfilled. This failure had the potential to attract rodents, insects, and flies which could place residents at risk for cross contamination (the process by which bacteria are unintentionally transferred from one substance or object with harmful effect) and foodborne illness (illnesses cause from ingestion contaminated food). Findings: During an observation on 11/6/23 at 8:33 a.m. outside the facility. The facility green recycle dumpster was not fully closed and was overflowing with boxes, tree branches, leaves and landscaping materials. During a concurrent observation and interview on 11/6/23 at 8:38 a.m. with the Dietary Service Director (CDM), in front of the green recycle dumpster. The CDM confirmed the facility dumpster was not fully close and was overfilled with boxes, tree branches, leaves and landscaping materials. The CDM stated…

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

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. Resident 2 did not a have a comprehensive care plan implemented for the used of supplemental oxygen (is the use of oxygen as a medical treatment for patients who have low oxygen in their blood and need more oxygen) with interventions which included replacing the nasal cannula (a lightweight tube placed in the nostrils used to deliver supplemental oxygen to patients) weekly and properly storing the nasal cannula inside a storage bag when not in use. 2. Residents 1 and Resident 3's did not have a comprehensive care plan for the used of nebulizer machine (a device used to turn liquid medication into a mist so it can be breathed directly into the lungs through a face mask) with interventions which included replacing the nebulizer mask (a face mask used to deliver aerosol medications for breathing treatments) weekly and properly storing the nebulizer mask inside a storage bag when not in use.…

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 for three of five sampled resident (Resident 1, Resident 2, and Resident 3) when: 1. Resident 2' nasal cannula (a lightweight tube placed in the nostrils used to deliver supplemental oxygen to patients) was on the floor without a date per physician order and not stored inside a bag. 2. Residents 1 and Resident 3's nebulizer mask (a face mask used to deliver aerosol medications for breathing treatments) was placed on top of the nightstand without a date and not stored inside a bag. These failures placed Resident 1, Resident 2, and Resident 3 at increased risk for healthcare associated infections (infections patients get while they are receiving health care for another condition) from cross contamination (a process by which bacteria are unintentionally transfer from one person or object). Findings: 1. During a concurrent observation and interview on 9/12/23 at 9:17 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 2's room, Resident 2's nasal…

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.