Corona Post Acute Center

Based on observation, interviews, and record review, the facility failed to ensure the appropriate food textures was provided when1. 11 out of 11 sampled Residents on pureed texture received grainy pureed beef and pureed bread during lunch on 4/7/2026.2. 13 out of 13 sample Residents on soft and bite sized received wrong texture for green bean and beef during lunch on 4/7/2026.These failure had the potential to place the residents at risk of choking.Findings:1. On April 7, 2026, at 1:10 p.m., with the Director of Food and Nutrition (DFN), at the RNA dining room, a test meal was performed for the pureed diet. The DFN verified the pureed beef and bread tasted grainy. The DFN stated pureed diet supposed to be smooth consistency. The DFN stated cooks should have left the beef and bread in the blender for a longer period with adding some broth to reach the smooth consistency. The DFN stated Resident could choke with this kind of grainy texture. During a review of the facility's provided Diet Type Report (same as physician diet order), dated April 8, 2026, the Diet Type Report indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' food preference was honored for two of 146 sampled residents (Resident 10 and Resident 117) when1. Resident 10 had food preferences for double protein and dislikes included carrots on the meal ticket but Resident 10 did not receive double protein and received carrots during lunch service on April 6, 2026.2. Resident 117 had food preference as soup on the meal ticket but Resident 117 did not receive soup during lunch on April 9, 2026. (Cross reference 692)This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising Resident 10 and 117's nutritional and medical status.Findings: 1. A review of Resident 10's admission Record dated April 8, 2026, indicated the resident was admitted on [DATE], with diagnosis which included cirrhosis of the liver (liver impairment). A review of Resident 10's Minimum Data Set (MDS – an assessment tool) dated April 3, 2026,…

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 beverages were served in accordance with residents' meal tickets for four out of seven sampled residents (Resident 90, 102, 139, 146) during lunch service. This failure had the potential to result in decreased fluid intake, which may lead to dehydration and compromise residents' hydration and overall medical status. Findings:On April 6, 2026, at 12:31 p.m., a concurrent observation and meal ticket review were conducted with Resident 90 in the RNA dining room. Resident 90's meal ticket indicated an 8 fluid ounce (oz-unit for measurement) beverage. Resident 90 was observed being served a 4 oz beverage.On April 6, 2026, at 12:33 p.m., a concurrent observation and meal ticket review were conducted with Resident 102 in the RNA dining room. Resident 102's meal ticket indicated an 8 oz beverage. Resident 102 was observed not being served 8 oz beverage.On April 6, 2026, at 12:34 p.m., a concurrent observation and meal ticket review were conducted with Resident 146 in the RNA dining room. Resident 146 meal…

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 dietary observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. A food preparation sink in Prep area did not have an air gap (refers to a fixture that provides back-flow prevention.)2. Two dietary staff did not know cooling process for egg and tuna salad. 3. Ice machine in kitchen found brown grime buildup on ice maker.4. [NAME] splash spots found on the wall and ceiling in dishwashing area and food Prep area.5. Cooking pans did not air dried before stacked and stored.6. Four broken plastic containers and covers found in kitchen.7. Trash found on floor in several area in kitchen.8. Grease buildup on hood.9. Grime buildup found on several pieces of equipment.10. Several dietary staff had exposed facial hair during meal preparation.11. Dust found on several pieces of equipment and area in the kitchen.12. An expired soy sauce found in cook area. 13. Opened food items exposed to the air in walk in freezerThese…

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

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash were found outside surrounding the compactor dumpster.This failure had the potential to attract pests and rodents.Findings:On April 7, 2026, at 4:01 p.m., a concurrent observation and interview were conducted with the Registered Dietitian and Director of Food and Nutrition (DFN) at the outside back building. There was a compactor dumpster. On the floor, trash was observed surrounding the dumpster with strong unpleasant odor. Unknown liquid was observed on the ground near the compactor dumpster. The DFN stated surrounding the compactor dumpster should keep clean and without any smell, otherwise it was going to attract pests.During a review of the facility's policy and procedure (P&P) titled Food - Related Garbage and Rubbish Disposal, dated January 23, 2026, indicated, Outside dumpsters provided by garbage pickup services will be kept . free of surrounding litter.During a review of FDA (Food and Drug Administration) Food Code 2022, Section 5-502.11, the FDA Food…

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 proper maintenance of essential equipment when:1. One walk-in refrigerator was maintained in good working condition.2. Walk-in freezer was maintained in good working condition with ice condensation buildup.3. The dish machine wash temperature was not maintained per manufacturer guideline.These failures had the potential to cause food borne illnesses and poor quality of food served to a population of 146 of 150 residents who received food from the kitchen.Findings:1. During a review of FDA (Food and Drug Administration) Food Code 2022, Section 4-501.11, Equipment Good Repair and Proper Adjustment, the FDA Food Code indicated, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding…

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 pest control program to ensure the facility remained free of pests when drain flies and a house fly were found in the kitchen.This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) for 146 out of 146 sample residents who eat food prepared in the kitchen. Findings:On April 6, 2026, at 10:07 a.m., a concurrent observation and interview were conducted with the Director of Food and Nutrition (DFN) in the dishwashing area. Five flies were seen on the wall of the dishwasher room. The DFN stated he could not identify the type of flies. The DFN stated flies were not supposed to be present in the kitchen. The DFN stated flies could fly throughout the kitchen, causing cross-contamination and posing a food safety concern. On April 7, 2026, at 10 a.m., a concurrent observation and interview were conducted with the DFN in the dishwashing area. Five flies were again observed on the dishwashing room wall. The DFN…

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 Interdisciplinary Team ( IDT- a collaborative group of healthcare professionals who work together to develop and implement a comprehensive care plan tailored to a resident's specific physical, mental, and psychosocial needs) determined that self-administration of medications was clinically appropriate and safe before allowing a resident to keep a prescribed Ciclesonide inhaler (inhaled medication used to prevent asthma [lung disease that cause airway inflammation] at the bedside for self-administration for one of one residents reviewed for self-administration of medications (Resident 177).This failure had the potential to result in medication mismanagement by the resident which could compromise asthma control and delay needed medical intervention. Findings:On April 7, 2026, at 8:46 a.m., Resident 177 was observed alert, oriented, and sitting on the edge of his bed. One medication inhaler Ciclesonide 160mcg (micrograms - a unit…

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 PASRR (Preadmission Screening and Resident Review - a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs) was accurately updated when the resident's Level 1 screening was not corrected to reflect the resident's diagnoses of psychosis (symptom involving the distortion or loss of contact with reality) and anxiety (a strong feeling of worry, fear, or nervousness that is hard to control and can affect how you think, feel, and act in everyday life), for one of two residents reviewed for PASRR (Resident 145).This failure had the potential to result in the inappropriate admission of the residents to the facility and for Resident 145 to not receive necessary specialized services.Findings:A review of Resident 145's PASSR dated January 3, 2025, completed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) for one of five sampled residents (Resident 45) had adequate interventions in accordance with facility policy when Resident 45 was prescribed a psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication. This failure had the potential to result in delays in treatment and care for Residents 45. Findings: A review of Resident 45's admission Record, dated April 9, 2026, indicated Resident 45 was originally admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses including major depressive disorder and anxiety. A review of Resident 45's medical record indicated a physician's order for Xanax 0.5 mg (milligram, unit of measurement) Give 2 tablets by mouth two times a day for anxiety m/b (manifested by) self report of anxiety, dated February 20, 2026. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan to reflect the resident's ongoing poor oral intake and ordered nutritional interventions, for one of six residents reviewed for nutrition (Resident 101).This failure had the potential to delay implementation of appropriate, person-centered interventions and placed the resident at risk for nutritional decline. Findings:A review of Resident 101's record indicated Resident 101 was admitted to the facility on [DATE], with diagnosis including morbid obesity (severe fat accumulation), chronic kidney disease (reduced kidney function), and anemia (a condition of the blood which reduces the blood's ability to transport oxygen).The Minimum Data Set (MDS - an assessment tool), dated March 15, 2026, indicated a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact).A review of the Care Plan dated March 16, 2026, indicated the following:- .At risk in alteration in Nutrition r/t (related too) Dx…

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

Based on observation and interview, the facility failed to ensure good oral hygiene for one of three residents reviewed for Activities of Daily Living (ADL) (Resident 180) when the resident was observed with poor oral hygiene. This failure had the potential to contribute to poor nutrition, infection, and unplanned weight loss for Resident 180.Findings:On April 9, 2026, at 3:18 p.m., a concurrent observation and interview were conducted with Certified Nurse Assistant (CNA 2) and Resident 180 in the resident's room. Resident 180 was observed with several areas of yellowish, dry, clumpy, old residue on the tongue, the roof of his mouth, and lodged between the teeth. Resident 180 stated that oral care had not been performed. CNA 2 stated Resident 180 did not look like oral care had been provided and it should have been. CNA 2 stated oral care should be performed by the assigned CNA in the morning and after dinner. CNA 2 stated oral care was important to maintain hygiene and prevent dental damage. A review of Resident 180's admission Record dated April 10, 2026, indicated an admission…

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 ordered side rail (a device used to assist with in-bed mobility) was evaluated, care planned, and installed for one of three residents reviewed for mobility needs (Resident 175).This failure had the potential to cause further decline in limited mobility and loss of independence for Resident 175, who required services, equipment, assistance to maintain or improve mobility with the maximum practicable independence. Findings:On April 6, 2026, at 11:47 a.m., a concurrent observation and interview were conducted with Resident 175 in the resident's room. Resident 175 was alert and observed lying on her left side in bed. No side rails were present on the bed frame. Resident 175 stated she was admitted a week ago to the facility for mobility rehab and the lack of side rails made it difficult for her to reposition herself in bed. Resident 175 stated she had requested rails and was told staff would assess and install them but had not…

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 intravenous (IV - a small, flexible tube inserted into a vein to deliver medication) sites were maintained in accordance with professional standards of practice, including proper labeling (dating, timing, and identification) and ongoing monitoring for one of two residents reviewed for IV (Resident 19). Resident 19's IV site was unlabeled, and there was no monitoring for signs and symptoms of complications.These failures had the potential to place the resident at risk for catheter-related bloodstream infection.Findings:1.On April 6, 2026, at 3:51 p.m., Resident 19 was observed alert, oriented, and lying in bed watching television., with her right arm exposed on top of a blanket. Resident 19's right forearm IV site was observed with an unlabeled dressing.During a concurrent interview, Resident 19 stated the IV was placed while she was in the hospital and was removed when she returned to the facility. Resident 19 stated a facility…

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 provision of pharmacy services met the needs of the residents when one IV (intravenous, into the vein) Medication Emergency Kit (E-kit; a sealed kit/box containing medications and supplies for immediate use during a medical emergency) was stored open and unsealed, medications were used without documentation on the E-kit logbook, and the E-kit was not replaced timely after being opened in accordance with facility policy. These failures resulted in the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: On April 6, 2026 at 3 p.m. an observation and concurrent interview was conducted with the Director of Nursing (DON) in the medication storage room at the North Station. One IV Medication E-kit was identified unsealed and unlocked. The DON stated nursing staff should have resealed the E-kit after it was opened, documented usage (date, medication used and resident's name) in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for two of five sampled residents (Residents 16 and 45) when: 1. Resident 16 was administered quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer's specified monitoring during use of quetiapine; and 2. Resident 45 was administered Xanax (or alprazolam, used to treat anxiety) without adequate documentation of behavioral monitoring and without adequate monitoring for signs and symptoms of adverse effects during use of Xanax.This failure had the potential for medications not being optimized for best possible health outcome, and increased risk for adverse effects for Resident 16 and 45. Findings: 1. A review of Resident 16's admission Record, dated April 9, 2026, indicated Resident 16 was elderly, originally admitted to the facility on [DATE], and had diagnoses…

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

Based on observation, interview, and record review, the facility had a medication error rate of 12% when three (3) medication errors occurred out of 25 opportunities during the medication administration for one out of three residents (Resident 179). The errors resulted in one medication given without a physician's order and two medications given not in accordance with manufacturer's instructions and had the potential for Resident 179 not receiving the full therapeutic effects of medications.Findings: During a medication pass observation on April 7, 2026 at 9:07 a.m., licensed vocational nurse (LVN) 2 was observed preparing four oral (by mouth) medications for Resident 179. The medications included: one famotidine (used to treat heartburn) 10 mg tablet, one multivitamin with minerals (supplement) tablet, one ferrous sulfate (iron supplement) 325 mg tablet, and one doxycycline (antibiotic to treat infection) 100 mg tablet. During the same medication pass observation at 9:18 a.m., LVN 2 was observed administering the above medications to Resident 179 and Resident 179 requested a pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications in one of three medication carts inspected and one of two medication rooms inspected when:1a. Medication cart D in South Station contained one (1) expired medication vial; and1b. Medication room in South Station contained one (1) refrigerated medication vial opened without an open date label.The deficient practices had the potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.Findings: 1a. During a concurrent observation and interview on [DATE] at 10:04 a.m., an inspection of Medication cart D in the South Station with Licensed Vocational Nurse (LVN) 3 identified Resident 25 had one expired Insulin Lispro (fast-acting insulin, medication to lower blood sugar level) vial that was labeled opened on [DATE]. Additionally, the pharmacy's label on the Insulin…

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

Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program to ensure that linens and environmental surfaces such as shower and privacy curtains, were maintained clean and free of visible soil. These failures had the potential to result in cross-contamination and spread of infection among residents. Findings: 1.On February 19, 2026, a concurrent observation and interview was conducted with the Director of Housekeeping and Laundry (DHL) and the following were observed:-At 10:24 a.m., in the North Shower Room of the facility, a shower curtain was observed in North Shower room with black stain and discoloration noted on the bottom of the shower curtain. The DHL stated that they needed to remove the shower curtain and get it washed. -At 10:28 a.m., in the Medically Complex Unit shower room, a shower curtain was observed with a brown stain discoloration. The DHL stated the curtain needed to be removed and washed. 2.On February 19, 2025, at 10:20 a.m., a concurrent observation and interview was conducted with the DHL in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of the medical records for one of four sampled residents (Resident 1) when Resident 1's care plan (a personalized guide to support the individual healthcare needs of a resident) inaccurately listed neurogenic bladder (occurs when the nerves that control the bladder are damaged causing problems with storing or emptying urine) as a diagnosis related to the use of a Foley catheter (a flexible tube used to continuously drain urine). This failure resulted in an inaccurate care plan and had the potential to affect clinical decision-making, lead to inappropriate interventions, and compromise the resident's care and safety.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included benign prostatic hyperplasia (BPH- enlargement of the prostate gland) with lower urinary tract symptoms, unspecified urinary incontinence (loss of bladder control), and retention 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 interview and record review, the facility failed to provide timely access to medical records for one of one sampled resident (Resident A).This failure had the potential to delay Resident A's ability to obtain personal health information needed for continuity of care after discharge. Findings:A review of Resident A's admission Record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (gradual loss of kidney function over time). Resident A was discharged on November 11, 2023. On August 26, 2025, at 3:20 p.m., a concurrent interview and record review were conducted with the Medical Records Director (MRD). The MRD stated a written request for medical records submitted by Resident A's legal representative was received on August 12, 2025. The MRD stated, Resident A's medical records should have been released within two working days of the request. The MRD further stated, the request had been forwarded to the facility's legal department 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician documented the clinical rationale for the discharge for one of three sampled residents (Resident 1). This failure had the potential to result in an inappropriate discharge without medical justification, compromising the resident's health, safety, and continuity of care. Findings:On July 18, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included fusion of the spine and depression (more than just feeling sad or having a bad day).A review of Resident 1's progress notes dated June 1, 2025, indicated, .Assessment and Plan.Pt (Resident 1) is recommendedfor [sic] f/u (follow-up) imaging within one year due to presence of polyp [small growth that can form on the lining of organs inside the body] .Pt (Resident 1) increasing tolerance to ambulance and functionality.Pt (Resident 1) would benefit from continued care.A review of Resident 1's Notice of Proposed Transfer/…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for two of three sampled residents (Residents 1 and 2) when Licensed Vocational Nurses (LVN 1 and 2) did not wear personal protective equipment (PPE- equipment, such as gloves and gown, used to protect against infection or illness) while administering medications via G-tube (a feeding tube inserted through the abdominal wall directly into the stomach) to residents on Enhanced Barrier Protection (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics).This failure had the potential to expose vulnerable residents to cross-contamination and increase the risk of developing infections.Findings:1. A review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnosis which included gastrostomy status (an opening into the stomach for food).…

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, for three of three sampled residents (Residents 1, 4, and 6), the facility failed to ensure appropriate assessment, monitoring, and a follow-up evaluation of skin conditions and injuries were conducted when: 1. For Resident 1, the treatment for a burn injury was not initiated or monitored upon return from the hospital on April 10, 2025. In addition, a follow-up appointment for evaluation of the burn injury was not arranged; 2. For Resident 4, a new skin injury (bruising [skin discoloration] to the left and right hands) identified by the Certified Nursing Assistant (CNA) on April 27, 2025, was not addressed or referred to the physician for appropriate care and treatment. In addition, the licensed nurse did not conduct an ongoing skin assessment, monitored the injury, or evaluated the resident for potential complications after the skin injury was noted; 3. For Resident 6, a change in condition related to a known foot injury was not identified and communicated 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 observation, interview, and record review, the facility failed to ensure telephone calls for the resident were answered by the facility staff for one of three residents reviewed (Resident A). This failure had the potential to to lead to physical and psychosocial distress for Resident A. Findings: On March 26, 2025, at 10:10 a.m., an unannounced visit to the facility was conducted to investigate a quality of care issue. On March 26, 2025, at 2:30 p.m., during an interview with Resident A and Resident A's Family member (FM), Resident A stated, her call light had fallen to the floor. She stated, she began hollering out for staff assistance, but no one came into the room. Resident A stated she called a family member for help. Resident A's FM stated, she had experienced issues with the facility's phone systems. She stated, she attempted to call the facility multiple times from 9:11 p.m to 9:22 p.m. but received no response. Resident A's FM stated, the phone was answered after 9:22 p.m., was transferred 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 to ensure that Hydrocodone (a strong pain medicine) was reordered in a timely manner for one of three sampled residents (Resident A), resulting in the medication not available when needed. This failure had the potential for Resident A's pain to be uncontrolled and not following the physician-ordered pain management regimen. Findings: On March 26, 2025, at 10:10 a.m., an unannounced visit to the facility was conducted to investigate a quality of care/treatment issue. A review of Resident A's admission Record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included spinal stenosis lumbosacral region ( refers to a narrowing of the spinal canal in the lower back, which can put pressure on the spinal cord [A column of nerve tissue that runs from the base of the skull down the center of the back ] and nerve roots, potentially causing pain, numbness, and weakness). A review of Resident A's progress notes titled,…

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 the resident's medical records within the required 48-hour time frame for one of four sampled residents (Resident 7). This failure had the potential to deny the resident representative access to review records and delay critical legal or medical decision making for the resident. Findings: On February 4, 2025, at 4:05 p.m., a telephone interview was conducted with Resident 7's legal representative. The legal representative stated, a valid authorization and request for Resident 7's medical records were sent to the facility on January 16, 2025. A review of Resident 7's medical records indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (damage to an area of the skin) and diabetes mellitus (high blood sugar level). A review of the Minimum Data Set (an assessment tool) dated April 26, 2024, indicated no cognitive impairment. Further review of Resident 7's medical records indicated that Resident 7…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure pressure ulcer treatment was provided as ordered by the physician for 3 (Resident #57, #63, and #160) of 5 residents reviewed for pressure ulcers. Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frames. 1. An admission Record revealed the facility admitted Resident #57 on 10/11/2023. According to the admission Record, the resident had a medical history that included a diagnosis of Stage 4 pressure ulcer of the sacral region. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/2024, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one Stage 4 pressure ulcer that was present upon admission/entry or reentry. Resident #57's care plan included a focus area initiated 10/12/2023,…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide equipment in good condition for 1 (Resident #125) of 5 residents reviewed for environmental hazards. Findings included: An undated facility policy titled, Wheelchair Maintenance Policy, indicated, Policy: It is the policy of this facility that wheelchairs be maintained in good working order. The policy revealed, Inspection includes: b. Checking that removable leg/arm rests are in place, upholstery in good repair and not posing a safety hazard, i.e. [id est, that is], might cause skin injuries if torn etc. [et cetera; and so forth]. The policy revealed, 3. In addition, any staff member aware of a wheelchair needing repairs should give written notice to the maintenance department. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024 revealed the facility admitted Resident #125 on 12/13/2024. According to the MDS, the resident had diagnoses that included hemiplegia (partial paralysis) following cerebral infarction (stroke) affecting the 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.

Based on the interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #72) of 4 residents reviewed for Preadmission Screening and Resident Review (PASRR) was referred for a Level II screening. Specifically, Resident #72 was admitted to the facility with a negative Level I screening; however, the resident had a diagnosis of bipolar disorder, a serious mental illness (SMI). The facility failed to identify the SMI and subsequently failed to refer the resident for a Level II PASRR screening. Findings included: A facility policy titled, PASRR, dated 09/26/2023, revealed, 2. If the resident is admitting from the hospital, the hospital discharge planner will complete the Level I PASRR screen prior to admission to the facility and will provide a copy of the Level I to the facility. The policy revealed, Following admission: admission of a resident with a primary major mental illness or developmental disability diagnosis: a. The Social Service Director or designee is responsible for notifying the local mental health authority (OBRA [Omnibus Budget…

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

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to provide residents with activities of daily living that included fingernail care for 1 (Resident #69) of 3 residents reviewed for activities of daily living. Findings included: An undated facility policy titled, Fingernails/Toenail, Care of, revealed, 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. An admission Record revealed the facility admitted Resident #69 on 03/21/2021. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (stroke) affecting the left nondominant side, left hand muscle wasting and atrophy, and age-related physical debility. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2024, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 15,…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory breathing treatments as ordered by the physician for 1 (Resident #15) of 2 residents reviewed for respiratory services. Findings included: A facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, specified, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The policy revealed, Preparation included 2. Review the resident's care plan, current orders and diagnoses to determine resident needs. 3. Check the treatment record. 4. Assemble the equipment and supplies as needed. An admission Record indicated the facility admitted Resident #15 on 04/29/2022. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #15 had a Brief Interview for…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene and glove changes during wound and peri-care for 2 (Resident #57 and Resident #63) of 5 residents reviewed for pressure ulcers. Findings included: An undated facility policy titled, Wound Care, indicated, Steps in the Procedure included 2. Wash and dry your hand thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Further review revealed, 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. The policy revealed, 12. Apply treatments as indicated. 13. Dress wound. The policy revealed, 15. Remove disposable gloves and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reassess the vital signs, including blood pressure, for one of three sampled residents (Resident 1). This failure had the potential to delay the staff from acting promptly if the blood pressure remained persistently low which could lead to complications such as confusion, fainting, and organ damage. Findings: On November 22, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening complication of an infection) and enterocolitis (inflammation that occurs throughout the intestines). A review of Resident 1's document titled, Change of Condition dated November 5, 2024, indicated, .The change in condition .Abnormal vital signs .Vital Signs Evaluation .Blood Pressure: 65/49 .New irregular pulse . A review of Resident 1's progress notes dated November 5, 2024, indicated, .21:00 (9 p.m.) Checked vital signs and noticed BP (blood pressure) was 65/49 .received order 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 observation, interview and record review, the facility failed to implement infection control practices when disposable equipment, including a stethoscope (a medical instrument) and sphygmomanometer (blood pressure machine), was not readily available for one of one sampled resident (Resident 1) with Clostridium Difficile (C. diff - a highly contagious bacteria). This failure increased the risk of spreading infection to other residents and staff. Findings: A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE], with diagnoses which included enterocolitis (inflammation of the digestive tract) due to clostridium difficile. Resident 1 was placed on contact precautions. On November 21, 2024, at 11:20 a.m., a concurrent observation and interview with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was on isolation due to C. diff. Outside Resident 1's room, an isolation cart was observed with personal protective equipment (gowns, face shield, 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 assistance with meals for one of four residents, (Resident 1). This failure had the potential to negatively affect Resident 1 ' s psychosocial wellbeing. Findings: On October 7, 2024, at 11:32 a.m., an unannounced visit to the facility on a complaint investigation was initiated. A review of Resident 1 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. the body either resists the effects of insulin — a hormone that regulates the movement of sugar into the cells — or doesn't produce enough insulin to maintain normal sugar levels), anxiety disorder, , (a chronic condition characterized by an excessive and persistent sense of apprehension), coronary artery dissection, (an emergency condition that occurs when a tear forms in a wall of a heart artery), legal blindness, and hypertensive heart disease, (heart…

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 requested medical records for four of four residents, within 48 hours in accordance with the facility policy and procedure. This failure could led to missed opportunity for potential claims and other legal consequences for the residents. Findings: On August 20, 2024, at 9:10 a.m., an unannounced visit was conducted to investigate an issue on medical records requests. On August 20, 2024, at 4:04 p.m., an interview was conducted with the Medical Records Assistant (MRA), who stated, the procedure to request medical records, included the requestor filling out a request form, then the form is sent to the corporate office for approval. Upon approval, the facility would send the records to the requestor, or notify the requestor the request was not approved. The MRA further stated, the process to request, and receive medical records could take A week or two. On August 21, 2024, at 10:30 a.m., an interview was conducted with the Medical Records Director…

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 was within reach for one of the three sampled residents (Resident 3). This failure has the potential to result in unmet needs. Findings: On August 20, 2024, at 9:10 a.m., an unannounced visit to the facility was conducted to investigate a quality care issue. On August 20, 2024, at 9:39 a.m., an observation of Resident 3 was conducted. Resident 3 was in bed, positioned on her back, head of bed elevated 30 degrees, resting. Resident 3 ' s call light was clipped to her pillowcase, hanging off the left side of her bed, out of reach. A review of Resident 3 ' s medical records titled, Face sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included Alzheimer ' s Disease (A brain disorder that affects memory, and function). On August 20, 2024, at 9:45 a.m., during a concurrent interview, and observation of Resident 3 ' s call light, Licensed Vocational Nurse (LVN) 1 verified Resident…

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

Based on interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 3), when pest treatment was conducted while the resident was inside the room. This failure has the potential for the resident to inhale pesticide vapor placing the resident at risk for an allergic reactions. Findings: On August 20, 2024, at 9:39 a.m., an observation of Resident 3, and her bedroom, was conducted. Resident was lying in her bed, positioned on her back, with her eyes closed resting. Resident was unresponsive to interview questions. On August 20, 2024, at 11:20 a.m., during an interview, the Maintenance Supervisor (MS) verified spraying pesticide inside Resident 3's room while the resident was in bed. The MS stated, he did not move Resident 3 before spraying for ants, because the spray was not toxic to humans and he only sprayed a little of the pesticide. The MS further verified Resident 3 had a visitor at the time he sprayed the pesticide, and he did not ask the visitor if it was ok to spray in the room. On August 20,…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) were repositioned at least every two hours, in accordance with the resident ' s written care plan. This failure had the potential to result in Resident 3 ' s pressure injury (the breakdown of skin integrity due to pressure) to worsen. Findings: On August 20, 2024, an observation of Resident 3 ' s bed positioning was conducted at the following times: - at 9:50 a.m., the resident was positioned on her back, with the head of her bed elevated 30 degrees. - at 10:29 a.m., the resident was position on her back, with the head of the bed elevated 30 degrees. - at 11:40 a.m., the resident was position on her back, with the head of the bed elevated 30 degrees. - at 12:59 p.m., the resident was position on her back, with the head of the bed elevated 30 degrees. - at 1:20 p.m., the resident repositioned in bed, eating lunch with the assistance of Certified Nursing Assistant (CNA) 2. A review of Resident 3 ' s medical records, titled, Progress Notes, dated, August 10,…

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 clean and sanitary resident's room, when two of four resident's rooms (rooms [ROOM NUMBERS]) had trash, food, and dried blood on the floors. This failure had the potential to expose residents to germs and pests. Findings: On August 20, 2024, at 9:10 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On August 20, 2024, at 9:39 a.m., an observation of room [ROOM NUMBER] was conducted, and indicated, the wall under the window had a brown colored splatter of an unknown substance on the window wall, dirty gloves sitting on the floor outside of the trash can, and three dried drops of blood on the floor to the right side of Bed B. On August 20, 2024, at 9:39 a.m., an interview was conducted with Resident 2, in room [ROOM NUMBER], and the resident stated the dried blood on the floor was Old blood from my toe. Resident 2 could not specify how long the blood had been on the floor. On August 20, 2024,…

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 for one of three residents reviewed for discharges (Resident 1) to provide a written notice of transfer/discharge to the resident and or resident representative (RR). This failure had the potential in resident not being protected from inappropriate transfers or discharges. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses that included depression (loss of pleasures or interest in activities for long period of time) and schizoaffective disorder (mental disorder including schizophrenia and mood disorder.) A review of Resident 1's Progress Notes, dated June 24, 2024, indicated, Discharge note: Resident discharged to (Name of Acute Hospital) for psyche evaluation and med management . A review of Resident 1's Notice of Proposed Transfer/ Discharge, dated June 24, 2024, indicated, .Name/Relationship of Person Notified .blank (no entry) .Mailed to Representative .Blank (no entry) .Resident/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 interview and record review, the facility failed to protect Resident 1's personal space when a staff (Certified Nursing Assistant [CNA1]) touched Resident 1 on the shoulder near her breast without her consent, making her uncomfortable. This failure resulted in the violation of Resident 1's right to respect and dignity, potentially causing psychosocial harm including low self-esteem, irritation, sadness, and anxiety. Findings: On May 29, 2024, at 11:10 a.m., an unannounced visit was conducted to investigate an allegation of abuse. A review of Resident 1's admission Record (contains medical and demographic information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome and major depressive disorder. A review of Resident 1's Minimum Data Set (as assessment tool), dated May 19, 2024, indicated, Resident 1 had no impairment in cognition. A review of Resident 1's Progress Notes, dated May 28, 2024, indicated, .At 2200 (10 p.m.) resident reported…

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 properly manage and account for the personal belongings, of one of three sampled residents, Resident A. This failure had the potential to make Resident A feel disrespected and undignified due to lack of protection of her personal property. Findings: On May 1, 2024, at 9:30 am, an unannounced visit to the facility was conducted to investigate an admission, transfer, and discharge rights issue. During an interview on May 1, 2024, at 9:03 a.m., with Resident A, she stated she was discharged from the facility on April 18, 2024. Resident A stated, the facility gave her personal belongings after discharge, and she noticed the following personal belongings were missing upon receipt: a. Groceries worth 193 dollars; b. Dentures and contact lenses; c. Underwear; and d. (brand) speaker A review of Resident A's admission record, indicated she was admitted on [DATE], with diagnoses which included diabetes (elevated blood sugar). Resident A's history and physical…

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 care and services for activities of daily living (ADLs), for one of three sampled residents (Resident 1), when feeding assistance was not provided according to the physician's orders and plan of care. This failure had the potential to negatively affect the resident's physical well-being and lead to continued weight loss. Findings: On April 17, 2024, at 10:25 a.m., an unannounced visit was conducted at the facility for a complaint. On April 17, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal sugar in the blood), and dementia (memory loss that affects thinking and can interfere with daily functioning). Resident 1's History and Physical, dated December 3, 2023, indicated Resident 1 had fluctuating capacity to understand and make decisions. Review of Resident 1's Order Summary, included a physician's order, dated April 1, 2024,…

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: 1. Monitor blood glucose (blood sugar) levels, as ordered by the physician for Residents 1, 2 and 3. This failure has the potential to result in complications due to delayed provision of treatment. 2. Monitor indwelling catheter (a tube inserted into the urinary tract to help decrease urinary retention) for signs and symptoms of Urinary Tract Infection (UTI), and provide catheter care, every shift, as ordered by the physician for Resident 2. This failure has the potential to result in infection. 3. Provide wound care treatments, as ordered by the physician for Residents 1 and 2. This failure has the potential to result in delayed healing or worsening of the pressure injury. Findings: On December 8, 2023, at 11:15 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. 1. A review of Resident 1 ' s admission records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 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 interview and record review, the facility failed to provide accurate, and consistent assessments of Resident 1 ' s skin conditions. These failures had the potential to delay treatment for Resident 1 ' s skin conditions. Findings: On December 8, 2023, an unannounced visit was made to the facility for Quality-of-Care issues. A record review of Resident 2 ' s admission records, indicated the resident was admitted to the facility on [DATE], with a diagnoses which included hemiplegia (Paralysis of one side of the body). A record review of Resident 2 ' s admission skin assessment, titled, Admission/readmission Data Collection, dated May 3, 2023, untimed, by the Tx nurse, indicated, .new admission, (Tolerated skin assessment well noted (with) (Middle abdomen gastrostomy tube {A tube inserted into the stomach for feedings/nutritional purposes}), no other (Skin) issues . A record review of Resident 2 ' s physician orders, dated May 3, 2023, indicated the following admission orders: a.Bacitracin-Polymyxin B,…

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 accurately document the reporting and the physician ' s response to the laboratory (lab) abnormal result the abdominal wound culture & sensitivity ({C&S}- A test to determine the types of germs in a wound, and their sensitivity, to certain drugs for treatment) for Resident 4. This failure resulted in the resident's record not to reflect accurate communication between staff regarding treatment and services needed by Resident 4. Findings: On December 13, 2023, an unannounced visit was made to the facility for a Quality-of-Care issue. Review of Resident 4 ' s admission records, indicated resident was admitted to the facility on [DATE], with a diagnosis of Partial Intestinal Obstruction (Only partial food and fluid can get through the intestines). A review of Resident 4 ' s medical records, titled, Change of Condition (COC - Documented change in a resident ' s physical/mental condition), dated, October 11, 2023, at 4:42 p.m., indicated, .started on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed, for three of five sampled employees, to ensure infection control policy and procedures for Covid-19 (a highly infectious respiratory illness) were implemented when: 1. One Certified Nursing Assistant (CNA 1) did not perform hand hygiene upon exiting Covid-19 positive (residents infected with Covid-19) isolation rooms and entering a contact isolation room (room for resident who could spread a disease by contact). In addition, CNA 1 did not perform hand hygiene upon donning (putting on) and doffing (taking off) the isolation gown (protective apparel used by medical personnel to avoid exposure to blood, body fluids, and infectious droplets); and 2. Two CNAs (CNAs 1 and 2) did not wear face shields (personal protective equipment [PPE] for protection of the facial area and associated mucous membranes [eyes, nose, mouth] from splashes, sprays, and spatter of body fluids) while providing care for Covid-19 positive residents. 3. One Restorative…

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 for one of six residents reviewed (Resident 1) the resident's use of a foley catheter (a plastic flexible tube inserted into the bladder to collect urine) had a physician's order, was assessed and monitored by licensed staff, and a plan of care (POC) was developed. This failure had the potential for Resident 1 to develop catheter associated urinary tract infections, skin irritations from faulty equipment, and for Resident 1's use and need of the catheter to go unassessed. Findings: On November 14, 2023, at 10:20 a.m., an unannounced visit was conducted at the facility. On November 14, 2023, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included severe sepsis (infection of the blood), surgical aftercare, and overactive bladder (bladder function which causes a sudden need to urinate and lead to an involuntary loss of urine). Resident 1 was discharged from the facility on October…

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, for one of three residents (Resident 1) with pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin), the facility failed to ensure an informed consent for wound treatment was secured for Resident 1 on seven separate occasions on November 2, 9, 16, 23, 2022; and January 5, 12, and 19, 2023. The facility failure resulted to seven separate invasive debridement (removal of damage tissue from a wound) procedures performed on a dependent vulnerable resident. The resident ' s representative (RR) was bypassed and was not included in the decision-making to the discussion of risks and benefits of the procedure. Findings: On September 6, 2023, a complaint on behalf of Resident 1 was received with allegation of quality of care issues that there was no pressure ulcer precaution taken to prevent PU development on a vulnerable resident. On September 20, 2023, at 9:20 a.m., an unannounced visit was conducted for investigation 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 bilateral floor mats were in place for one of four residents, (Resident 3), reviewed for fall, when only one floor mat was in place. This failure had the potential to result in injury if Resident 3 fell from her bed. Findings: On June 2, 2023, at 11:57 a.m., an unannounced visit to the facility was initiated for a complaint investigation. A review of Resident 3 ' s medical record indicated she was admitted on [DATE], with diagnoses of displaced intertrochanteric fracture of right femur, (broken hip bone), history of falling, type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin — a hormone that regulates the movement of sugar into the cells — or doesn't produce enough insulin to maintain normal sugar levels), hemiplegia, (paralysis of one side of the body), hemiparesis, (weakness of one side of the body), following a stroke affecting right dominant…

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 two persons assist during repositioning for one of three sampled residents (Resident 1) on June 20, 2023. This failure resulted in Resident 1 falling from the bed during activities of daily living (ADL) on June 20, 2023. Resident 1 was transferred to the acute care hospital for evaluation. Findings: On July 18, 2023, at 10:20 a.m., an unannounced visit was conducted to investigate a quality care issue. On July 18, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness and hemiplegia (paralysis of one side of the body). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) admission assessment dated [DATE], Section G - Functional Status. G0110. Activities of Daily Living Assistance. indicated, A. Bed mobility – how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate 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.

Based on observation, interview, and record review, the facility failed to ensure dietary staff was able to safely and effectively carry out the functions of food and nutrition services when: 1. The dietary staff did not perform testing of sanitizing solution properly; 2. The dietary staff did not use the designated scoop for the ice; and 3. The dietary staff entered the kitchen without performing handwashing. Findings: 1. On May 12, 2022, at 3:05 p.m., the Dietary Staff (DS) was observed testing sanitizing solution for dishwashing machine using the chlorine test strip. The DS was observed dipping the test strip for approximately 3 seconds, removed the test strip and compared with the color chart. In a concurrent interview with the DS, he stated he did not remove the test strip immediately and compared the test strip to the color chart on the test strip container. On May 17, 2022, at 7:36 a.m., in an interview with the Dietary Manager (DM), he stated when testing the sanitizing solution, the dietary staff should follow the manufacturer's instructions. A review of the Chlorine Test…

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 written information on advance directive (AD - a written instruction related to the provision of health care when the resident is no longer able to make decisions) for four of 10 residents reviewed for AD (Residents 39, 69, 110 and 122). This failure had the potential for the residents requests not be honored in the event of a medical emergency. Findings: 1. On May 11, 2022, Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of memory) and diabetes (high blood sugar). An AD acknowledgment was signed by the responsible party (RP) on July 14, 2021. The document indicated Resident 39 had not executed an AD. On May 11, 2022, at 11:36 a.m., the Social Service Assistant (SSA) and the Social Service Director (SSD) were interviewed. The SSA stated assistance were offered to all residents without an AD. The SSD stated there was no documentation Resident 39 or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct a self-administration assessment for one of 30 residents reviewed for self-administration of medication (Resident 501). This failure had the potential to result in an unsafe administration of medication for Resident 501. Findings: On May 10, 2022, at 9:25 a.m., Resident 501 was observed sitting in bed. A bottle of eye drops was observed on top of Resident 501's bedside table. In a concurrent interview with Resident 501, she stated she self-administered the eye drops the night before. Resident 501 stated the bottle of eye drops was brought from home by her daughter 2 days ago.She stated the licensed nurses were aware. On May 10, 2022, Resident 501's record was reviewed. Resident 501 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), chronic obstructive pulnonary disease (a group of lung diseases causing difficulty in breathing). There was no documentation Resident 501 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call lights were within reach for two of five residents reviewed for environment (Residents 254 and 132). This failure had the potential to result in the residents to not be able to call for staff assistance when needed. Findings: 1. On March 10, 2022, at 3:21 p.m., the call light was observed not within reach of Resident 254. Resident 254's call light was observed on the left side, clipped on top of resident's head of the bed. On May 10, 2022, at 3:35 p.m., in a concurrent interview with Resident 254 and Licensed Vocational Nurse (LVN) 2, LVN 2 stated the call light was too high for the resident to reach. Resident 254 stated she could not reach the call light. Resident 254's record was reviewed. The resident was admitted on [DATE], with diagnoses including polyneuropathy (multiple nerve problem that causes pain, discomfort and mobility issues) and hypertension (high blood pressure). Resident 254 was alert and able to make…

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 physician was notified when the resident had episodes of vomiting for one of one resident reviewed for notification of change of condition (Resident 146). This failure had the potential to result in the delay in treatment which could lead to worsening of the resident's condition. Findings: A review of Resident 146's record indicated Resident 146 was admitted to the facility on [DATE], with diagnoses which included gastroesophageal reflux (a chronic disease when stomach acid flow into the food pipe and irritates the lining). A review of Resident 146's progress notes indicated on May 5, 2022, Resident 146 had four episodes of vomiting and on May 16, 2022, the resident was given Ondanestron (medication for nausea and vomiting) at 12:04 a.m. and 1:33 a.m. for complaints of nausea and vomiting. There was no documentation the physician was notified when Resident 146 had episodes of nausea and vomiting on May 5, 2022, and on May 16, 2022. On May…

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 did not provide a safe, homelike environment by not protecting personal belongings from loss for two of three residents reviewed for personal property (Residents 114 and 306). Findings: 1. On May 11, 2022, at 12:25 p.m., Resident 114 was observed in the dining area, sitting in a wheelchair. Resident 114 stated she was missing her wool blanket and some clothes. Resident 114 stated the staff was aware her wool blanket was missing On May 11, 2022, Resident 114's record was reviewed. Resident 114 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition in which the heart does not pump adequate blood supply to the body) and diabetes (high blood sugar). The history and physical, dated January 9, 2022, indicated Resident 114 had the capacity to understand and make decisions. On May 13, 2022, at 8:10 a.m., the Social Service Assistant) SSA and the Social Service Director (SSD) were interviewed. The SSA…

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 notification of transfer/discharge was provided to the office of the state long-term care Ombudsman (a representative that helps families and residents by investigating and resolving complaints and serving as an advocate) for two of seven residents reviewed for hospitalizations (Resident 123 and 255). This failure increased the potential for the Ombudsman to not be aware or involved of facility practices and activities related to the resident's transfer and discharge. Findings: 1. Resident 255's record was reviewed. Resident 255 was re-admitted to the facility on [DATE], with diagnoses which included right facial cellulitis (skin infection) and dementia (loss of memory). The facility's document titled, SBAR (Situation Background Assessment Recommendation)/ COC (Change of Condition) Report, dated April 30, 2022, indicated, .Resident daughter request to be send her out to ER (emergency department) . There was no documented evidence the long-term…

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 a written notice to the resident or Resident's Representative (RR) of the bed-hold policy (reserving a resident's bed while the resident is out of the facility for therapeutic leave or hospitalization) for one of seven residents reviewed for hospitalization (Resident 84). This failure had resulted in the resident (Resident 18) or the RR not knowing their right to hold the bed while out of the facility and the right to be readmitted back to the facility. Findings: A review of Resident 84's record, indicated she was admitted to the facility on [DATE], with diagnoses which included CAD (coronary artery disease - is a narrowing or blockage of your coronary arteries usually caused by the buildup of fatty material called plaque) s/p (status post) CABG (Coronary artery bypass grafting -surgery in which a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery leading to the heart). 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 meet professional standards of nursing care for three of 30 residents reviewed for quality of care (Residents 39, 253, and 257) when: 1. Resident 253's IV (intravenous - administered through the vein) tubing for Cefepime (an antibiotic) was observed to be undated. In addition, Resident 253's IV tubing for Vancomycin (an antibiotic) was not changed as per physician order and was observed without an end cap (covering for the exposed end of the IV tubing). This failure had the potential to result in an IV catheter-related blood stream infections for Resident 253. 2. Resident 257's yankauer suction tip (oral suctioning tool to allow effective suction without damaging surrounding tissue) was observed used and undated. This failure has the potential for Resident 257 to develop respiratory infection. 3. Resident 39's enteral feeding was not labeled with date and time. This failure had the potential for Resident 39 to experience food-borne…

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 for two of 30 residents reviewed for quality of care (Residents 61 and 84), residents were provided treatment and care when: 1. For Resident 61, an assessment, monitoring were conducted and treatment was provided for resident's change in skin condition; and 2. For Resident 84, an assessment and treatment were conducted during the initial episode of choking. These failures had the potential for delayed services, treatment, and care resulting in deterioration in residents' medical condition. Findings: 1. On May 13, 2022, at 1:45 p.m., Resident 61 was observed with rashes on the face. In a concurrent interview with Resident 61, she stated she could not remember if there was a treatment for her facial rash. Resident 61's record was reviewed. Resident 61 was admitted to the facility on [DATE], with diagnoses which included intertrigo (skin inflammation in between skin folds). Resident 61's document titled Weekly Summary, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident (Resident 34) received the necessary treatment and services consistent with professional standards of practice to prevent infection for one of four residents reviewed for pressure ulcer (bed sores), when the treatment nurse during dressing change did not perform hand washing. This failure had the potential to result in cross contamination affecting the healing process of resident's pressure ulcer. Findings: A review of Resident 34's record indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level) and pressure ulcer of sacral region (bed sore at the bottom of the spine between the fifth segment of the lumbar spine and the tailbone). A review of Resident 34's Order Summary Report, for the month of May 2022, indicated, .sacral-coccyx: cleanse w/NS (with Normal Saline), pat dry, apply Dakin's (an antiseptic) soaked gauze to wound bed, cover…

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 respiratory care and treatment in accordance with the facilities policy and procedures for one of one resident (Resident 76) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On May 10, 2022, at 11:14 a.m., Resident 76 was observed in bed, in his room. An oxygen concentrator (a machine that supplies oxygen) was at Resident 76's bedside in use. The oxygen meter read 2 liters (a unit of measure). The oxygen tubing was observed with date of 4/4. A humidified cannister (plastic cannister filled with water to humidify air flow) was dry and unlabled. On May 10, 2022, at 3:06 p.m., CNA 2 was interviewed. CNA 2 stated it was the LVN's responsiblity to check the oxygen tubing and equipment for residents on oxygen. On May 10, 2022, at 3:10 p.m., the Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated oxygen tubing is supposed to be changed every Sunday on night shift…

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 reviewed for medically related social services (Resident 63) when Social Service Director (SSD) did not obtain cardiology consult for Resident 63. This failure had the potential to result in Resident 63 not to receive care and treatment for her heart condition. Findings: On May 10, 2022, at 9:55 a.m and 3:14 p.m., Resident 63 was observed sleeping, with 3 L (liter) O2 (oxygen) via nasal canula, moaning, with shallow breathing. A review of Resident 63's record, indicated, she was admitted to the facility on [DATE], with diagnoses which included, acute respiratory failure with hypercapnia (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) and chronic atrial fibrillation (irregular heart rate). A review of Resident 63's Nurses Progress Note dated April 30, 2022, at 2:06 a.m., indicated, .Topic:: MD visit .Note:: .04/29/22 PM shift: MD…

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 pharmacy recommendation was followed up with the physician for one of five residents reviewed for unnecessary medications (Resident 123). This failure had the potential for the resident to receive unnecessary medications. Findings: A review of Resident 123's record indicated Resident 123 was re-admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning). A review of the facility document titled, MED (Medication) REGIMEN REVIEW REPORT, dated March 19, 2022, indicated, .The following two medications may be considered to be 'duplicative therapy' when used together. Please have the physician document in their progress notes the reason both medications are needed .Trazadone and duloxetine both antidepressants . Further review of Resident 123's record dated April 1, 2022, indicated .I agree…

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.