Harvard Creek Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hemodialysis (HD - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) device access dressing was removed as ordered by the physician for one of one sampled resident (Resident 43).This deficient practice had the potential for Resident 43 to develop complications related to HD device access.Findings:During a review of Resident 43's admission Record (AR), the AR indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), dependence on renal hemodialysis, and congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently).During a review of Resident 43's Order Summary Report (OSR) dated 7/20/2025, the OSR indicated Resident 43 had an order for hemodialysis on Mondays, Wednesdays and Fridays with extra…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 19) was properly identified during Resident 19's medication administration. This failure had the potential to result in medication errors from Resident 19 receiving incorrect medications. Findings: During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and hypertension (HTN-high blood pressure). During a review of Resident 19's History & Physical (H&P) dated 4/25/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 1/23/2026, the MDS indicated Resident 19 had intact cognition (ability to understand). During a Medication Administration observation on 2/12/2026 at 8:11 am in Resident 19's room, Resident 19 was lying in bed and did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of four sampled residents (Resident 1) by failing to wear required personal protective equipment (PPE, equipment that protects people from injury or illness in hazardous environments) while providing care to Resident 1 who was on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection to Resident 1 and staff that could result in a widespread infection in the facility. Findings: During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), received appropriate treatment to prevent further decrease in Resident 1's range of motion (ROM, the full movement potential of a joint or body part) in Resident 1's left shoulder. This failure resulted in Resident 1 experiencing pain and joint stiffness on Resident 1's left shouder due to a decrease in range of motion. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/29/2019 and readmitted Resident 1 on 6/10/2022 with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), dementia (a group of thinking and social symptoms that interferes with daily functioning), and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction…

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 incorporate Assessments and Care Planning Goals and Objectives in the Care Plans that lead to the residents' highest obtainable level of independence for one of five residents (Resident 1). Resident 1's care plan did not include Resident 1's behavior of crawling on the floor. This failure result in no nursing interventions for Resident 1's behavior of crawling on the floor and placed Resident 1 at risk for not reaching Resident 1's highest obtainable level of independence. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses which included cerebral infarction (also called ischemic stroke, occurs as result of disrupted blood flow to the brain) and cognitive communication deficit (impaired attention, memory, perception, organization, language, and lack of coordination, symptoms and signs involving the musculoskeletal system). A review of Resident 1's fall risk care plan (CP), dated 2/7/2025, the CP indicated Resident 1 was at risk for…

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

Based on interview and record review, the facility failed to implement its Policy and Procedure, titled Falls and Fall Risk, Managing, for one of five sampled residents (Resident 1) when: 1. Resident 1 was not assessed for injury whenever staff (in general) found Resident 1 on floor crawling on the floor mats (a padded cushion placed on the floor next to the bed to help reduce injuries from a fall) as indicated in Resident 1's fall risk care plan. 2. Resident 1's care plan did not include Resident 1's behavior of crawling on the floor. 3. Licensed Vocational Nurse (LVN) 1 did not document Resident 1's wander guard trial in Resident 1's medical record. This failure placed Resident 1 at risk for harm and injury. Cross reference F656, F842 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses which included cerebral infarction (also called ischemic stroke, occurs as result of disrupted blood flow to the brain) and cognitive communication deficit (impaired attention, memory, perception, organization,…

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

Based on interview and record review, the facility failed to implement its Policy and Procedure titled, Charting and Documentation, for one of five sampled residents (Resident 1) when: Licensed Vocational Nurse 1 (LVN 1) did not document Resident 1's wander guard trial in Resident 1's medical record. This failure result in incomplete documentation for Resident 1 and placed Resident 1's inter disciplinary team at risk for miscommunication regarding the Resident 1's condition and response to care. Cross Reference: F689 and F656 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses which included cerebral infarction (also called ischemic stroke, occurs as result of disrupted blood flow to the brain) and cognitive communication deficit (impaired attention, memory, perception, organization, language, and lack of coordination, symptoms and signs involving the musculoskeletal system). A review of Resident 1's fall risk care plan (CP), dated 2/7/2025, the CP indicated Resident 1 was at risk for falls…

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

Based on interview and record review, the facility failed to follow a physician's order to collect a stool sample for one of three sampled residents (Resident 1). This deficient practice had the potential for a delay of care and services to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 3/25/2024, and recently admitted Resident 1 on 11/27/2024, with diagnoses of acute respiratory failure with hypoxia (a serious medical condition that occurs when the body does not have enough oxygen in its tissues), end stage renal disease (irreversible kidney failure), and dependence on renal dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are no longer functioning properly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/2/2024, the MDS indicated Resident 1 was understood by others and had the ability to usually understand others. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for three of three sampled residents (Residents 13, 17 and 35). These deficient practices had the potential for the residents not to receive necessary care or receive delayed services to meet the residents' needs that could result in a fall or injury. Findings: a. During a review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints caused by gradual loss of cartilage), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and chronic obstructive pulmonary disease (COPD, a chronic lung diseases causing difficulty in breathing). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 9/6/2024, the MDS indicated Resident 17 had severely impaired cognition…

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 its Policy and Procedure (P&P) on the use of side rails/bed rails (adjustable metal or rigid plastic bars attached to the bed) for three of three sampled residents (Residents 21, 33 and 48) by failing to: a. (1). Ensure appropriate alternative interventions were attempted before the installation of side rails for Resident 21. (2). Assess Resident 21 for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and obtained an informed consent to review the risks and benefits prior to installing bed rails. b. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 33 before the installation of side rails. c. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 48 before the installation of side rails. These failures placed Residents 21, 33 and 48 at risk for entrapment, injury 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.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure food items were dated when it was first opened in one of two facility refrigerators. This deficient practice had the potential risk for food borne illnesses (infections caused by ingesting contaminated food or beverages) to the residents. Findings: During an observation and initial tour of the kitchen on 12/17/2024 at 9:24 am, together with the Lead [NAME] (LC), one unlabeled bag of tortilla and 2 pound (lbs.- unit of measurement) open bag of corn tortilla did not have a label or date when it was first opened, inside one facility refrigerator. The LC stated the bags of tortillas were not labeled nor dated when it was first opened. The LC stated the staff who opened the food item needed to label it with the date opened to keep track of how long the food item was opened. During an interview on 12/18/2024 at 12:01 pm with the Dietary Supervisor (DS), the DS stated, all food items needed to have a label with date opened to determine the use by date and 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 one of one sampled resident (Resident 21) was informed in advance, of the risks and benefits of a psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). This failure violated the residents' right to make an informed decision regarding the use of a psychoactive medication. Findings: During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), anemia (a condition where the body does not have enough healthy red blood cells), and dysphagia (difficulty swallowing). During a review of Resident 21's History & Physical (H&P) dated 6/12/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 21's Order Summary Report (OSR-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment for one of one resident (Resident 51). This failure resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Resident 51 not to receive interventions to address the resident's specific care concerns. Findings: During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare (the treatment and care the patient received after surgery) following surgery on the digestive system (group of organs that work together to digest and absorb nutrients from food) and chronic kidney disease (progressive damage and loss of function of the kidneys).…

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 utilize bilateral landing mats as ordered, for one of three sampled residents (Resident 13) who had a history of falls. This deficient practice had the potential to result in serious consequences that may accompany a fall for Resident 13. Findings: During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) without dyskinesia (a movement disorder that involves involuntary muscle movements) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 13's Order Summary Report (OSR) dated 2/27/2022, the OSR indicated for staff to place bilateral floormat for fall…

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 staff failed to ensure one of one sampled resident (Resident 40) received two liters of oxygen as needed according to physician's order and monitor the resident's oxygen usage in accordance with professional standards of practice. This deficient practice had the potential to cause complications associated with oxygen therapy for Resident 40. Findings: During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening blood infection), respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 40's Order Summary Report (OSR) of Active Orders dated 7/15/2024, the OSR indicated Resident 40 had an order for two liters per minute (L/min) of oxygen via (through)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases for a resident on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) with indwelling medical device placed on Enhanced Barrier Precautions (EBP, infection control measures used to prevent the spread of multidrug-resistant organisms [MDROs] in healthcare settings) for one of six sampled residents (Resident 44). This failure had the potential to expose Resident 44 to infection. Findings: During a review of Resident 44's admission Records (AR), the AR indicated Resident 44 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement fall intervention to utilize bilateral landing mats for two of two sampled residents (Resident 15 and Resident 17) who had history of falls as indicated in residents care plan titled Fall Risk. These deficient practices had the potential to result in serious consequences like fractures (break in the bone) and bleeding that may accompany with falls. Findings: a. During a review of Resident 15's admission record indicated, the facility admitted Resident 15 on 11/14/2021 with diagnoses that included Parkinson's disease (an age-related brain condition that affects movement resulting in lack of coordination and tremors) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/16/2023, the MDS indicated, Resident 15's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental oxygen) for three of three sampled residents (Residents 199, 149 and 8) according to standards of practice and with the facility's Policy and Procedure (P&P) titled, Oxygen Therapy. a. Resident 199 did not receive two liters of oxygen as ordered by the physician. b. Resident 149 received continuous oxygen therapy without a physician's order. c. Resident 8 received continuous oxygen therapy without a physician's order. These deficient practices placed Residents 199, 149 and 8 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead to serious complications. Findings: a. During a review of Resident 199's admission Record, the admission record indicated the facility admitted Resident 199 on 12/12/2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- a type of obstructive lung disease characterized by long…

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 bilateral handsocks (a type of glove that covers the hands) for one of two sampled residents (Resident 8) in accordance with the physician's order. This deficient practice had the potential to affect Resident 1's self-esteem (self-worth) and psychosocial well-being. Findings: During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses that included dementia (progressive loss of intellectual functioning, impairment of memory and thinking) and contracture (shortening and hardening of muscles, tendons and other tissue leading to deformity and rigidity of joints) of the left elbow. During a review of Resident 8's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 10/20/2023, the MDS indicated Resident 8 had severely impaired cognition (ability to understand) and was totally dependent on staff with oral hygiene, toileting, shower,…

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 (an alerting device for staff to assist a resident in need) was within reach for one of one sampled resident (Resident 42). This deficient practice had the potential to result in Resident 42 not receiving care and assistance in a timely manner. Findings: During a review of Resident 42's admission Record, the admission record indicated Resident 42 was admitted on [DATE], with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass) and malignant neoplasm of the brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, had ability to express ideas and wants and had ability to understand others. The MDS indicated Resident 42 was cognitively intact (able to think and reason). The MDS indicated Resident 42 required substantial/maximal assistance (helper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure to provide information of advance care planning (a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.) for one of one sampled resident (Resident 42). This deficient practice had the potential for facility staff to provide treatment against the resident's will. Findings: During a review of Resident 42's admission Record, the admission record indicated Resident 42 was admitted on [DATE], with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass) and malignant neoplasm of brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, had ability to express ideas and wants and had ability to understand others.…

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

Based on observation, interview, and record review, the facility failed to provide a comfortable and home like environment for one of one sampled resident (Resident 42). This failure had the potential to result in Resident 42 not residing in a comfortable environment that could affect Resident 42's quality of life. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted Resident 42 on 10/2/2023, with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass), and malignant neoplasm of brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, had ability to express ideas and wants and had ability to understand others. Resident 42 was cognitively intact (able to think, reasoning and organize). Resident 42 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) 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 develop and implement an individualized a person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives and interventions to meet the residents' needs for one of one sampled resident (Resident 5) as indicated in the facility's Policy and Procedure, titled Care Plans, Comprehensive. This deficient practice had the potential for Resident 5 not to receive appropriate care, treatment and/or services. Finding: During a review of Resident 5's admission record, the admission record indicated, the facility readmitted Resident 5 on 11/26/2023 with diagnoses that included unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) with mood disturbance and Alzheimer's Disease (a…

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

Based on observation, interview and record review the facility failed to revise a plan of care for one of one sampled resident (Resident 15), who sustained a fall from his bed on 9/25/2023 as indicated in the facility's policy Care Plans, Comprehensive. This deficient practice had the potential to place Resident 15 at risk for recurrent falls. Findings: During a review of Resident 15's admission record indicated, the facility admitted Resident 15 on 11/14/2021 with diagnoses that included Parkinson's disease (an age-related brain condition that affects movement resulting in lack of coordination and tremors) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/16/2023, the MDS indicated, Resident 15's cognition for daily decision making was severely impaired. The MDS indicated Resident 15 required total dependence with eating, oral and toileting hygiene, shower, upper…

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 an effective communication method for one of one non-English speaking sampled resident (Resident 18). This failure had the potential for Resident 18 to not receive the necessary care and services due to the lack of effective communication aids. Findings: During a review of Resident 18's admission Record, the admission Record indicated the facility admitted Resident 18 on 9/29/2023, with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problems) and type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high). During a review of Resident 18's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/20/2023, the MDS indicated Resident 18 had clear speech, usually understood others, and usually made self-understood. The MDS indicated Resident 18 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for eating, personal hygiene,…

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 assign a designated staff to coordinate with hospice care (end of life care) for one of one sampled resident (Resident 42). This failure had the potential for Resident 42 to not receive individualized compassionate care that could affect Resident 42's quality of life. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted Resident 42 on 10/2/2023, with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass), and malignant neoplasm of brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, ability to express ideas and wants, and ability to understand others. Resident 42 was cognitively intact (able to think, reasoning and organize). Resident 42 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort)…

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

Based on observation, interview, and record review, the facility failed to follow the physician's order to set up Gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feeding of Fibersource HN (nutritionally complete tube feeding formula) via pump (a machine used to infuse nutrition formula through G-Tube to the stomach) for one of four sampled residents with tube feeding (Resident 28). This failure had the potential to result in weight loss and malnutrition for Resident 28 and could affect Resident 28's health condition. Findings: During a review of Resident 28's admission Record, the admission Record indicated the facility readmitted Resident 28 on 12/15/2022, with diagnoses that included gastrointestinal hemorrhage (bleeding in digestive tract) and dysphagia (difficulty swallowing). During a review of Resident 28's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/31/2023, the MDS indicated Resident 28 had clear speech, usually understood…

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 complete a performance evaluation for at least once every 12 months for one of two sampled Certified Nursing Assistants 3 (CNA 3). This failure had the potential for the facility to not be aware of CNA 3's competency skills and techniques and miss the opportunity to provide the necessary in-service education specific to CNA 3's performance which could negatively affect the provision of care to residents. Findings: During a review of CNA 3's personnel file and Employee Evaluation Report, the report indicated CNA 3 had a general performance evaluation on 3/7/2022. There was no evaluation report for 2023 in CNA 3's personnel file. During an interview on 12/21/2023 at 10:21 am with the Director of Staff Development (DSD), DSD stated CNA 3's last performance evaluation was completed on 3/7/2022 and there was no performance evaluation completed for CNA 3 in 2023. DSD stated, CNA 3's annual performance evaluation should have been completed in 3/2023. DSD stated, performance evaluation should be done at least every 12 months for…

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

Based on interview and record review, the facility failed to act upon the pharmacist's monthly medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation to obtain an informed consent for the use of Venlafaxine (medication used to treat depression, anxiety disorder and panic disorder) for one of five sampled residents (Resident 38) on psychotropic medication (medication that affects brain activities associated with mental process and behavior). This failure had the potential to result in Resident 38 receiving an unnecessary medication and could prevent Resident 38 from maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being. Findings: During a review of Resident 38's admission Record, the admission Record indicated the facility admitted Resident 38 on 9/20/2023, with diagnoses that included Type 2 diabetes mellitus (a disease in which there is a high level of sugar in the blood)…

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 nasal cannula (NC, small flexible tube with two prongs that sit inside the nostrils to deliver supplemental oxygen) was labeled and dated, the tubing was not touching the floor, and the NC prongs were not touching the oxygen humidifier (device used to provide moistened oxygen) when not in use for one of three sampled residents (Resident 20) on oxygen therapy in accordance with the facility's policy and procedure titled, Oxygen Therapy. This deficient practice had the potential to result in an increased risk of spread of infection to the residents, staff, and other visitors in the facility. Findings: During a review of Resident 199's admission Record, the admission Record indicated the facility admitted Resident 199 on 12/12/2023, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that block airflow and make it difficult to breathe). During a review of Resident 199's History and Physical (H&P), dated 12/15/2023, the H&P indicated, Resident…

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