The Rowland

Based on interview and record review, the facility failed to ensure there was a m/b (manifestation by- refers to the specific, observable signs, symptoms, or behaviors that show a resident needs the antidepressant. It provides concrete, measurable clinical proof [e.g., crying spells, insomnia, weight loss] that justifies the medication and ensures it meets regulatory standards for residents) behavior documented for Sertraline (an antidepressant medication) ordered for one (1) of one (1) sampled resident (Resident 53). This deficient practice had the potential to result in serious health complications for Resident 53.Findings:During a review of Resident 53's admission Record (AR), the AR indicated the facility admitted Resident 53 on 1/06/2025 with diagnoses including psychosis (a mental state where a person loses touch with reality, resulting in disrupted thoughts and perceptions), dementia (a decline in mental abilities severe enough to interfere with daily life), Alzheimer's (a progressive brain disorder and the most common cause of dementia. It slowly destroys memory 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 accurately complete a Preadmission Screening and Resident Review Level I screening (PASRR I-the prescreening process which determines if a resident has a serious mental illness [SMI-diagnosable mental, behavioral, or emotional disorder that significantly impairs a person's ability to function in major life activities], intellectual disability [ID], developmental disabilities [DD], or related condition [RC]) for one of two sampled residents (Resident 3) when Resident 3's PASRR I indicated Resident 3, who was diagnosed with schizophrenia (a mental illness characterized by disturbances in thought), did not have a SMI.This failure resulted in Resident 3 not receiving the PASRR level 2 screening (PASRR II-a required federal assessment that ensures individuals with a SMI or ID are placed in appropriate facilities) and had the potential for Resident 2 to not receive specialized services (the services specified by the State that exceed the services ordinarily…

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 a care plan for one of one sampled resident (Resident 12), who sustained a fall on 3/11/2026. This failure had the potential to place Resident 12 at risk for recurrent falls. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including history of falling, dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's Care Plan (CP) dated 3/4/2026, the CP indicated Resident 12 was at risk for falls related to diagnosis of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 12 had severely impaired cognition (ability to understand). During a review of Resident 12's Accident/Incident…

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 nasal cannula oxygen tubing (a flexible tube that administers oxygen through the nose) for one of two sampled residents (Resident 1) was labeled with date and time in accordance with the facility's policy on oxygen administration. This deficient practice had the potential to result in respiratory complications for Resident 1 associated with oxygen therapy. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including pneumonitis (the swelling or irritation of tiny air sacs in the lungs), cardiomyopathy (when the heart muscle has become thick, stiff, or enlarged), and anemia (a condition where a person lacks enough healthy red blood cells to carry oxygen throughout the body). During a review of Resident 1's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition)…

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 one of two sampled residents (Resident 110) received dialysis (a treatment involving the removal of extra fluid and waste products from the blood when the kidneys are unable to function properly) care consistent with professional standards of practice, when the facility failed to take Resident 110's vital signs (measurements of the body's most basic functions such as heart rate and blood pressure) upon arrival to the facility after receiving dialysis on 6/30/2026. This deficient practice had the potential to result in adverse (harmful) consequences on Resident 110. Findings: During a review of Resident 110's admission Record (AR), the AR indicated Resident 110 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (when the kidneys can no longer function on their own to filter blood) and heart failure (when the heart muscle is too weak to pump blood efficiently). During a review of Resident 110's History 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 ensure residents received treatment and care in accordance with professional standards of practice for four resident of four sampled residents (Resident 1, 3, 4 and 5) by: 1. Not ensuring Resident 1 and 3 had floor mats at bedside. 2. Not ensuring Resident 1, 4, and 5 had a fall risk assessment (a comprehensive, non-invasive evaluation conducted to determine an individual's likelihood of falling, typically focusing on older adults or high-risk patients) after experiencing a fall. These deficient practices placed Residents 1, 3, 4 and 5 for recurring falls and increased the risk for the residents to sustain injuries after a fall from their beds. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into the blood) 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 safe oxygen administration practices ([oxygen therapy], is the medical practice of delivering oxygen at a concentration greater than ambient air) for three of four sampled residents (Residents 1, 3, 4) by: 1. Not ensuring Resident 1's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated with an open date and did not ensure nasal cannula was not touching the floor. 2. Not ensuring Resident 3 had a bag at the bedside for oxygen equipment and did not ensure nasal cannula was not touching the floor. 3. Not ensuring Resident 4 received oxygen administration when using motorized wheelchair and did not ensure the nasal cannula was not touching the floor and placed over the restroom doorknob. These deficient practices increased the risk for Resident 1, 3, and 4) to acquire a respiratory infection (infectious disease caused by bacteria, viruses, or fungi that affects the…

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

Based on observation, interview and record review, the facility did not ensure dietary staff followed the dietary menus for two of two meals: 1. Facility did not ensure residents received meals according to dietary menu (a structured, planned selection of food items tailored to meet specific nutritional, health, lifestyle, or cultural needs) on 4/21/2026 and 4/22/2026. 2. Facility did not ensure the Dietary Services Supervisor (DSS) checked food before food left the kitchen. 3. Facility did not notify residents there was a change in food that was served on 4/21/2026 and 4/22/2026. These deficient practices had the potential to impact on resident's nutritional status and placed all (112) residents at risk for unintentional weight loss. Findings: During an observation on 4/21/2026 at 12:20 p.m., residents received meat, a salad, and broccoli for lunch. During a review of facility's lunch menu titled [NAME] Nutrition consulting Spring Menu Week Seven, dated 4/21/2026, the lunch menu indicated residents were scheduled to receive Chicken cacciatore, garlic noodles, sauteed squash, French…

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 the correct food texture-modified diet (alters the consistency of food and liquids to make swallowing safer and easier for people with chewing or swallowing difficulties) for two of four sampled residents (Residents 1 and 2) when: 1. The facility did not ensure Resident 1 and Resident 2 received the correct food texture. 2. The facility did not ensure Dietary Supervisor checked for food texture for Resident 1 and Resident 2 before the food leaving the kitchen. These deficient practices had the potential for Residents 1 and 2 to have problems chewing and swallowing and increased the risk of choking for Residents 1 and 2 while eating. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into 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 and interview, the facility did not provide a working call light to one of four sampled residents (Resident 2). This deficient practice had the potential to cause a delay or the inability in obtaining necessary care and services for Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (a group of conditions affecting the blood vessels that supply the brain, causing temporary or permanent damage due to restricted blood flow, blockage, or rupture) and dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). During a review of Resident 2's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 4/25/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions due to vascular dementia (changes to memory, thinking, and behavior resulting from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice of infusion therapy for peripheral intravenous catheter (PIV - small flexible tube placed into a vein to administer fluids and/or medications) and total parenteral nutrition (TPN- a medication used to manage and treat malnourishment) care for two of two sampled residents (Resident 55 and 307) by failing to: a. Ensure Resident 55's PIV site was labeled with a date and initials upon insertion. b. Ensure Resident 307's total parenteral nutrition (TPN- a medication used to manage and treat malnourishment) administration set was labeled with a date and time when hung. These failures had the potential to result in infection at Resident 55's IV site, and contamination of Resident 307's TPN and/or TPN tubing that could have led to further infection. Findings: a. During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that…

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 necessary care and services for residents receiving oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with professional standards of practice for four of four sampled residents (Residents 16, 73, 206, and 256) by failing to: a. Ensure Resident 16 received oxygen therapy as ordered by the physician and ensure that the nebulizer face mask (a soft pliable mask that covers the nose and mouth used to deliver liquid medication in the form of a mist directly into the lungs) was stored in a sanitary condition when not in use. b. Ensure a sign Oxygen No Smoking, No Open Flames, was posted outside Resident 206's room in accordance with the facility's policy and procedure. c. Ensure Resident 73's oxygen and nebulizer tubings were not on the floor. d. Ensure Resident 256's nasal cannula was not on the floor with the nasal prongs directly touching the floor. These failures had the potential to result in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bedrails/siderails (adjustable metal or rigid plastic bars attached to the bed) for two of three sampled residents (Residents 56 and 75). These failures placed Residents 56 and 75 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed), and injury from the use of bedrails/siderails. Findings: a. During a review of Resident 56's admission Record (AR), the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 3/16/2025, the MDS indicated Resident 56 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered in a timely manner and as prescribed to meet the therapeutic (treatment, therapy, or drug) needs of the resident for one of one sampled resident (Resident 62). This failure had the potential to increase the risk of adverse drug reactions and potential medical complications for Resident 62. Findings: During a review of Resident 62's admission Record (AR), the AR indicated Resident 62 was admitted to the facility on [DATE] with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), depression (characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and dementia (a progressive state of decline in mental abilities). During a review of Resident 62's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2025, the MDS indicated Resident 62 had severely impaired cognition (ability to understand 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 observations, interviews, and record reviews, the facility failed to ensure the medication error (any preventable event that may cause or lead to inappropriate medication use or patient harm) rate was five (5) percent (%) or lower during medication administration on 5/15/2025 for one of four sampled residents (Resident 62). This failure resulted in five medications errors out of twenty-eight (28) opportunities for errors, which resulted in medication administration error rate of seventeen and eighty-six hundredths (17.86) %. Findings: During a review of Resident 62's admission Record (AR), the AR indicated Resident 62 was admitted to the facility on [DATE] with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), depression (characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and dementia (a progressive state of decline in mental abilities). During a review of Resident 62's Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications were kept secure with limited access by failing to: 1. Ensure to lock the medication cart (Med Cart) that contained residents' medications on North Station when not attended and outside of view. 2. Ensure the Wixela Inhub Inhalation Aerosol Powder Breath (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma or ongoing lung disease) was in Resident 34's possession. These deficient practices had the potential to result in residents' medications to be accessible to others not authorized to have access to drugs (medications) and biologicals (drugs derived from natural sources) and increased the risk for loss of control, safety, and security of all medications necessary to meet the health care needs of residents. Findings: 1. During a medication Pass Observation on 5/15/2025 at 8:03 a.m. with a Licensed Vocational Nurse 1 (LVN 1) on the North Station, LVN 1 left the medication cart (Med Cart) in the…

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

Based on observation, interview, and record review, the facility failed to maintain safe food handling practices by failing to ensure: a. Two of four red sanitization buckets with chemical that used in the kitchen to sanitize kitchen surfaces was maintained at the correct chemical concentration to maintain effectiveness of the disinfectant. b. One of one plastic container of expired red tomato salsa, with an open date of 5/4/25, and one plastic container of green salsa, with an open date of 5/2/25, were inside the walk-in refrigerator. c. One of one bag of open penne pasta noodles and one bag of open spaghetti pasta noodles was in dry storage area and was not labeled with an open date and use by date. These deficient practices had the potential to result in food surfaces not being properly sanitized and foodborne illness (illness caused by contaminated food) due to expired food. Findings: During an observation, on 5/13/25, at 8:33 a.m., with the Dietary Supervisor (DS), one pack of penne pasta noodles and one pack of spaghetti pasta noodles was observed in the dry storage…

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 b. During a review of Resident 16's AR, the AR indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of the lung, pneumonia (an infection/inflammation in the lungs) and chronic kidney disease (gradual loss of kidney function). During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 16 required substantial/maximal assistance (helper did more than half the effort) with eating, upper and lower body dressing and dependent (helper did all the effort, resident did none of the effort to complete the activity) with oral hygiene, toileting, shower and personal hygiene. During a review of Resident 16's Order Summary Report (OSR), dated 5/12/2025, the OSR indicated Resident 16 had an order for Enhanced Barrier Precautions due to Stage 3 pressure injury (full-thickness loss of skin.…

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 staff promoted dignity while assisting one of one sampled resident (Resident 64) during meals by feeding the resident at eye level to maintain face-to-face contact with the resident. This deficient practice had the potential to affect Resident 64's self-worth, dignity, and safety. Findings: During a review of Resident 64's admission Record (AR), the admission Record indicated Resident 64 was admitted on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 64's Order Summary Report, dated 1/10/2025, the Order Summary indicated Resident 64 had a diet order started on 7/8/2024 for a puree diet with pureed texture.…

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 47) call light was within reach. This failure had the potential to result in Resident 47 not receiving the necessary care or delayed services. Findings: During a review of Resident 47's admission Record (AR), the AR indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the right dominant side, muscle weakness (lack of muscle strength), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 47's Care Plan (CP), dated 8/14/2023, the CP indicated Resident 47 required assistance with activities of daily living (ADLs). The CP interventions included keeping the call light within the resident's reach. During a review of Resident 47's Minimum Data Set (MDS, a resident assessment tool), dated 2/27/2025, the MDS…

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 resident's Advance Directive (AD, a legal document indicating a resident's preference for end-of-life treatment decisions) and AD Acknowledgement Form was in the resident's medical record for one of three sampled residents (Resident 16). This failure had the potential to result in the staff providing care and services against the will of Resident 16. Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of the lung, pneumonia (an infection/inflammation in the lungs) and chronic kidney disease (gradual loss of kidney function). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/2025, the MDS indicated Resident 16 had moderately impaired cognition (ability to understand and process information). The MDS 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.

Based on interview and record review, the facility failed to screen one of two randomly selected employees (Certified Nurse Assistant 2 [CNA 2]) with the Office of Inspector General (OIG - investigates alleged violations of criminal and civil laws) data base prior to hire in accordance with the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice had the potential for employees with a history of abuse get hired, which could lead to possible harm and abuse of the residents. Findings: During a concurrent interview and record review of CNA 2's employee file on 5/15/2025 at 2:08 pm with the Director of Staff and Development (DSD), the DSD stated CNA 2 was hired on 8/1/2024. The DSD stated there was no documented evidence that CNA 2's background check was done prior to hire or recently. The DSD stated that the administrator did the staff background check before hire. The DSD stated it was important to do a background check to ensure employees were safe to work, with no criminal records and residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services for a resident with Foley catheter (FC, a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on catheter care for one of one sampled resident (Resident 257). This failure had the potential to result in catheter-related complications for Resident 257. Findings: During a review of Resident 257's admission Record (AR), the AR indicated Resident 257 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), hypertension (HTN, high blood pressure) and chronic kidney disease (CKD- a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood.) During a review of Resident 257's Order Summary Report (OSR) dated 5/2/2025, the OSR indicated for licensed staff to check every shift to ensure…

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 307), who had a biliary drain (biliary drain- allows bile to flow out from a blocked bile duct from the liver into a collection bag outside the body) did not have biliary drainage on the resident's floor. This failure had the potential to result in the transmission of infection from bodily fluids. Findings: During a review of Resident 307's admission Record (AR), the admission Record indicated Resident 307 was readmitted on [DATE] with diagnoses that included bladder cancer and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 307's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 2/13/2025, the MDS indicated Resident 307 had intact cognition (ability to understand) and needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides…

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 act upon the pharmacist's 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 for one of five sampled residents (Resident 72). This failure had the potential for Resident 72 to receive unnecessary medications and result in undesirable or non-therapeutic effect of the medication to the resident. Findings: During a review of Resident 72's admission Record (AR), the AR indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy on the use of an antibiotic and a change in condition for one of five sampled residents (Resident 84) for a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure resulted in Resident 84 receiving antibiotics without meeting facility criteria and had the potential to result in Resident 84 developing antibiotic resistance. Findings: During a review of Resident 84's admission Record (AR), the admission Record indicated Resident 84 was admitted on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that may cause persistent sadness or loss of interest in activities). During a review of Resident 84's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 4/11/2025, the MDS indicated Resident 84 had…

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 their Policy and Procedure (P&P) titled, Handwashing and Hand Hygiene for one of eight sampled residents (Resident 3), when Certified Nursing Assistant 1 (CNA 1) did not wash CNA 1's hands after touching the overbed table and bed linens of a resident who tested positive for clostridium difficile (C. diff; bacteria that can cause diarrhea, enterocolitis [inflammation of the small and large intestines], and other intestinal conditions) infection. This failure had the potential to spread infection to other residents, staff, and visitors in the facility. Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD; irreversible kidney failure) and enterocolitis due to C. diff. During a review of Resident 3's History and Physical (H&P; a physician's clinical evaluation and examination of the 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 transmit assessments within 14 days of completion for 23 of 23 sampled residents (Residents 1, 4, 17, 21, 22, 26, 28, 29, 31, 33, 35, 41, 49, 52, 56, 61, 62, 70, 71, 72, 78, 79, and 80). This failure had the potential to result in inaccurate facility information submitted to the Centers for Medicare and Medicaid Services (CMS, federal agency that works with the health care community to improve quality, equity, and outcomes in the health care system) and would affect the quality of care to the residents. Findings: During record review of the Minimum Data Set (MDS, a standardized assessment and care planning tool) 3.0 Final Validation Report, the MDS 3.0 Final Validation Report indicated it was submitted on 6/6/2024 for Residents 1, 4, 17, 21, 22, 26, 28, 29, 31, 33, 35, 41, 49, 52, 56, 61, 62, 70, 71, 72, 78, 79, and 80. During an interview on 6/6/2024 at 8:46 AM with the MDS Nurse, the MDS Nurse stated the Assistant Administrator (AADM) was responsible for transmitting the MDS assessments to CMS. During an interview 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 provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) tubing and site as ordered by the physician and as indicated in the plan of care for two of three sampled residents (Residents 193 and 195). These failures had the potential for infection and adverse consequences related to tube feedings for Residents 193 and 195. Findings: a. During a review of Resident 193's admission Records (AR), the AR indicated Resident 193 was admitted to the facility on [DATE] with diagnoses that included subdural hemorrhage (a pool of blood between the brain and its outermost covering) and epilepsy (a seizure disorder) During a review of Resident 193's untitled Care Plan (CP), dated 5/1/2024, the CP indicated Resident 193 had a feeding tube related to dysphagia (difficulty swallowing). The CP goal was for Resident 193 to tolerate tube feeding without complications.…

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 necessary care and services for residents on oxygen therapy (a treatment that provides with extra oxygen to breathe in) as ordered by the physician, as indicated in the residents' plan of care and in accordance with the facility's Policy and Procedure (P&P) on Oxygen Administration for four of seven sampled residents (Residents 2, 31, 64 and 189). These failures had the potential to result in respiratory complications and infection for Residents 2, 31, 64 and 189. Findings: a. During a review of Resident 189's admission Record (AR), the AR indicated the facility admitted Resident 189 on 4/7/2024 with diagnoses that included hypertension (high blood pressure), morbid obesity (a disorder that involves having too much body fat) and atherosclerosis of the aorta (a condition that occurs when plaque builds up on the inner walls of the aorta). During a review of Resident 189's Minimum Data Set (MDS, a standardized assessment and care…

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 dialysis emergency kit was readily available for staff use in case of bleeding in resident's dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) access site for two of two sampled residents on dialysis (Residents 44 and 85). This deficient practice placed Residents 44 and 85 at risk for excessive bleeding from dialysis access site. Findings: a. During a review of Resident 85's admission Record (AR), the AR indicated the facility admitted Resident 85 on 4/6/2024, with diagnoses that included diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high) and dependence on renal dialysis. During an observation on 6/4/2024 at 11:09 a.m., Resident 85 was lying on his back in bed, alert and coherent. Resident 85's left upper arm dialysis access site was intact. During a concurrent observation and interview with the Treatment Nurse (TN) in Resident 85's room on 6/4/2024 at 11:17 a.m., the TN stated…

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

Based on observation, interview, and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. The staffing information was not posted in a prominent location for two of four days during the recertification survey. This deficient practice had the potential to mislead the residents and visitors of the actual hours worked by licensed and unlicensed nursing staff directly providing resident care and had the potential to affect the quality of nursing care provided to the residents. Findings: During a concurrent observation and interview on 6/4/2024 at 9:30 a.m. and 6/5/2024 at 9 a.m., the facility's staffing information was posted inside the North Nurses' Station and no staffing information was posted in the South Nurse's Station of the facility. The staffing information indicated actual hours worked by the nursing staff on all shifts (7 am-3 pm, 3pm-11 pm and 11 pm-7 am). During a concurrent interview and review on 6/5/2024 at 10 a.m., 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 five of five sampled residents (Residents 13, 25, 41, 47 and 77) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication by failing to: A. Attempt a Gradual Dose Reduction (GDR- tapering of a dose) for Residents 25 and 47 B. Ensure PRN (as needed) orders for psychotropic medications were limited to 14 days use for Residents 13, 41, and Resident 77. These deficient practices had the potential for the facility to use psychotropic drugs inappropriately and had the potential to affect residents' physical, emotional and psychosocial wellbeing. Findings: A.1. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted Resident 25 on 4/28/2023, under Hospice Care (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) due to diagnosis of end stage Alzheimer'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 interview and record review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection by failing to: a. Establish facility wide systems and water safety management based on national standards of practice and the facility assessment for the prevention, identification, investigation, and control to prevent the growth of Legionella (bacteria that causes Legionnaires [severe form of pneumonia [lung infection caused by bacteria] and other opportunistic waterborne pathogens [any organisms or agent that can cause disease]) in the building water systems. b. Ensure signage was posted and personal protective equipment (PPE, specialized equipment or clothing that protects against infectious materials) cart was provided to one of one sampled resident (Resident 189) with Foley catheter (FC, thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) who was on Enhanced Barrier Precaution (EBP, an approach 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 follow the facility's policy on Advance Directives (AD, a legal document that informs healthcare providers what kind of care a person would want to receive if the individual was unable to speak for self) to ensure a current copy of a resident's AD was in the medical chart for one of three sampled resident (Resident 288). This failure had the potential for Resident 288's AD to not be followed by the facility staff. Findings: During a review of Resident 288's admission Record (AR), the AR indicated Resident 288 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI, occurs when bacteria enters the urethra [tube through which urine leaves the body] and multiply), hyperlipidemia (high levels of cholesterol in the blood), and constipation (stool becomes hard and difficult to pass). During a review of Resident 288's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated…

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

Based on observation, interview, and record review, the facility failed to provide privacy during a bed bath to one of one sampled resident (Resident 28.) This deficient practice had the potential to cause embarrassment and lowered self-esteem for Resident 28. Findings: During a review of Resident 28's admission Record (AR), the AR indicated the facility admitted the resident on 12/10/2023, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and epilepsy (brain disorder in which a person has repeated seizures (convulsions) over time). During a review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/24/2024, the MDS indicated the resident had moderately impaired cognition (ability to understand). The MDS indicated Resident 28 was dependent with showers, self-bathing and toileting and required moderate (helper does less than half the effort) assistance with bed mobility. During an observation on 6/4/2024 at 10:03 am to…

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

Based on observation, interview, and record review, the facility failed implement its policy and procedure (P&P) on Translation and Interpretation services to ensure needs and questions from the resident with limited English proficiency (LEP) were addressed by staff for one of one sampled resident (Resident 289). This failure had the potential to not meet Resident 289's needs. Findings: During a review of Resident's 289 admission Record (AR) the AR indicated the facility admitted Resident 289 on 5/10/2024 with diagnoses that included wedge compression fracture (bone in front of the spine collapsing forming a wedge shape) of first lumbar vertebra (bones in spine to provide support to the body), unspecified hearing loss, and a history of falling. During a review of Resident 289's History and Physical (H&P, a formal document of a medical provider's examination of a patient) dated 5/11/2024, the H&P indicated Resident 289 had the capacity to understand and make decisions. During a review of Resident 289's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated…

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

Based on observation, interview, and record review, the facility failed to answer the call light and provide assistance to a resident in a timely manner in accordance with the resident's care plan (CP) and the facility's Policy and Procedure (P&P) on answering call lights, for one of one sampled resident (Resident 289). This failure had the potential to result in fall or injury to Resident 289 who had a history of falling. Findings: During a review of Resident's 289 admission Record (AR) the AR indicated the facility admitted Resident 289 on 5/10/2024 with diagnoses that included wedge compression fracture (bone in front of the spine collapsing forming a wedge shape) of first lumbar vertebra (bones in spine to provide support to the body), unspecified hearing loss, and a history of falling. During a review of Resident 289's History and Physical (H&P, a formal document of a medical provider's examination of a patient) dated 5/11/2024, the H&P indicated Resident 289 had the capacity to understand and make decisions. During a review of Resident 289s untitled CP, dated 5/11/2024, the CP…

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 interventions were developed and implemented to address the resident's positioning preference for one of one sampled resident (Resident 16.) Resident 16 had a non-healing wound to the left lateral (side) ankle and left medial (middle) ankle and Resident 16 preferred to lie on the left side. This deficient practice had the potential to delay wound healing for Resident 16. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted the resident on 7/27/2021 and readmitted on [DATE], with diagnoses that included benign neoplasm of endocrine pancreas (non-cancerous tumors of the pancreas) and infection and inflammatory reaction (pain, swelling, and discomfort) due to internal orthopedic prosthetic devices, implants, and grafts (medical devices or tissues placed inside or on the surface of the body). During a review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care…

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 care and services was provided to prevent pressure ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for one of five sampled residents (Resident 16.) Resident 16 developed redness at the base of the left lateral toe and redness at the base of the right big toe. This deficient practice had the potential for the development of pressure ulcer. Cross Reference: F684 Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted the resident on 7/27/2021 and readmitted on [DATE], with diagnoses that included benign neoplasm of endocrine pancreas (non-cancerous tumors of the pancreas) and infection and inflammatory reaction (pain, swelling, and discomfort) due to internal orthopedic prosthetic devices, implants, and grafts (medical devices or tissues placed inside or on the surface of the body). During a review of Resident 16's Minimum Data Set (MDS -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) on Restorative Services (care designed to improve or maintain the functional ability of residents) to provide restorative services in accordance with Medical Doctor's (MD-physician) order for one of four sampled residents (Resident 2). This failure had the potential to result in a decrease in range of motion (ROM, full movement potential of a joint [where two bones meet]) in Resident 2's bilateral (both) legs. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis (narrowing of spinal canal in lower part of the back) of the lumbar region (lower part of the back) and bilateral artificial knee joints. During a review of Resident 2's untitled Care Plan (CP) dated 8/6/2021, the CP indicated Resident 2 required variable assistance with activities of daily living (ADL, basic…

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 necessary care and services for a resident with foley catheter (FC, thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) as indicated in the resident's plan of care for one of two sampled residents (Resident 189). This failure had the potential to result in catheter-related complications for Resident 189. Findings: During a review of Resident 189's admission Records (AR), the AR indicated Resident 189 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI, an illness in any part of the urinary tract, the system of organs that makes urine) and benign prostatic hyperplasia (BPH, prostate gland enlargement that can cause urination difficulty). During a review of Resident 189's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 189 had intact cognition. Resident 189 was dependent (helper does all of the effort, resident does none of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately monitor the resident's fluid intake (measurement of the fluids that enter the body) for one of one sampled resident (Resident 30) as ordered by the physician. This failure had the potential for complications related to electrolyte imbalance for Resident 30. Findings: During a review of Resident 30's admission Records (AR), the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), anemia (a condition that occurs when the body doesn't have enough red blood cells to carry oxygen to the body's tissues) and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). During a review of Resident 30's untitled Care Plan (CP), dated 8/5/2021, the CP indicated Resident 30 had hypertension. The CP interventions included for staff to implement diet restrictions as ordered, monitor for compliance, monitor laboratory work and notify…

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, Licensed Vocational Nurse 2 (LVN 2) failed to ensure enteric coated (barrier to prevent gastric acids in the stomach from dissolving or degrading medications after being swallowed) Aspirin (medication to prevent blood clot) was not crushed for one of four sampled residents (Resident 7) during medication administration. This deficient practice had the potential to affect Resident 7's medication efficacy and placed the resident at risk for adverse complications. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted the resident on 5/2/2016 and readmitted on [DATE] with diagnoses that included gastroesophageal reflux disease with esophagitis (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach) dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and atherosclerotic 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 observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on Storage of Medications to ensure drugs and biologicals (class of medicines which were grown and purified) were stored in the Medication Refrigerator (MR) at required temperature for one of one sampled Medication Storage room [ROOM NUMBER] (MSR 1). This failure had the potential to result in medications to become unstable and ineffective. Findings: During a concurrent observation and interview on 6/7/2024 at 9:27 AM with Licensed Vocational Nurse 4 (LVN 4) in MSR 1, the MR thermometer inside MR indicated a temperature of 62 degrees Fahrenheit (F, unit to measure temperature). LVN 4 stated the temperature reading inside the MR was 62 degrees F. LVN 4 stated the thermometer was unsure if the thermometer was broken. LVN 4 stated the temperature in the MR was rechecked and indicated a temperature of 56 degrees F. LVN 4 stated the required MR temperature needed to be between 36 degrees F and 46 degrees F…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment to prevent the spread of infection during a Coronavirus (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season), as evidenced by failing to: a. Ensure the Activities Director (AD) performed hand hygiene after contact with objects in the immediate vicinity of two of two residents (Residents 4 and 5). b. Ensure Certified Nursing Assistant 1 (CNA 1) changed gloves and performed hand hygiene before and after providing care to two of two residents (Residents 6 and 7). c. Ensure one of one shower chair was disinfected with EPA( Environmental Protection Agency- an agency that develops and enforces environmental regulation to protect people and environment from significant health risk) approved disinfectant (chemical that destroys bacteria). These deficient…

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.