Courtyard Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate discharge for one of three sampled residents (Resident 1), when 1. The facility did not follow physician discharge orders;2. The 30-day notice of discharge was given to Resident 1 at time of discharge; 3. The facility failed to develop post discharge care follow up for a June neurology referral; 4. There was no physician discharge summary in the medical records; and5. Minimum Data Sheet (MDS - a federally mandated resident assessment tool) discharge assessment was incomplete and not submitted. These failures led to inappropriate discharge of Resident 1 from the facility and reduced the facility's potential in discharging Resident 1 safely.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in April 2025 with diagnoses that included benign neoplasm of cerebral meninges (brain tumor), cognitive communication deficit, and symptoms and signs involving cognitive…

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 resident safety for one out of three sampled residents (Resident 1) when Resident 1 eloped from the facility and failed to implement interventions per facility policy.This failure reduced the facility's potential in keeping Resident 1 safe from harm.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in April 2025 with diagnoses that included benign neoplasm of cerebral meninges (brain tumor), cognitive communication deficit, and symptoms and signs involving cognitive functions and awareness. Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) indicated Resident 1 had severe cognitive impairment.During a review of Resident 1's Speech Therapy Discharge summary, dated [DATE], the speech therapy notes indicated that Resident 1 .[had] difficulty following directions. [Resident 1] requires max [maximum] cues.memory impaired [decline in the ability 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 to ensure food preferences were accommodated for three of three sampled residents (Resident 1, Resident 2, and Resident 3), when:Resident 1 did not receive double portions of protein;Resident 2 did not receive salad; andResident 3 did not receive fresh fruit for lunch on 7/8/25 as listed in the meal tickets.These failures had the potential to negatively impact the residents' nutritional status.Findings:1. A review of Resident 1's admission Record, indicated she was admitted to the facility in 6/23 with diagnoses including anemia (the body does not have enough red blood cells to carry oxygen effectively throughout the body) and vitamin D deficiency (not enough vitamin D).A review of Resident 1's meal ticket, dated 7/8/25, indicated Resident 1 had double the portion of protein listed in the preference list. During a concurrent observation, interview, and record review on 7/8/25 at 12:28 p.m. with Resident 1, Resident 1's meal ticket, dated 7/8/25, was reviewed. Double portion of protein was listed 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 store food in a sanitary condition for a census of 109 residents, when:Two boxes of 48 cups of four ounces (oz, a unit of measurement) of yogurt were left in the kitchen floor at room-air for more than three hours; andThe freezer's temperature was not monitored on 7/7/25 in the evening shift.These failures had the potential to cause foodborne illness among residents.Findings:1. During a concurrent observation and interview on 7/8/25 at 11:15 a.m. with the Dietary Manager (DM), 20 boxes of fresh vegetables, fruits, milk, yogurt, eggs, and meat were in the kitchen floor at room air. DM stated the food products' delivery arrived today.During an interview on 7/8/25 at 11:40 a.m. with Dietary Aid (DA), DA stated the food products were delivered to the kitchen around 10 a.m.During an observation on 7/8/25 at 1:13 p.m., two boxes of 48 cups (four oz per cup) of yogurt were in the kitchen floor at room air temperature.During an interview on 7/8/25 at 1:35 p.m. with DM, DM confirmed the fresh produces were delivered…

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 protect the rights to be free from abuse for 1 of 4 sampled residents (Resident 1) when staff witnessed Resident 2 hitting Resident 1 ' s hand. This failure resulted in Resident 1 experiencing abuse including physical pain and emotional distress. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility in March 2016 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the right side. During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/5/25, the MDS indicated Resident 1 had no memory impairment. During a review of Resident 1 ' s SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) Form, dated 4/25/25, the SBAR indicated Resident 1…

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 protect the residents, rights to personal privacy and confidentiality of their personal and medical records when 16 resident meal tickets were left unattended in the facility's memory unit dining area. This resulted in the facility's failure to protect the residents' rights to personal privacy and confidentiality of their personal and medical records relating to sensitive information about residents' names, allergies and therapeutic diets. Findings: During a concurrent observation and interview on 4/16/25 at 1:14 p.m. in the Memory Unit with Registered Dietician (RD), observed resident meal tickets left unattended on a table in the Memory Unit. RD stated, They shouldn't be out there. Should be taken to shredder. HIPAA (Health Insurance Portability and Accountability Act) violation. Those are the meal tickets for the residents for memory unit dining. During an interview on 04/17/25 at 12:41 p.m. with DON, DON stated, That's HIPAA (Health Insurance Portability and Accountability Act) if meal tickets are…

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 were provided according to accepted professional standards of clinical practice when: 1. The licensed nurse (LN) did not administer medications in a timely manner for Resident 16, Resident 19, Resident 37, Resident 59 and Resident 71. 2. The LN did not check the residents' identity and did not explain the medications administered for (Resident 15, Resident 23, Resident 222, and Resident 102) and; 3.The Licensed Nurse failed to follow physician orders for continuous gastrostomy feeding for Resident 18 for a census of 104. These failures had the potential to result in medication errors and for Resident 15, Resident 16, Resident 18, Resident 19, Resident 23, Resident 37, Resident 59, Resident 102 and Resident 222 not meeting their highest practicable well-being. Findings: 1. During a review of Resident 16's admission Record (AR, front page of the chart that contains a summary of basic information about 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow scheduled mealtimes comparable to mealtimes in the community and in accordance with resident preferences for five of 33 sampled residents (Resident 81, Resident 94, Resident 30, Resident 69 and Resident 3). This failure resulted in residents' dissatisfaction with their meals and had the potential for decreased food intake leading to unplanned weight loss and nutritional deficiencies. Findings: Review of Resident 81's admission Record (AR), the AR indicated, Resident 81 was admitted in early June 2023 with diagnoses including type 2 diabetes with hypoglycemia (a condition that makes it difficult to control blood sugar and with episodes of low blood sugar). Review of Resident's 81's Minimum Data Set (MDS-A federally mandated resident assessment tool) dated 1/15/25, the MDS indicated Resident 81 had moderately impaired cognition (mental process of acquiring understanding and knowledge). During an interview on 4/15/25 at 12:28 p.m., with…

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 food service staff adhered to current standards of practice for food service safety when: 1. Staff failed to label, date, and monitor refrigerated and frozen food when expired food was found in 2 out of 4 refrigerators, food without expiration dates were found in 2 out of 4 refrigerators and 2 out of 3 freezers, and temperature logs were incomplete for 4 out of 4 refrigerators and 3 out of 3 freezers; 2. The facility failed to keep non refrigerated foods in a clean dry environment safe for consumption when fruit flies and flies were present and flying in the dry storage room over a container of uncovered sugar, two boxes of opened and unsealed dry instant hot cereal mix, a bag of unsealed oats with a ripped opening, a bag of unsealed Raisin Bran cereal with a ripped opening; and, 3. Staff failed to adhere to current standards of practice by failing to wear beard restraints to prevent hair from contacting food. These failures had the potential to result in food contamination and foodborne illness 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 facility assessment and ensure staff adherence to the established contingency plan during an electronic health record (EHR) system downtime when nursing staff were not provided timely direction and were unaware of procedures to follow when the EHR was inaccessible for a census of 104. This failure resulted in the facility's EHR inaccesibility, which resulted delays in medication administration and the potential to affect the residents' health and safety. Findings: During an interview on 4/15/25 at 11:21 a.m. with Director of Nursing (DON), DON stated the internet was down, preventing access to the EHR. The outage began at approximately 5:00 a.m. The DON stated, when this occurs, nurses are expected to print their own medication administrator record (MARs) from the backup computer located in the medication room. The DON stated, the emergency backup computer was also not functioning, and they had to connect to a different computer. The DON also stated the medication administration expectation was for…

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

Based on observation, interview, and record review, the facility failed to ensure an effective and comprehensive Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) program was performed for a census of 104, when the facility did not maintain documentation and did not present evidence of the previous three quarterly meetings. This failure had the potential to result in quality care improvement activities to not be evaluated and revised as needed and had the potential to negatively impact the quality care for the residents. Findings: During an interview on 4/18/25 at 8:40 a.m. with the Director of Staff Development (DSD), the DSD stated, I did attend the last QAA/QAPI .I don't know about the previous three quarterly meetings. I am not sure about the previous quarterly QAPIs .I am not sure what they did before. With the eight months that we've been here . it has been a hard to get a grasp on things. During an interview on 4/18/25 at 8:49 a.m. with the Social Services Director (SSD), the SSD stated, . table issues and concerns [from QAPI…

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 3. During a review of Resident 97's AR, indicated Resident 97 was readmitted in early 2025 with diagnoses which included pneumonia (an infection/inflammation in the lungs) and respiratory failure (lungs cannot properly exchange gases causing abnormal levels of carbon dioxide and/or oxygen). During a review of Resident 97's OSR, dated 3/29/25, the OSR indicated, O2 [oxygen] 5 L/min [liters per minute] via T [trach]-mist continuous at night as needed. During an concurrent observation and interview on 4/15/25 at 9:35 a.m. in Resident 97's room, Resident 97 sat in bed, awake and verbally responsive, with a trach collar (a soft adjustable neck device that secures a tracheostomy tube in place) connected to an oxygen tubing with no label or date. Resident 97 put her passy muir valve (speaking valve, allows one with a tracheostomy to potentially voice and produce speech sounds) to the trach, and stated, This [oxygen] tubing, they change this tube every two weeks. I don't know when they changed it. They don't put a label…

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 kitchen equipment in safe operating condition when: 1. Frozen brownish residue on the bottom shelf of Freezer 1 was present; 2. Boilerless Steamer was found leaking clear liquid onto the floor pooling at the base of a metal panel; and, 3. Two ovens with brownish black residue, and all four stove burners were observed with food and black burnt residue. These failures had the potential for mold growth and food contamination of resident food stored in the freezer and prepared in the steamer, oven, and stovetop. Findings: During a concurrent observation and interview on 4/15/25 at 8:40 a.m. in the kitchen with Dietary Manager (DM), brownish tinted frozen residue on the bottom shelf of freezer was observed. DM confirmed presence of frozen residue on shelf. The DM stated, expectation is that there should not be any residue or crumbs on shelf of freezer. During a concurrent observation and interview on 4/15/25 at 9:20 a.m. in the kitchen with Registered Dietician (RD), observed two ovens with brownish black…

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 communication boards were available at the bedside for three of 33 sampled residents (Resident 19, Resident 24 and Resident 58) who did not speak English. This failure had the potential to result in reduced ability for the residents to express their needs, preferences, and choices, placing them at risk for unmet care needs and taking away their right to participate in decisions about their care. Findings: During a review of Resident 19's admission Record (AR), the AR indicated, Resident 19 was admitted on [DATE] with diagnoses which included chronic kidney disease stage 3B (kidneys are not filtering blood as well, moderate to severe kidney damage), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete paralysis and weakness following a stroke). The AR also indicated Resident 19's primary language was Russian. During a review of Resident 19's Care Plans (CP), the CP indicated, 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 maintain a homelike environment when: 1. Shower room [ROOM NUMBER] was found to have a dark brown substance on the floor; and, 2. Four out of 11 rooms (C15, C17, C18 and C21) in the memory care unit had curtains by the sliding doors that were worn and had visible brown discolorations on them. These failures reduced the facility's potenital to provide residents with a homelike environment and had the potential to negatively impact the resident's quality of life. Findings: 1. During a review of Resident 69's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 69 was admitted to the facility in early June 2023 with multiple diagnoses of myopathy (disease that affects the muscles that control voluntary movement in the body) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 69's Minimum Data Set (MDS- 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 ensure pressure injury prevention consistent with the professional standards of practice for one of 33 sampled residents (Resident 106), when regular and timely turning and repositioning was not implemented. This failure had the potential risk to result in skin breakdown and Resident 106 not attaining his highest practicable physical and psychosocial well-being. Findings: During a review of Resident 106's admission Record (AR, a page of resident's medical chart containing admission information, diagnoses, etcetera) was admitted to the facility in early 2024 with diagnoses which included hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) of skin and subcutaneous (innermost layer of skin) tissue following surgery, chronic kidney disease, muscle weakness and limitation of activities due to disability. During a review of Resident 106's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/21/25, the MDS indicated Resident 106 had no memory…

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 33 sampled residents (Resident 58) significant weight loss was addressed and monitored. This failure resulted in further weight loss for Resident 58. Findings: During a review of Resident 58's admission Record (AR), AR indicated, Resident 58 was admitted on [DATE] with diagnoses which included metabolic encephalopathy (a change in how the brain works due to an underlying condition), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), hypothyroidism (the thyroid gland, an organ doesn't produce enough thyroid hormones which can disrupt all types of metabolism), hyperosmolality (blood has a high concentration of salt) and hypernatremia (blood has an abnormally high concentration of sodium) and dysphagia oral phase (problems using mouth, lips and tongue to control food or liquid). During a review of Resident 58's Nutritional Risk Assessment…

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 2. During a review of Resident 6's AR, the AR indicated, Resident 6 was admitted on [DATE] with diagnoses which included other intervertebral disc degeneration (natural breakdown of discs between the bones of the spine), chronic pain syndrome, rheumatoid arthritis with rheumatoid factor of multiple sites (immune system is attacking the joints causing pain, swelling and stiffness), unilateral primary osteoarthritis (joint pain and degeneration affecting only one side of the body), varicose veins of bilateral lower extremities with pain (swollen, twisted veins in the legs that can cause discomfort like aching, throbbing or burning). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had no memory impairment. During an observation and interview on 4/15/25 at 9:35 a.m. in the hallway, Resident 6 appeared to be in distress, moaning and grimacing while saying 'dolor' (pain). At 9:49 a.m. Certified Nursing Assistant (CNA) 5 went in the room and stated that Resident 6 was talking about pain…

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

Based on observation, interview, and record review the facility failed to adequately maintain pharmacy services for 11 residents out of a census of 104 when: 1.The facility did not have a complete controlled drug (medication that may be abused or cause addiction) destruction record log, and; 2.The facility did not reconcile the controlled drug records when the original controlled drug sheets went missing for medication cart A2. These failures had the potential to cause inaccurate accountability of controlled medications and the potential to result in residents' controlled meedication diversion. Findings: 1.During a concurrent observation and record review of the controlled medication storage on 4/16/25 at 9 a.m. in the Director of Nursing's (DON) office, a review of 11 random residents' controlled drug records, indicated no documented evidence a destruction log was recorded when receiving discontinued controlled medications from the nurses. During an interview on 4/16/25 at 9:15 a.m. with the DON, the DON verified the 11 controlled medications did not have a destruction log 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 for a census of 104 to ensure : 1.Observed in the medication room [ROOM NUMBER]: -Treatment supplies had expiration dates. - Expired Tube feeding formulas were removed. 2. Observed in the medication carts A1 and A2: -Narcotic cabinet is used only for narcotics in accordance with facility policy and procedure, -Expired and discharged resident medications were disposed accordingly -Medications and over the counter products were appropriately labeled with open and discard dates. 3. Narcotic count sheets are signed by both incoming and off going shift's licensed nurses in accordance with facility policy and procedure. These failures decreased the facility's potential to provide an updated treatment and nutrition supplies, and prevent medication administration errors. Findings: 1. During a concurrent observation and interview on 4/17/25 at 8:20 a.m. with Director of Nursing (DON) in Medication room [ROOM NUMBER], the following expired tube feeding…

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 administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) as prescribed for one of three sampled residents (Resident 3). This failure had the potential for ineffective drug therapy. Findings: A review of Resident 3 ' s admission record indicated she was admitted to the facility 2/26/25 with diagnoses that included diabetes (blood sugar is too high) and orthopedic aftercare following surgical amputation. During a review of Resident 3's admission Minimum Data Set (MDS-a federally mandated assessment tool), dated 3/4/25, described Resident 1 as having clear speech, able to understand others, able to make herself understood and as having a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (score of 13-15 indicated cognitively intact). During a review of Resident 3 ' s Order Summary Report for March 2025 contained a physician ' s…

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

Based on observation, interview, and record review the facility failed to ensure sanitary practices in the kitchen were established for residents in the facility for a total census of 106 when: 1. Freezer temperatures were not maintained in acceptable food range; 2. Unsafe infection control practices were observed in the kitchen. These failures had the potential to lead to food borne illness. Findings: 1. During a concurrent observation and interview on 2/19/25 at 9:49 a.m. with the Registered Dietician (RD), the freezer temperature for the freezer at the entrance of the kitchen was observed at 10 degrees Fahrenheit, the RD confirmed the observed temperature. During a concurrent observation and interview on 2/19/25 at 9:56 a.m. with RD the freezer next to the dishwashing area was observed at 38 degrees Fahrenheit and the freezer temperature log indicated a temperature of 20 degrees Fahrenheit on 2/18/25. The RD confirmed the freezer temperature was out of range and stated should have notified environmental services immediately so it could be resolved timely. During a concurrent…

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 availability of routine medications for one (Resident 1) of four sampled residents, when Resident 1 ' s medication was not in stock for administration. This failure had the potential for not meeting Resident 1 ' s therapeutic needs or for worsening of the resident's medical conditions. Findings: Resident 1 was admitted to the facility in November of 2024 with diagnoses that included anemia (disorder of blood cells ' oxygen carrying capacity), depression, and diabetes. A review of Resident 1 ' s Order Details, dated 11/23/24, indicated, Vitamin D3 Oral Tablet 25 MCG (1000 UT [International Units, a unit of measurement for certain medications]) (Cholecalciferol [Vitamin D3]). Give 1 tablet by mouth one time a day for Supplement. During an interview on 1/22/25 at 12:14 p.m. with Licensed Nurse (LN) 1, LN 1 indicated that the facility did not have Vitamin D3 tablets in dosage of 1000 IU. LN 1 further indicated that, due to the lack of Vitamin D3 1000 IU, she was forced to cut unscored (a lack of a line…

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 store and prepare food in accordance with professional standards of food safety for a census of 102, when two packages of frozen salmon filets and two packages of frozen cod filets were not thawed according to food safety standards, and nine opened bottles of dry spices, one opened bottle of beef base, and one bag of opened pink lemonade powder were unlabeled. These failures had the potential to cause foodborne illnesses for residents eating facility prepared meals. Findings: During a concurrent observation and interview on 1/22/25 at 10:15 a.m., in the kitchen with the Dietary Supervisor (DS), the DS confirmed four packages of frozen fish filets to be used for dinner were thawing on a kitchen table countertop. The DS also confirmed nine opened bottles of dry spices, one opened bottle of beef base, and one bag of opened pink lemonade powder were unlabeled. During an interview on 1/22/25 at 11:58 a.m., with the Registered Dietitian (RD), the RD indicated food labeling was important, so kitchen staff knew when…

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 equipment in safe operating condition for a census of 102, when a kitchen freezer was found with ice build-up on its ceiling and a broken seal gasket (rubber lining around freezer doors to keep outside air out and maintain a consistent temperature). This failure had the potential of leading to food borne illness for the residents eating facility prepared meals. Findings: During a concurrent observation and interview on 1/22/25 at 10:31 a.m., with the Dietary Supervisor (DS), the DS confirmed the freezer nearest the dishwashing area had a broken gasket seal and had ice buildup on its ceiling near its doors. Furthermore, the DS confirmed that five bags of hash browns were not frozen solid, and one bag of vegetables had freezer burn. The DS indicated the freezer having a poor seal can affect the quality of food. A review of the facility's document titled, DIETARY SERVICES – KITCHEN SANITATION / FOOD STORAGE, undated, indicated for kitchen staff to inspect, Freezer & motor clean; seals tight; no ice build…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of eight sampled residents (Resident 5) when facility staff witnessed Resident 4 punch Resident 5. This failure resulted in Resident 5 not being free from abuse and had the potential for Resident 5 to feel afraid and scared. Findings: Resident 5 was originally admitted to the facility in 2016 with multiple diagnoses which included dementia (impaired ability to remember, think, or make decisions), major depressive disorder (health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (mental health condition that causes extreme mood swings) and undifferentiated schizophrenia (symptoms may include signs of psychosis, such as delusions and hallucinations, or drastic changes in behavior, speech, or mobility). A review of Minimum Data Set (MDS, an assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide monitoring and supervision for one of eight sampled residents (Resident 5) when Resident 5, who has a history of disruptive behavior, was hit by Resident 4 while out in the courtyard unsupervised. This failure resulted in Resident 5 getting punched and had the potential for harm to other residents. Findings: Resident 5 was originally admitted to the facility in 2016 with multiple diagnoses which included dementia (impaired ability to remember, think, or make decisions), major depressive disorder (health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (mental health condition that causes extreme mood swings) and undifferentiated schizophrenia (symptoms may include signs of psychosis, such as delusions and hallucinations, or drastic changes in behavior, speech, or mobility). A review of Minimum Data Set (MDS, an assessment 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 protect resident information when meal tickets (containing resident information) were discarded into the garbage and subsequently into the outside dumpster. This failure had the potential of compromising resident information for 103 residents receiving facility provided meals for a census of 109. Findings: During a visit to the kitchen on 5/22/24 at 10:33 a.m., Dietary Aide 1 (DA 1) was taking breakfast meal trays off the carts to wash. As DA 1 grabbed the trays, she separated out like items for wash, and threw leftover food, napkins, and meal tickets into the garbage. When asked, she stated that this was the usual process for setting up for dish washing. Tray tickets noted to include resident name, room number, diet order, food allergies, food preferences, and special dietary needs. Subsequent interview with Dietary Manager (DM) on 5/22/24 at 10:38 a.m., DM stated throwing tray tickets into the trash was a problem since trash is brought to the outside dumpsters which is open to the public. As such, this would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two residents (Resident 80 and Resident 93) of 30 sampled residents had adequate indications for the use of psychotropic medications (drug prescribed to affect the mind, emotions, or behavior) when: 1. Resident 80 was administered olanzapine (a psychotropic medication indicated for psychosis); and, 2. Resident 93 was administered aripiprazole (a psychotropic medication indicated for psychosis). This failure decreased the facility's potential to prevent residents from experiencing adverse effects such as sedation, falls and abnormal involuntary movements from the use of antipsychotic medication. Findings: 1. A review of Resident 80's admission record indicated admission to the facility in February 2023 with diagnoses which included hemiplegia (paralysis that affects one side of your body) and hemiparesis (muscle weakness that affects one side of your body) following a cerebral infarction (blockage of blood flow in the brain causing brain damage…

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 medication error rate did not exceed 5% (five percent) for one resident (Resident 712) of 30 sampled residents when Licensed Nurse 3 (LN 3) administered Resident 712's medications not in accordance with standard nursing principles and practices or the facility policy. This failure resulted in a medication error rate of 30.3%. Findings: During an observation on 5/21/24 at 8:08 a.m. of a medication administration through a gastrotomy tube (GT, also known as a Peg-tube, a placed into a patient's stomach through the abdominal wall), the LN 3 was observed crushing six pills together and at the same time. The LN 3 immediately placed the crushed pills in a 110 milliliter (ml, a unit of measure) medication cup with two liquid medications and two powdered medications. The mixture of the crushed pills, powdered medication and liquid medication were administered at the same time in a bolus (medical administration given all at one) administration with a 60 ml syringe, in two parts through the GT. The LN 3 did…

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 medications were stored in a clean and sanitary environment and labeled correctly with open and discard dates, when: 1. A loose pill was found in medication cart 2; 2. A medication cup was found stored in the top drawer of medication cart 2, containing 11 loose pills and was not labeled with resident's name or drug identifiers; 3. An opened inhaler and eye drops were not dated with open or discard dates in medication cart 2; and, 4. A medication blister pack found displaced and in the back of medication cart 1. These failures decreased the facility's potential to prevent drug diversion and medication administration errors. Findings: 1. During an inspection of medication cart two on 5/22/24 at 9:55 a.m. with Licensed Nurse 1 (LN 1), the LN 1 verified there was a loose pill in the medication cart. During an interview with the Assistant Director of Nursing (ADON) on 5/24/24 at 11:30 a.m., the ADON acknowledged having loose pills in the medication cart was an issue. The ADON stated, NOC [night] shift…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety when: 1. There were no functional thermometers for dry storage room monitoring and for internal temperature monitoring for freezer #1; 2. There were incomplete records of daily temperature logs for refrigerators, freezers, and dry storage area; 3. Food items were not properly labeled or sealed and expired foods were not discarded; 4. The racks in refrigerator #2 and refrigerator #3 had rust on the surface and were unable to be readily sanitized; 5. The facility did not install or maintain a drain air gap in the sink used to prepare fruits and vegetables; 6. The facility did not maintain a clean can opener; 7. The facility did not ensure the exterior surface of the dishwasher and drawers containing kitchen utensils were clean; 8. The kitchen surfaces were stained, had chipped paint, and missing floor tiles; 9. Kitchen staff did not perform hand hygiene when moving from dirty to clean surfaces;…

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 obtain informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) on the use of psychotropic medication (drugs that affect a person's mental state) from the resident's Responsible Party (RP, a person designated to make decisions for the resident who is unable to make decisions for himself) for one resident (Resident 73) of 30 sampled residents. This failure decreased the facility's potential to ensure residents and RPs were aware of the risks, benefits, and alternatives of treatment offered to them. Findings: A review of Resident 73's admission record indicated admission to the facility April 2022 with diagnoses which included hemiplegia (complete paralysis of one side of the body) and hemiparesis (partial paralysis of one side of the body) affecting the right side, dementia (the impaired ability to remember, think, or make decisions) with psychotic disturbance, anxiety disorder (a feeling of fear, dread, 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.

Based on observations, interviews and record reviews the facility failed to develop and implement person-centered comprehensive care plans for three residents (Residents 30, 53, and 73) out of 30 sampled residents. This failure decreased the facility's potential to provide appropriate interventions in order for residents to maintain their highest medical and physical practicable level of function. Findings: A review of Resident 30's admission record indicated the resident was admitted to the facility in June 2023 with diagnoses including adult failure to thrive and generalized weakness. A review of Resident 30's Order Summary Report (OSR, physician orders) indicated an order for oxygen at 2 L (liter, a unit of measurement) per minute through a nasal cannula with a start date of 8/4/23. During an observation on 5/21/24 at 8:54 a.m., in Resident 30's room, Resident 30 was observed laying supine (on their back) in bed wearing a nasal cannula (a plastic tube used to deliver oxygen into your nose) connected to an oxygen concentrator (a medical device that provides oxygen) with oxygen…

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 care plans for two residents (Resident 38 and 82) out of 30 sampled residents when the care plans were not revised within a timely manner. This failure decreased the facility's potential to provide appropriate interventions for the residents to maintain their highest medical and physical practicable level of function. Findings: A review of Resident 38's admission record indicated admission to the facility in August 2017 with diagnoses which included dysphagia (inability or refusal to swallow) and the presence of a gastrostomy tube (G-tube, an opening into the stomach for nutritional support). A review of Resident 38's Order Summary Report (OSR, physician orders) indicated Resident 38's tube feeding order started on 12/24/19. A review of Resident 38's nutritional care plan, revised on 2/15/24, indicated Resident 38 was to receive Jevity (R), therapeutic nutrition, 1.2 at 75 ml (milliliters, a unit of measurement) per hour. During on observation on 5/21/24 at 9:53 a.m. in Resident 38's room, Resident 38…

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 nursing care was provided per professional standards of quality for one resident (Resident 73) of 30 sampled residents when Licensed Nurses (LNs): 1. Did not ensure informed consent was obtained from Resident 73's Responsible Party (RP, a person who has legal authority to make health care decisions for a person who is unable to for himself) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior); 2. Did not obtain a physician's order to flush Resident 73's midline catheter (a thin, flexible tube inserted into the larger veins in the upper arm used to administer intravenous medication); and, 3. Did not follow the prescribed physician's order for oxygen administered to Resident 73. These failures decreased the facility's potential to provide responsible and accurate nursing care to Resident 73. Findings: 1. A review of Resident 73's admission record indicated admission to the facility in April 2022 with diagnoses which included hemiplegia (complete…

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 pharmacy services were maintained for a census of 109 residents, when a medication was improperly disposed of in an opened, regular trash can on the side of the medication cart. This failure decreased the facility's potential to prevent: unauthorized staff, residents, and visitors access to prescription drugs, the potential for drug diversion, and medical adverse consequences. Findings: During an inspection of medication cart two on [DATE] at 9:55 a.m., with Licensed Nurse (LN 1), the LN 1 verified there was a loose pill in the medication cart. The LN 1 was observed disposing of the loose pill in an opened, regular trash can on the side of the medication cart. The LN 1 stated, That is the trash can I use for non-narcotic [a class of medications that are not addictive] medications that need to be thrown away. When asked about the risks of throwing medications away in an open trash can, the LN 1 acknowledged throwing the pill 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 ensure pureed (cooked food blended to the consistency of a cream paste) foods were prepared in a manner that conserved nutritive value and palatability (taste) when foods were thinned with an unmeasured amount of tap water or liquid from the can containing the food. This failure decreased the facility's potential to ensure food met resident nutritional needs and was flavorful. Findings: During an observation and concurrent interview on 5/22/24 at 9:08 a.m., [NAME] 1 (CK 1) was preparing pureed roast beef. The CK 1 opened a bag of precooked roast beef and drained off the liquid. The CK 1 placed meat in blender and added an unmeasured amount of hot tap water. The CK 1 blended the roast beef and water until the mixture was a smooth, pureed texture. The CK 1 proceeded to blend a second batch of roast beef which was too watery and needed to be corrected to thicken the product. The CK 1 next made mashed sweet potatoes by placing canned sweet potatoes and an unmeasured amount of liquid from the can into the blender.…

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

Based on observation, and interview, the facility failed to maintain two reach-in freezers (freezer #1 and #3) and two reach-in refrigerators (refrigerator #2 and #3) in safe operating condition when door seals were observed with tears or gaps and did not provide a complete seal. This decreased the facility's potential to ensure food safety and quality for 103 residents who ate facility prepared meals with a census of 109. Findings: During the initial kitchen tour on 5/21/24 at 8:48 a.m. with the Dietary Manager (DM) reach-in refrigerator and freezer doors were checked for complete seals. The seal on freezer #1 had two gaps in two opposite corners about one inch wide. The freezer #3 had two gaps in the bottom corners of the door: one gap at the door hinge side about one inch wide, and on the opposite corner gap under one inch wide. The refrigerator #2 had two smaller gaps at the bottom (under one inch) and a black tape covering majority of the bottom seal. The refrigerator #3 had torn seal on the unhinged part of the door with about 2-3 inches of seal material hanging down. The DM…

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

Based on interview and record review, the facility failed to ensure rehabilitative services were adequately provided for three of three sampled residents (Resident 1, Resident 2 and Resident 3) when occupational therapy (OT) was not performed according to their plans of care. This failure had the potential to result in the residents failing to attain their highest practicable level of physical and functional well-being. Findings: A review of Resident 1's admission record indicated he was admitted in 1/24 with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis) following unspecified cerebrovascular disease (a term used for conditions that affect blood flow to the brain) affecting his right dominant side. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) indicated the resident had no cognitive impairment. A review of Resident 1's clinical record included the following documents: An Order Summary Report, dated 2/26/24 indicated the following physician's (MD) orders for OT: 1. An order, dated 1/9/24, for services five times a week 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, record review and facility document review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) was free from abuse when Resident 1 slapped and punched Resident 2 in the face and nose. This failure resulted in Resident 2 sustaining a swollen and reddened nose and a lump on the right temple. Findings: Resident 1 was admitted to the facility over 9 years ago and diagnoses included Parkinson's disease (disorder that affects someone's movement) and neurocognitive disorder (decreased mental function due to a medical disease), bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), and schizophrenia (mental illness that affects how a person thinks, feels and behaves). During a review of Resident 1's Quarterly MDS (Minimum Data Set-an assessment tool), dated 10/19/23, described Resident 1 as able to make himself understood and as having the ability to understand others. The MDS described Resident 1 as having a BIMS (a brief screening that aids in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when she was struck in the face by Resident 2. This failure resulted in Resident 1 sustaining a small, reddened area to her forehead and a bloody nose. Findings: A review of Resident 1's admission record indicated she was last admitted in 8/21 with diagnoses including anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). An MDS (Minimum Data Set, an assessment tool), dated 11/15/23, indicated Resident 1 had moderate cognitive impairment and unclear speech. A review of Resident 1's clinical record included the following documents: An SBAR (Situation, Background, Assessment and Recommendation)…

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 abuse policy for two of five sampled residents (Resident 1 and Resident 2) when the results of the investigation of an alleged abuse incident between the residents were not reported to the Department within 5 working days of the incident. This failure could have potentially caused a delay in the investigation of the alleged event. Findings: In an interview, on 12/11/23 at 9:09 a.m., the Administrator (ADM) confirmed the facility had reported an allegation of abuse concerning Resident 1 and Resident 2 to the Department on 11/20/23 and the results of the facility's investigation had not been provided to the Department within 5 working days. A review of the facility's policy titled, Abuse Prevention, Intervention, Investigation & Crime Reporting Policy, revised 2016, indicated the facility would report the results of an alleged abuse allegation to the State Survey Agency within 5 working days of the incident.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received care which met professional standards when she was involved in a resident-to-resident altercation, sustained a bloody nose and it was not documented in the nursing assessment. This failure resulted in inaccurate assessment documentation and had the potential to result in unmet nursing needs for Resident 1. Findings: A review of Resident 1's admission record indicated she was last admitted in 8/21 with diagnoses including anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). An MDS (Minimum Data Set, an assessment tool), dated 11/15/23, indicated Resident 1 had moderate cognitive impairment and unclear speech. A review of Resident 1's clinical record included the following…

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 three sampled residents (Resident 1) was free from abuse, when Resident 2 punched Resident 1 in the face and pulled her hair. This failure resulted in injury to Resident 1. Findings: Resident 1 was admitted to the facility in late 1999 with diagnoses which included chronic kidney disease (loss of kidney function), and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Minimum Data Set (MDS, an assessment tool) dated 7/21/23, indicated Resident 1's memory was intact. Resident 2 was admitted to the facility in mid-2021 with diagnoses which included anxiety disorder (intense, excessive, and persistent worry), bipolar disorder (mood swings and or emotional ups and downs), and psychosis (difficulty determining what is real and what is not). A review of Resident 2's most recent MDS, dated [DATE], indicated Resident 2's memory was severely impaired. During an interview on 10/9/23, at 12:45 p.m.,…

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

Based on interview and record review, the facility failed to ensure the health, safety and security of one of three residents (Resident 1) when the facility failed to report an alleged resident to resident altercation involving Resident 2. This failure had the potential to endanger the health and well-being of all 101 residents in the facility. Findings: Resident 2 was admitted to the facility in mid-2021 with diagnoses which included anxiety disorder (worry, difficulty thinking), bipolar disorder (mood swings and or emotional ups and downs), and psychosis (difficulty determining what is real and what is not). During a review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 8/30/23, the MDS indicated the BIMS (Brief Interview for Mental Status, an assessment tool), reflected a severe knowledge and memory impairment. During an interview on 10/9/23 at 1:15 p.m., with License Vocational Nurse 1 (LVN 1), LVN 1 stated, .[Resident 2] was put on 1:1 as an intervention. She [Resident 2] has behaviors such as .She [Resident 2] had an encounter about a month ago with another…

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 only authorized personnel had access to medications and biologicals (type of medical therapy derived from living organisms) for a census of 105 when: 1. An unlocked medication cart was left unattended in the hallway of the facility; 2. Loose pills were found at the bottom of drawers of a medication cart and a container of unpackaged medications were in the bottom drawer of the medication cart; and, 3. A container of medications awaiting destruction was stored in an unlocked room. This failure had the potential to place the facility at risk for drug diversion and accidental use of controlled medications by residents. Findings: On [DATE] at 8:20 a.m., a medication cart (Cart A) was observed in the hallway of facility A-Hall. The cart was at the door of Room A1, the Licensed Nurse 1 (LN 1) could not be seen through the open door of the room. In a subsequent interview, the LN 1 confirmed the cart was unlocked and the drawers could be…

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

Based on interview and record review, the facility failed to ensure measures were taken for two residents (Resident 70 and Resident 36) for a census of 105, when: 1. Resident 70's recommended blood tests were not conducted; and, 2. Resident 36's medication regimen review (MRR) recommendations were not addressed by the physician. These failures increased the potential for Resident 70 and Resident 36's health to deteriorate. Findings: 1. A review of Resident 70's clinical record indicated he was admitted in early 2020 with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertensive chronic kidney disease stage 4, and hyperglycemia (a high sugar level in the blood). A review of Resident 70's MRR dated 2/17/22 indicated the pharmacist (PharmD) recommended blood tests to be conducted to monitor for preventable adverse effects of the medication olanzapine (an antipsychotic medication to treat psychosis). A review of Resident 70's clinical record between 2/17/22 and 5/25/22 showed no documented…

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

Based on observation, interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for a census of 105 when: 1. Unsealed medications had no written open date; and, 2. Expired medications were found in medication carts. These failures had the potential to result in ineffective and expired medication to be administered to the residents. Findings: During an observation on 5/24/22 at 9:56 a.m., the following items were found in Cart A (medication cart for A-Hall) without open dates indicated on them: -one bottle of ciprofloxacin eye drops (used to treat eye infection) 5ML (milliliters, unit of measure for volume of fluids) labeled with, use for 7 days; -one inhaler of atrovent HFA (used to control and prevent wheezing and shortness of breath) 12.9 grams (unit of measure for weight); and, -one inhaler of albuterol sulfate (used to control symptoms of asthma) 6.7 grams. In an concurrent observation on the following medications were found expired: -two bottles of timolol 5ML (used to treat high pressure inside the eye) with a discard date 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 that the nutritive value of pureed food was maintained when excess water and thickener were used in the preparation. This failure had the potential of leading to malnutrition and/or weight loss for eight (out of 105 residents) receiving pureed meals. Findings: On 5/24/22 at 10:42 am [NAME] 1 (Ck 1) began to make pureed turkey for the lunch meal. She took an unmeasured amount of turkey (filling about 1/2 of the blender) and added an unmeasured amount of water before turning on the blender. She stopped blending to add more turkey and proceeded to blend. She then poured the mixture into a small steamtable pan. When asked about the texture, she stated it was too liquid, and added an unmeasured amount of thickener. Cov Care-Courtyard Health Care Center Roast turkey pureed recipe, Amount of thickener required may vary relative to liquid content of cooked product .alternate processing and thickener checking consistency periodically. During a visit to kitchen on 5/25/22 at 9:33 a.m. Ck 1 was preparing a Beef…

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 assure food safety when 1) unpasteurized eggs (eggs are gently heated in their shells, just enough to kill the bacteria but not enough to actually cook the egg, making them safe to use in any recipe that calls for uncooked or partially cooked eggs) were used in the preparation of meals, 2) food in the refrigerator was found undated and/or unlabeled, 3) expired foods were found in the refrigerator, and 4) resident refrigerator/freezer was dirty. These failures had the potential of leading to food born illness for the 103 residents (out of 105) eating at the facility. Findings: 1) During the initial kitchen tour on 5/24/22 at 8:12 a.m. with the Certified Dietary Manager (CDM), the first reach-in refrigerator had 1 and 1/2 half boxes of eggs that were not pasteurized, and no other eggs were found. In a subsequent interview with [NAME] 1 (Ck 1), she stated that she does make eggs per resident request such as sunny side up or soft-cooked.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper infection prevention and control practices were performed for a census of 105, when: 1. Housekeeping Staff (HS) incorrectly cleaned and disinfected residents' rooms; and, 2. There was no trash bin available inside the yellow isolation room to discard doffed (removed) Personal Protective Equipment (PPE). These failures decreased the facility's potential to prevent the spread of infection. 1. During a concurrent observation and interview on 5/27/22, at 9:15 a.m., Housekeeping Staff (HS) 1 cleaned and disinfected Room A14. The HS 1 cleaned and disinfected the room, cleaned and disinfected the bathroom, then returned to clean and disinfect the bedroom. The HS 1 stated, I clean and disinfect the bedroom first, then the bathroom, then back to the bedroom. During an interview on 5/27/22 at 9:17 a.m., the Housekeeping Director (HD) acknowledged the proper room cleaning and disinfecting process should have been clean-to-dirty, bedroom…

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

Based on interview and record review, the facility failed to ensure a care plan was created for one resident (Resident 103) of three sampled residents when Resident 103 had a change of condition. This failure decreased the facility's potential to provide Resident 103 person-centered care. Findings: A review of an admission record indicated Resident 103 was admitted to the facility in March 2021 with diagnoses which included cerebral infarction (a disruption of blood flow to the brain). A review of a physician's order, dated 2/16/22 at 8:40 p.m., indicated, .Hospice Diagnosis: Heart Failure .Patient is being followed by [hospice services] .Do not transfer to hospital, no labs or weight .vital signs as needed to assess pain/ respiratory distress . A review of care plans showed no documented evidence a care plan regarding Resident 103's change to hospice care. In an interview on 5/26/22 at 2:30 p.m., the Director of Nursing (DON) stated it was facility policy to review and update the care plan of residents upon returning from acute care hospital based on diagnoses and health 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.

Based on observation, interview, and record review, the facility licensed nurses failed to disconnect and flush Resident 46's feeding tube for a census of 105. This failure increased the potential for Resident 46's feeding tube to become obstructed. Findings: A review of an admission record indicated Resident 46 was admitted in August 2017 with diagnoses which included dysphagia (difficulty swallowing), unspecified feeding difficulties, and gastrostomy- tube (G-tube, a tube placed into the stomach used to deliver nutrients). In an observation on 5/25/22 at 10:59 a.m., Resident 46 was in bed with her G-tube connected to a feeding pump at bedside. The feeding pump and tubing was filled with nutritional formula and was turned off. In an interview on 5/25/22 at 11:01 a.m., the Licensed Nurse 8 (LN 8) stated the physician ordered Resident 46's formula to run over 20 hours and then the feeding was to be turned off and disconnected from the resident by 10 a.m. The LN 8 stated Resident 46 should be disconnected from the feeding pump and her G-tube should be flushed with water to keep 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 ensure one resident (Resident 5) of 21 sampled residents took a medication when the medication was left on the bedside table by the a licensed nurse. This failure decreased the facility's potential to ensure medications were safely administered. Findings: A review of Resident 5's clinical record indicated she was admitted in late 2014 with diagnoses which included hypokalemia (lower than normal potassium level in the bloodstream). A review of a Minimum Data Set (MDS, an assessment tool), dated 3/16/22, indicated Resident 5 had no memory problems. A review of a physician's order, dated 11/11/16, indicated Resident 5 does not have the capacity to make healthcare decisions. A review of a physician's order, dated 10/12/21, indicated, Potassium Chloride liquid, give 30 milliliter [unit of measurement] by mouth two times a day for supplement. During an observation and concurrent interview on 5/27/22 at 8:58 a.m., Resident 5 was in bed and a medicine cup was on top of the overbed table. The medicine cup was full…

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.