Royal Terrace Healthcare

Based on observation, interview and record review, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis (working 40 or more hours a week) from 12/9/2025 to 12/23/2025 for 52 of 52 residents (census) in the facility.This deficient practice had the potential to impact the quality of care and outcomes that all residents experience in the facility.Findings: During an observation on 12/22/2025 from 8:05 AM to 5 PM and on 12/23/2025 from 8:02 am to 5 pm, there was no designated RN who served as the DON on a full-time basis in the facility. There were 52 residents in the facility on 12/22/2025 and on 12/23/2025. During a phone interview on 12/23/2025 at 9:08 AM with the former DON (FDON), the FDON stated FDON quit the facility in the first week of December 2025. The FDON could not recall the exact date of when the FDON quit the facility. During an interview on 12/23/2025 at 3:48 PM with the Administrator, the Administrator stated that the facility had not designated a specific RN to serve as a full-time DON for the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards possible and residents received adequate supervision for two of three sampled residents (Residents 2 and 3) when:a. Resident 2's bed sensor pad alarm (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed) did not sound when Resident 2 got up from Resident 2's bed unassisted by staff and walked to the bathroom.b. The facility's licensed nursing staff (in general) failed to conduct a fall risk assessment (an evaluation to determine a resident's likelihood of falling) or inaccurately assessed Resident 3 as low risk for fall following Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025. c. The facility's Interdisciplinary Team (IDT, a group of health care professionals who work together toward the goals of the resident) failed to conduct a comprehensive root cause analysis (systematic process to identify the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents right to be free from sexual abuse for one of three sample residents (Resident 2). This deficient practice resulted in Resident 2 being subjected to indecent exposure when Resident 1 masturbated in the room in front of Resident 2, and Resident 2 was afraid to go to sleep because Resident 2 feared for his safety.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 dementia in other diseases classified elsewhere, severe with psychotic disturbance (refers to the advanced stage of the dementia, where cognitive impairment significantly interferes with daily functioning), unspecified psychosis not due to a substance or known physiological condition (a condition where a person experiences delusions (false beliefs), hallucinations (seeing or hearing things that are not real), disorganized thinking and speech, and changes 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 Cross Reference F600Based on interview and record review, the facility failed to ensure residents the right to be free from sexual abuse for one of three sample residents (Resident 2). Based on interview and record review, the facility failed to provide supervision of Resident 1, when he inappropriately exposed himself and masturbated in the presence of Resident 2, after the facility had knowledge of another incident that had occurred where Resident 1 exposed himself masturbating to other residents in the hallway. This deficient practice had the potential to result in Resident 1's behavior to cause psychosocial harm to Resident 2 and other residents if the facility staff did not monitor Resident 1's whereabouts.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 dementia in other diseases classified elsewhere, severe with psychotic disturbance (refers to the advanced stage of the dementia, where 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 initiate a care plan for one of three sampled residents (Resident 1) which addressed Resident 1's behavior of inappropriately exposing himself and masturbating in the presence of Resident 2 and other residents in the hallway. 1. This deficient practice had the potential to result in psychosocial harm to Resident 2 and other residents in the facility. 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 dementia in other diseases classified elsewhere, severe with psychotic disturbance (refers to the advanced stage of the dementia, where cognitive impairment significantly interferes with daily functioning), unspecified psychosis not due to a substance or known physiological condition (a condition where a person experiences delusions (false beliefs), hallucinations (seeing or hearing things that are not real), disorganized thinking and speech, and changes 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.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), received interventions for the risk of elopement (a resident leaves the premises or a safe area without the facility's knowledge) when Resident 1 expressed to RN 1 that Resident 1 wanted to leave the facility. This failure resulted in Resident 1 leaving the facility unsupervised on 9/7/2025 and had the potential for Resident 1 to be injured. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/21/2025 with diagnoses including cirrhosis of liver (chronic liver damage), chronic congestive heart failure (a condition in which the heart cannot pump enough blood to all parts of the body), and hepatic encephalopathy (brain disease that alters brain function or structure). During a review of Resident 1's History and Physical (H&P), dated 5/23/2025, the H&P indicated Resident 1 had the capacity to understand and make own medical decisions. During a review of Resident 1's Progress Notes (PN), dated 9/9/2025, The PN…

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

Based on interview and record review, the facility failed to provide necessary (needed) care and services to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Changes in Resident Condition, when:a. Registered Nurse (RN) 3 and LVN 1 did not notify Resident 1's physician regarding Resident 1's complaint of pain and not feeling well, and Resident 1's request to be transferred to a General Acute Care Hospital (GACH) on 7/20/2025 during the 3-11 shift (3 PM to 11:30 PM).b. Registered Nurse (RN) 3 and LVN 1 did not document Resident 1's complaint of pain and not feeling well, and Resident 1's request to be transferred to a GACH in Resident 1's medical record on 7/20/2025.c. RN 1 did not notify a physician regarding Resident 1's complaint of pain and Resident 1's and Resident 1's Representative's (RR 1 - someone authorized to make healthcare decisions on behalf of another person) request for Resident 1 to be transferred to a GACH on 7/21/2025 at 2 AM.d. RN 1 did not document in Resident 1's medical record regarding Resident 1'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 ensure Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) and AD Acknowledgement Forms were filled out completely and correctly and added to the resident's medical record for two of three sampled residents (Residents 3 and 93) in accordance to the facility's policy and procedure (P&P) titled Advance Directives. This deficient practice had the potential to cause confusion among the healthcare workers in the event Residents 3 and 93 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment. Findings: a. 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 type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone…

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 safe and sanitary food storage in one of one facility's kitchen by failing to: a. Ensure leftover food from outside the facility was not stored in the kitchen refrigerator. b. Label food items and supplies in the dry storage area with a date open receipt, opened and used/best by date. c. Discard expired food items in the dry storage area. These failures had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that would lead to foodborne illness (an illness caused by eating contaminated food). Findings: a. During a concurrent observation and interview on 5/27/2025 at 8:11 a.m. with the Lead [NAME] (LC) in the facility's kitchen refrigerator there were two (2) to-go boxes inside a white plastic bag with leftover beef, chicken, macaroni salad and rice in the refrigerator which were not labeled and dated. These were stored together with food for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide privacy for one of one sampled resident (Resident 30) when staff did not close the privacy curtain while checking Resident 30's Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site. This deficient practice violated Resident 30's right to bodily privacy and resulted in unnecessary exposure of Resident 30's abdominal area and lower extremities. This deficient practice had the potential to affect Resident 30's psychosocial (mental and emotional) well-being, self-esteem, and self-worth. Findings: During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dysphagia (difficulty swallowing). During a review of Resident 30's Physician Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when needed) was within reach and appropriate to the patient's physical ability for one of one sampled resident (Resident 29). This failure had the potential to result in a delay in meeting Resident 29's needs for assistance and could have led to a fall or accident. Findings: During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and contractures of both hips, both knees and the left elbow. During a review of Resident 29's History & Physical (H&P), dated 10/17/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 4/12/2025, the MDS indicated Resident 29 had intact cognition (ability to understand), 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 interview and record review, the facility failed to develop an individualized and comprehensive hospice plan of care for one of two sampled residents (Resident 95). This failure had the potential for Resident 95 to not receive the necessary care, treatment, and services. Findings: During a review of Resident 95's admission Record (AR), the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses that included cirrhosis (a condition in which the liver is scarred and permanently damaged), hepatic encephalopathy (loss of brain function when a damaged liver doesn't remove toxins from the blood) and congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 95's Order Summary Report (OSR), dated 5/22/2025, the OSR indicated Resident 95 was admitted to the facility on hospice. During a concurrent interview and record review on 5/28/2025 at 11:19 a.m. with the Social Services…

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 Low Air Loss (LAL) mattress (Alternating Pressure Mattress which provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure injury which is a localized damage to the skin and underlying soft tissue usually over a bony prominence and maybe caused by intense or prolonged pressure over the site) was set up accurately according to manufacturer's instruction for one of two sampled residents (Resident 6). This deficient practice had the potential to result in the risk of reoccurring of pressure injury for Resident 6. Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) of sacral (large, triangular bone at the base of the spine) region…

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 dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents had a dialysis emergency kit (E-kit, contains the main items needed in an emergency) at the bedside for one of three sampled residents (Resident 93). This failure had the potential to result in Resident 93 to not receive or to receive delayed care and emergency treatment from complications caused by unexpected bleeding from the hemodialysis access site. Findings: During a review of Resident 93's admission Record (AR), the AR indicated Resident 93 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (irreversible kidney failure), hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine) and dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer Dilaudid (a controlled pain medication) within ordered parameters for one of four sampled residents (Resident 193). This failure resulted in professional standards of practice not being followed and had the potential to ineffectively manage Resident 193's pain. Findings: During a review of Resident 193's admission Record (AR), the AR indicated Resident 193 was admitted to the facility on [DATE] with diagnoses that included multiple left-sided rib fractures and high blood pressure. During a review of Resident 193's History & Physical (H&P), dated 5/14/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 193's Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 193 had intact cognition (ability to understand). During a review of Resident 193's Order Summary Report, the report indicated Resident 193 had an active order 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 the medication refrigerator (MR) was maintained at a temperature between 36 degrees Fahrenheit (F, unit of measurement for temperature) to 46 degrees F for one of one sampled medication refrigerator. This failure had the potential to result in medications stored in the medication refrigerator to become unstable and ineffective. Findings: During a review of the Medication Refrigerator MR temperature recording log, dated 5/2025, the MR temperature recording log indicated, the MR had a temperature recorded at 48 degrees F on 5/23/2025 and 5/24/2025. During a concurrent observation and interview while inside the facility's medication room on 5/29/2025 at 11:22 a.m. with Licensed Vocational Nurse 3 (LVN 3), the MR's temperature was 34 degrees F. LVN 3 stated the MR's temperature should always be kept between 36 to 46 degrees F. LVN 3 stated not keeping the temperature of MR between 36 to 46 degrees F might reduce the medications efficacy and effectiveness. During an interview on 5/29/2025 at 12:50 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for two of three sampled residents (Resident 9 and 99): a. To perform a screening for Advance Directive (AD, a written instruction, recognized under State law relating to the provision of health care when the individual became incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) upon admission and to obtain a copy of AD to keep/maintain in Resident 99's medical record (MR). b. To ensure Resident 9's AD acknowledgement form was filled out completely. These failures had the potential for the facility staff to provide treatment against the resident's will. Findings: During a review of Resident 99's admission Record (AR), the AR indicated Resident 99 was admitted to the facility on [DATE], with diagnoses that included sepsis (a serious infection affecting the entire body) and dehydration (body does not have enough water and fluids to carry out its function). During a review of Resident 99's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care and services for peripherally inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava) line and peripheral intravenous (PIV, a short , flexible plastic tube that is inserted into a vein through the skin) line for three of three sampled residents (Residents 43, 46 and 200) by failing to : a. Ensure the PICC line port was covered with a cap and not left open and exposed to the air, when not in use in accordance with the facility's Policy and Procedure (P&P) on Guidelines for Preventing Intravenous Catheter-Related Infections. b. Label and date the PIV for Resident 200) in accordance with the facility's P&P titled Peripheral IV Dressing Changes. c. Label the PICC line dressing with date of insertion and/or change of dressing. These deficient practices 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 ensure residents receiving oxygen therapy (a treatment that provides with extra oxygen to breathe in) were provided necessary respiratory care and services for four of four sampled residents (Residents 25, 27, 151 and 199) in accordance with the facility's Policy and Procedure (P&P) on Respiratory Therapy - Prevention of Infection. These failures had the potential to result in respiratory complications and infection for Residents 25, 27, 151 and 199. Findings: a. During a review of Resident 151's admission Records (AR), the AR indicated Resident 151 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (muscle weakness on one side of the body), hemiparesis (a condition that causes weakness or inability to move on one side of the body) and pneumonitis (inflammation of the lungs). During a review of Resident 151's Order Summary Report (OSR), dated 6/7/2024, the OSR indicated Resident 151 had an order for oxygen 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 interview and record review the facility failed to develop and implement an individualized person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 19) who had a diagnoses of Cystitis (inflammation of the bladder) and on Bactrim ([sulfamethoxazole/trimethoprim] medication that treat infection) as indicated in the facility's policy and procedure, titled Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 19 to not receive necessary care, treatment and/or services. Findings: During a review of Resident 19's admission Record (AR), the AR indicated the facility admitted Resident 19 on 5/8/2023 with diagnoses that included chronic cystitis (inflammation of the bladder) without hematuria (blood in the urine) and overactive bladder (sudden urges to urinate that may be hard to control). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to perform a smoking assessment (an assessment that helps to determine how can help a patient who smokes) upon admission for one of two sampled residents (Resident 100). This failure had the potential to result in unsafe smoking behaviors causing harm to residents. Findings: During a review of Resident 100's admission Record (AR), the AR indicated Resident 100 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (sudden condition when the lungs cannot get enough oxygen into the blood) and hypertension (increased blood pressure). During an observation on 6/15/2024 at 3:48 pm, in the facility's designated smoking area, Resident 100 was observed smoking together with one of Resident 100's visitors. During a concurrent interview, Resident 100 stated Resident 100 was newly admitted to the facility and had a smoking history of more than 40 years. During a review of Resident 100's History and Physical (H&P)…

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 supervision to a resident who used a plate guard (a dining aid that can help people with limited hand control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of two sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1's decline in nutritional status and inability to maintain independence during mealtime. Findings: During a review of Resident 1's admission Records (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (muscle weakness on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (a condition that causes weakness or inability to move on one side of the body). During a review of Resident 1's Order Summary Report (OSR), dated 7/24/2015, the OSR indicated Resident 1 had an order for plate guard at mealtime. During a review of Resident 1's untitled…

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 Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was accurately documented for one of three sampled residents (Resident 25). This failure had the potential to result in miscommunication among health care providers, resulting in inconsistent care for the resident. Findings: During a review of Resident 25's admission Record (AR), the AR indicated Resident 25 was admitted to the facility on [DATE], with diagnoses that included hydrocephalus (abnormal buildup of cerebrospinal fluid [fluid found within the tissues surrounding the brain] in the ventricles [cavities] within the brain) and hypertension (increased blood pressure). During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 had unclear…

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 interviews and record review, the facility failed to accommodate the needs and preferences of one of four sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's call light (device used by a resident to signal his need for assistance from the facility staff) was answered in a timely manner. 2. Ensure Certified Nursing Assistants (CNAs) assisted Resident 1 with Activities of Daily Living (ADL) in accordance with the resident assessment and care plan, including to assist when getting out of bed (OOB). 3. Ensure Resident 1 was not left soiled in urine for prolonged periods of time. These failures had the potential to result in a decline in Resident 1's physical and psychosocial well-being due to possible skin breakdown, loss of dignity, and loss of a homelike environment. (Cross Reference with F725) Findings: During a review of Resident 1's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 1 on 9/29/2023 with multiple diagnoses including a history of stroke (brain damage due to blocked blood supply to the brain), left shoulder…

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 interviews and record review, the facility failed to develop and implement an individualized care plan for six of 15 sampled residents (Residents 7, 9, 10, 11, 13, & 14) in accordance with the physician's orders by failing to: A. Ensure there was a physician's order for the intervention Assisted Active Range of Motion (AAROM, joint receives partial assistance from an outside force) exercises to both lower extremities (BLEs) in Resident 7's care plan. B. Perform Passive ROM (PROM, outside force exclusively causes joint movement) exercises to Resident 9's right upper extremity (RUE) as indicated in the care plan. C. Perform PROM exercises to Resident 10's BLEs and RUE as indicated in the care plan. D. Perform PROM exercises to Resident 11's BLEs as indicated in the care plan. E. Perform Active ROM (AROM, effort to move the body part without outside help or force) exercises to Resident 13's BLEs as indicated in the care plan. F. Apply Resident 14's left elbow splint (device applied to support the extremity in the best position while resting) and perform PROM exercises 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 interviews and record review, the facility failed to provide restorative nursing services (RNS, services provided to help residents maintain their function and joint mobility) as ordered by the physician for six of 15 sampled residents (Residents 7, 9, 10, 11, 13, & 14). A. For Resident 7, Restorative Nursing Aide (RNA) services were not provided for 5 days in 4/2024. B. For Resident 9, RNA services were not provided for 4 days in 4/2024. C. For Resident 10, RNA services were not provided for 6 days in 4/2024. D. For Resident 11, RNA services were not provided for 3 days in 4/2024. E. For Resident 13, RNA services were not provided for 3 days in 4/2024. F. For Resident 14, RNA services were not provided for 4 days in 4/2024. These failures had the potential to cause a decline/further decline in the residents' range of motion (ROM, measurement of the amount of movement around a specific joint or body part) with increased risks for pain and skin breakdown. (Cross Reference with F725 and F656) Findings: A. During a review of Resident 7's AR (AR 7), AR 7 indicated the facility…

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

Based on interviews and record review, the facility failed to ensure sufficient nursing staff, including certified nursing assistants (CNAs, staff to provide care to residents and assist with mobility ) and restorative nursing aides (RNAs, staff to help improve and/or maintain residents' function and joint mobility), were assigned to provide care for seven of 15 sampled residents (Residents 1, 7, 9, 10, 11, 13, & 14) in accordance with the residents' needs and preferences, physician's orders, and/or residents' care plans by failing to: A. Accommodate Resident 1's needs and preferences regarding the call light response time, getting out of bed (OOB), and incontinence brief changes. B. Provide Restorative Nursing Aide (RNA) services to Resident 7 as ordered by the physician in 4/2024. C. Provide RNA services to Resident 9 as ordered by the physician in 4/2024. D. Provide RNA services to Resident 10 as ordered by the physician in 4/2024. E. Provide RNA services to Resident 11 as ordered by the physician in 4/2024. F. Provide RNA services to Resident 13 as ordered by the physician 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 interviews and record review, the facility failed to verify the competencies and skills sets of the nursing staff to ensure appropriate nursing care and services were provided to the residents by failing to: A. Ensure three of nine sampled Certified Nursing Assistants (CNAs) had an active CNA certification. B. Ensure Director of Staff Development 1 (DSD 1) conducted a Skills Competency test for two of three sampled newly hired CNAs prior to working independently as a CNA. C. Ensure DSD 1 identified the learning needs of four of 27 sampled nursing staff and determine there was no documented evidence on file of a current Cardiopulmonary Resuscitation training (CPR, basic training on life-saving actions during cardiac emergencies) or Basic Life Support training (BLS, CPR training with additional life-saving techniques for those experiencing respiratory distress or an obstructed airway). D. Ensure DSD 1 addressed the staffing shortage brought up by the nursing staff that affected the quality of 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.