Eastland Subacute And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit the Minimum Data Set (MDS - a resident assessment tool) to the Centers for Medicare and Medicaid Services (CMS) system for two of four sampled residents (Resident 39, and Resident 85).This deficient practice resulted in CMS not having accurate information for Resident 39 and Resident 85.Findings:a. During a review of Resident 39's Face Sheet, the Face Sheet indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (characterized by a progressive decline in mental abilities), arthritis (a disease characterized by joint pain and inflammation), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 had severe cognitive impairment (problems with ability to reason, understand, or remember) and did not have limitations in movement of the upper and lower extremities (related to 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 one of six sampled residents (Resident 44) received necessary care and services to ensure resident's abilities to perform activities of daily living (ADL -routine tasks to perform daily care for themselves) do not diminish. Resident 44 was observed in bed for three days during the day shift and was not out of bed per physician's order. This deficient practice caused an increased risk in Resident 44's mental and physical abilities. Findings:During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (a group of conditions affecting the circulatory system that can impair blood flow), chronic kidney disease (damaged kidneys cannot filter blood as needed causes risks of high blood pressure and heart disease), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 32), who had a shoulder injury, received care and equipment assistance. Resident 32's splints (a medical device used to stabilize and support a body part), were not applied per physician's order. This deficient practice caused an increased risk in contractures (a stiffening/shortening at any joint, that reduces the join's range of motion) for Resident 32. Findings:During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body) and a dislocated right shoulder (injury in which the upper arm bone popped out that's part of the shoulder blade).During a review of Resident 32's History and Physical (H&P), dated 2/6/2025, the H&P indicated Resident 32 was able to make decisions for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 101), who had history of falls, had a fall mat at the bedside per the physician's order to prevent injury. This deficient practice caused an increased risk in Resident 101 being injured. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including lack of coordination, history of falling, and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of the Physician's Order Summary, dated 6/9/2025, the summary indicated Resident 101 was ordered for the bed at lowest position and a floor mat to prevent injury.During a review of Resident 101's History and Physical (H&P), dated 6/10/2025, the H&P indicated Resident 101 did not have the capacity to understand and make decisions.During a review of Resident 101'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label the nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing of a resident on oxygen therapy (treatment that provides supplemental oxygen, or extra oxygen) consistent with the facility's policy and procedure (P&P) for one of two sampled residents (Resident 75). This failure caused an increased risk for infection to Resident 75. Findings:During a review of Resident 75's admission Record (AR), the AR indicated Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (CRF, a condition where the lungs could not adequately exchange oxygen and carbon dioxide over an extended period), tracheostomy (a surgical procedure that creates an opening in the front of the neck, known as the trachea, or windpipe), acute embolism (the blockage of a blood vessel by a substance that has traveled through 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 interview and record review, the facility failed to ensure Resident 25 had a Total T3 level (a lab test that measures the amount of thyroid hormone in the blood) completed every two weeks per physician's order for 4/2025. This deficient practice resulted in a lack of monitoring of Resident 25's thyroid function (crucial for regulating metabolism, growth and development in the body).During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including thyrotoxicosis (excess of thyroid hormones in the blood) and hypertension (HTN - high blood pressure).During a review of Resident 25's Hyperthyroidism care plan, dated 2/20/2025, the care plan goal indicated Resident 25 would not experience avoidable symptoms of hyperthyroidism and the care plan interventions indicated the facility would complete labs if ordered by the physician.During a review of Resident 25's History and Physical (H&P), dated 3/14/2025, the 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 ensure one sampled resident (Resident 63) had a bottle of opened prune juice refrigerated as indicated on the product label.This deficient practice had the potential for Resident 63 to experience foodborne illness (diseases caused by contamination of food and occur at any stage in food production, delivery and consumption).Findings:During an observation on 7/22/2025 at 11:03 a.m., a bottle of opened and half consumed prune juice was seen on Resident 63's nightstand. The label on the bottle indicated to refrigerate after opening.During an observation on 7/22/2025 at 2:33 p.m., the bottle of the opened prune juice remained on Resident 63's nightstand. During a review of Resident 63's Face Sheet, the Face Sheet indicated Resident 63 was readmitted to the facility on [DATE] with diagnoses including diverticulosis (a condition where small pouches form in the lining of the colon and push outward through weak spots in the intestinal wall), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide dignity for two of two sampled residents (Residents 13 and 55) by failing to: a. Completely close the privacy curtain when Resident 55's back and buttocks were exposed while Certified Nursing Assistant 3 (CNA 3) changed Resident 55's gown and linen. b. Close the privacy curtain when Resident 13's abdominal area was exposed while Registered Nurse 1 (RN 1) checked the resident's gastrostomy tube (GT, surgically placed devised used to deliver supplemental feeding to the stomach) site. This failure had the potential to cause psychosocial (mental and emotional well-being) decline for Residents 13 and 55. Findings: a. During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (condition when the body does not have enough oxygen in the blood) and use of a tracheostomy tube (a tube placed…

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 reasonable accommodation of need for four of four sampled residents (Resident 5, 21, 24 and 99) by failing to ensure the residents' call light was within reach. These failures had the potential for the residents not to receive or received delayed care that could result in a fall or accident. Findings: a. During a review of Resident 24's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (ESRD, a medical condition where a person's kidneys permanently stop functioning), dependence on renal dialysis (HD- procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances) and hypotension (low blood pressure). During a review of Resident 24's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 7/31/2024, the MDS indicated Resident 24 had clear speech, understood others, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information regarding Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) to two of five sampled residents (Residents 23 and 65) in accordance to the facility's policy and procedure (P&P) titled, Advance Directives. This deficient practice had the potential for facility staff to provide treatment and services against Residents 23 and 65's will. Findings: a. During a review of Resident 23's admission Records (AR), the AR indicated, Resident 23 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a group of thinking and social…

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 c. During a review of Resident 7's AR, the AR indicated the facility readmitted the resident on 2/25/2022, with diagnoses that included COPD and diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high). During a review of Resident 7's OSR dated 2/25/2022, the OSR indicated an order for licensed staff to provide Resident 7 up to two liters (unit of measurement) per minute of oxygen continuously through nasal cannula for oxygen saturation (amount of oxygen circulating in the blood) less than 92 percent (%) every shift for diagnosis of COPD. During a review of Resident 7's CP for oxygen therapy dated 2/15/2024, the CP indicated Resident 7 will be free of adverse effects (undesirable or harmful result) related to use of oxygen by providing oxygen at two liters per minute through nasal cannula as ordered by the physician. During a review of Resident 7's Medication Administration Record (MAR) dated 8/13/2024, the MAR indicated Resident 7's oxygen saturation was at 96 percent. During an…

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 attempt to use appropriate alternative interventions before installation of bilateral (both sides) bedrails for five of five sampled residents (Residents 14, 24 78, 101, and 373). These failures placed Residents 14, 24, 78, 101, and 373 at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the bedrail) and physical injuries. Findings: a. During a review of Resident 373's admission Record (AR), the AR indicated Resident 373 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (when the body does not have enough oxygen) and use of tracheostomy tube (tube surgical inserted in the neck to provide an airway to the lungs). During a review of Resident 373's History and Physical (H&P) dated 8/12/2024, the H&P indicated Resident 373 was able to make decisions for activities and daily living. During a review of Resident 373's admission…

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

Based on observation, interview and record review, the facility failed to maintain safe food handling practices by failing to: 1. Discard one bowl of leftover egg salad in one of one facility walk-in refrigerator, stored for more than three days which exceeded food storage time limit in accordance with the facility's policy on Left Over Food. 2. Store one of one ice scoop in a sanitary condition. The ice scoop was stored in the ice scoop container that had some brown stains at the bottom. These deficient practices placed the residents at risk for food borne illnesses (illness caused by consuming contaminated food or beverages) Findings: During an observation and concurrent interview on 8/13/2024 at 9:23 am, in the facility's kitchen, with the Dietary Supervisor (DS), there was one bowl of egg salad dated 8/9/2024 in the facility's walk-in refrigerator. The DS stated the bowl of egg salad was the leftover food from 8/9/2024. The DS stated, leftover food had three days storage limit and should be removed from the refrigerator and discarded by 8/12/2024. During another observation,…

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 physician's order to apply heel protector (a device designed to minimize the risk of pressure injuries [pressure ulcer, lesion/wound caused by unrelieved pressure that results in damage of underlying tissue]) for one of two sampled residents (Resident 33). This failure had the potential risk for Resident 33 to develop pressure injuries. Findings: During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was readmitted to the facility on [DATE], with diagnoses that including type 2 diabetes mellitus (elevated blood sugar level) and dysphagia (difficulty swallowing) During a review of Resident 33's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 7/26/2024, the MDS indicated Resident 33 had clear speech, did not have the ability to make self-understood and understood others. Resident 33 was dependent (helper does all of the effort, resident does none of the effort to complete 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 necessary care and services for the resident's Foley catheter (a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on Indwelling Catheter Urinary Drainage Bag Maintenance for one of one sampled resident (Resident 88). This deficient practice had the potential to result in catheter-related complications. Findings: During a review of Resident 88's admission Records (AR), the AR indicated Resident 88 was admitted to the facility on [DATE] with the diagnoses that included obstructive (a condition in which the flow of urine is blocked) and reflux (a condition that occurs when urine flows back up the ureters and into the kidneys) uropathy (urine flow obstructed) and acute kidney failure (a condition in which the kidneys suddenly could not filter waste from the blood). During a review of Resident 88's untitled Care Plan (CP) dated 1/30/2023, the CP indicated Resident 88…

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 head of bed was elevated at 30 to 45 degrees for a resident with G-tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the facility's Policy and Procedure (P&P) titled Enteral Feedings for one of two sampled residents (Resident 36). This failure had the potential risk for aspiration (food, drink, or foreign objects accidentally entered the lungs), resulting to a decline in Resident 36's health. Findings: During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was readmitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing) and gastrostomy (an artificial external opening into the stomach for nutritional support). During a review of Resident 36's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform post (after) hemodialysis (HD, a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) assessment on 7/4/2024, 7/30/2024 and 8/10/2024 for one of one sampled resident (Resident 24). This failure had the potential risk for complications caused by unexpected and excessive bleeding from the hemodialysis site. Findings: During a review of Resident 24's admission Record (AR), the AR indicated the resident was admitted on [DATE], with diagnoses that included End Stage Renal Disease (ESRD, a medical condition where a person's kidneys permanently stop functioning and require dialysis or a kidney transplant to survive), dependence on renal dialysis (HD- procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances) and hypotension (low blood pressure). During a review of Resident 24's untitled Care Plan (CP) dated 11/6/2023, the CP indicated Resident 24 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its binding arbitration agreement included selection of a venue convenient to both facility and resident/resident responsible party (RP) for one of three sampled residents (Residents 13). This deficient practice placed Resident 13 at risk for an unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute. Findings: During a review of Resident 13's AR, the AR indicated the facility admitted Resident 13 on 9/4/2022 with diagnoses that included unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and encounter for attention to gastrostomy. During a review of Resident 13's History and Physical (H&P) dated 10/28/2023, 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 the voice messaging system (voicemail) for one of one Director of Social Service (DSS 1) staff was functioning in the facility's social services department (SSD - the staff in this department perform several duties beginning with assisting residents and families by providing information and helping them find placement). This deficient practice had the potential to result in missed information regarding residents or inability for family members to address important resident concerns between DSS 1 and the Case Manager (CM) due to the messaging system's malfunction. Findings: During a concurrent observation and interview on 5/20/2024 at 3:03 pm, in the presence of the Social Services Assistant (SSA) and Receptionist Staff 1 (RS 1), a phone call was placed to the facility to test the phone line. RS 1 received the phone call and transferred it to the DSS's extension. The DSS's phone line kept ringing and after multiple rings, there was a silent pause. There was no voicemail greeting that prompted the caller…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and protect one of three sampled residents (Resident 1) from physical abuse by failing to:Ensure Licensed Vocational Nurse (LVN) 1 reported the alleged abuse to the Administrator (ADM), State Survey Agency, Law Enforcement, and Ombudsman when Resident 1's Family Member (FM 2) reported to LVN 1 that Resident 1 told FM 2 that a male staff member (Registered Nurse [RN] 1) slapped Resident 1 on the face on 1/20/2024 at around 1:30 PM. This deficient practice violated the Federal mandated reporting timeframe. This had the potential to result in psychological (mental or emotional) and physical harm or injury, and placed Resident 1 at risk for further abuse from RN 1. Cross Reference- F610Findings:During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and protect one of three sampled residents (Resident 1) from physical abuse by failing to:1. Ensure Registered Nurse (RN) 1, who was the alleged perpetrator (the person identified in the initial report or during the investigation as the person suspected of committing an act of abuse), was placed on leave of absence (authorized absence from work for a certain period of time) and did not have contact with Resident 1 and other residents in the facility from 1/20/2024 to 2/17/2024.2. Ensure Licensed Vocational Nurse (LVN) 1 thoroughly investigated the alleged abuse when Resident 1's Family Member (FM 2) reported to LVN 1 that Resident 1 told FM 2 that a male staff member (RN 1) slapped Resident 1 on the face on 1/20/2024 at around 1:30 PM. These deficient practices resulted in Resident 1 feeling worried that RN 1 might…

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

Based on observation, interview, and record, review, the facility failed to provide care and services for one of three sampled residents (Resident 1), to prevent the development of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and promote healing by failing to: 1. Ensure facility staff applied bilateral heel protectors (padding to protect the back of heels and feet from pressure injuries) on Resident 1's heels as ordered by the physician. 2. Ensure the Wound Care Nurse (WCN, treatment nurse) accurately set Resident 1's low air loss mattress (LAL, mattress designed to distribute resident's body weight and help prevent skin breakdown) according to Resident 1's current weight. These deficient practices resulted in Resident 1 developing Stage 1 pressure ulcer (intact skin with localized area of non-blanchable [skin discoloration that did not turn white when pressed] redness) on Resident 1's right medial (towards the middle/center) foot and right buttocks. This had the potential to result in worsening or…

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

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility's policy and procedures (P&P) titled, Policy Respiratory Protection Program and the Department of Public Health (DPH) guidelines by failing to: Conduct an N95 mask or respirator (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) fit testing (a test to evaluate the fit and determine how effectively a mask or respirator will protect the wearer) upon hire for one of three sampled staff (Certified Nursing Assistant 1) during a COVID-19 outbreak. This deficient practice had the potential to result in the spread of COVID-19 to other residents and staff in the facility. Findings: During a concurrent observation and interview on 12/12/23 at 10:07 AM with CNA 1, CNA 1 was observed wearing a BYD DE2322 model N95 mask. CNA 1 stated, she had been…

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 Registered Nurse Supervisor 1 (RNS 1), Licensed Vocational Nurse 1 (LVN 1), Certified Nursing Assistant 1 (CNA 1), and CNA 2 had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) and to recognize when to provide CPR when: 1. On [DATE] at 5:45 am (as indicated in the video recording), Registered Nurse Supervisor 1 (RNS 1) and Certified Nursing Assistant 1 (CNA 1) did not start CPR after RNS 1 and CNA 1 found Resident 1 on the floor, in Resident 1 ' s room, unresponsive (not reacting to anything) with a weak pulse (movement of blood caused by the beating of the heart and that can be felt by touching…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the clinical record for one of three sampled residents (Resident 1) was complete and accurate when Resident 1 ' s clinical record did not indicate there was blood on the back of Resident 1 ' s head after a fall on [DATE]. This failure had the potential for Resident 1 to not get the appropriate care and treatment. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility readmitted Resident 1 on [DATE] with diagnoses which included end stage renal disease (ESRD, a medical condition in which a person ' s kidneys permanently stop working and can no longer clean waste products from the blood and send waste products out of the body in urine). During a review of Resident 1 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum…

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 competency evaluation for one of one Certified Nursing Assistants (CNA) was obtained from the Nurse Aide Registry before working in the facility on 10/2/23. This deficient practice placed Resident 1 at risk of not receiving needed care and possible injury of Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs), restless leg syndrome (a common condition of the nervous system that causes overwhelming, irresistible urge to move the legs) and generalized muscle weakness. During an observation on 10/5/23 at 2:20 p.m., Resident 1 was lying on her back in bed with tracheostomy tube connected to oxygen concentrator machine at five liters per minute. Resident 1 had an ongoing gastrostomy tube feeding (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician of a change of condition to one of four sampled residents (Resident 1) in accordance with the facility ' s policy and procedure. This deficient practice had the potential to negatively affect the delivery of care and services necessary for Resident 1. Findings: During a review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions) and osteoarthritis (most common form of arthritis mainly affects joints in your hands, knees, hips and spine). During a review of Resident 1's care plan titled, At risk for: sudden acute pain to any extremity .related to osteoarthritis. initiated on 1/3/2023, indicated for the nursing staff to observe for sudden acute pain, redness/discoloration, swelling/tenderness, guarded movement of extremity and to inform…

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

Based on observation, interview, and record review, the facility failed to follow safe resident smoking practices for one of three sampled residents (Resident 1). This deficient practice had the potential for accidents. Findings: During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/16/2022, with diagnoses that included mood disorder (bipolar - a mental health condition that primarily affects the emotional state in which a person experiences long periods of extreme happiness, extreme sadness or both) and anxiety disorder (a mental health condition where a person has feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat.). During a review of Resident 1 ' s Minimum Data Set (MDS – an assessment and care planning tool) dated 7/23/2023, indicated Resident 1 had no cognitive impairment (the ability to think and reason). The MDS indicated Resident 1 required limited assistance with one-person physical assistance for transfers, walking, dressing and personal hygiene and required supervision for locomotion (how a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an environment free of accident and hazard for two of three sampled residents (Resident 8 and Resident 64). 1. For Resident 8, call light was not within reach while Resident 8 was sitting in wheelchair at foot of the bed. 2. For Resident 64, padded side rails for seizure (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) precaution was torn off leaving metal side rails to the resident. These deficiencies had the potential risk for injury to Residents 8 and 64. Findings: a. A review of the facility's admission Record indicated Resident 8 was admitted on [DATE] with diagnoses included: Multiple Sclerosis (MS, affects the brain and spinal cord, symptoms include weakness, tingling, numbness, and blurred vision) and dystonia (a state of abnormal muscle tone resulting in muscular spasm and abnormal posture,…

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 respiratory care services for two of four sampled residents (Resident 14 and Resident 47). 1. For Resident 14, the facility failed to change the oxygen tubing and the oxygen humidifier (a device used to make supplemental oxygen moist) in accordance with the facility's policy and procedure. This deficient practice had the potential for the resident to develop respiratory infection. 2. For Resident 47, the facility failed to ensure that resident received continuous oxygen as ordered by the physician. This deficient practice had the potential to result in respiratory distress. Findings: a. A review of Resident 14's admission Record indicated the resident was admitted on [DATE], with diagnoses of chronic respiratory failure and sepsis (body's life-threatening response to infection that can lead to tissue damage, organ failure, and death). A review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care planning…

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 accordance with professional standards of food service safety by failing to: a. Label and date food in the freezer b. Discard freezer-burnt (discoloration or damage to frozen food due to inadequate packaging or storage condition in the freezer) food c. Store food 12 inches off the floor in accordance with the facility's policy and procedure. These deficient food practices had the potential to result in food borne illnesses (disease caused by ingesting contaminated food) for the residents. Findings: a. During an observation of Freezer Two in the facility's kitchen with Dietary Supervisor (DS) on 1/10/2022 at 9:20 a.m., one large clear bag of bacon taken from its original packaging was not labeled with the food item name and was dated 12/17/2021. One pack of beef patty in its original bag was not dated with an expiration date. In a concurrent interview, DS stated the bacon was opened on 12/17/2021 but staff did not write an expiration date on the bag. DS stated the bacon should have an expiration…

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 practice infection control measures for three of 26 total sampled residents (Resident 14, 85, and 368) by failing to: 1. Ensure staff wore required personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and perform hand hygiene when entering a Yellow Zone Room (designated area for residents in isolation for exposure or suspected of COVID-19 [Coronavirus disease, a mild to severe respiratory illness that spread from person to person]) for Residents 14 and 368. 2. Ensure Resident 85's oxygen humidifier (used to prevent airways from getting too dry while breathing air directly from the concentrator of supplemental oxygen) was changed weekly as ordered by the physician. These deficient practices had the potential to result in infection and spread of disease. Findings: a. A review of Resident 14's admission Record indicated the resident was admitted to 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 assist resident formulate an advance directive and/or obtain copies of the existing advance directive from the responsible party for two of 12 sampled residents (Residents 68 and 80). This deficient practice had the potential for the staff to violate the resident's right to refuse treatment and implement the preferred medical interventions. Findings: a. A review of Resident 80's admission Record indicated the resident was readmitted on [DATE], with diagnoses that included diabetes mellitus (high blood sugar) with diabetic chronic kidney disease (decrease in kidney function that occurs in some people with diabetes) and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 80's Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 11/30/21, indicated the resident was assessed with good short and long term memory recall ability. Resident 80 required…

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 26 sampled residents (Resident 97) received treatment and care in accordance with professional standards of practice by failing to verify the physician's order of metoprolol succinate extended release (ER) 25 milligram (mg) tab when the actual medication administered to Resident 97 was metoprolol tartrate, immediate release 25 mg tab for hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat). This deficient practice had the potential to result in medication error from not checking the physician order with the actual medication on hand. Findings: A review of Resident 97's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation, hypertension, dysphagia (difficulty swallowing), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and tracheostomy (an opening surgically created through 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 attempt the use of appropriate alternatives to bed rails before its installation for one of one sampled resident (Resident 112). This deficient practice placed Resident 112 at risk for entrapment and injury from the use of bed rails. Findings: A review of Resident 112's admission Record indicated the resident was admitted on [DATE], with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and hypertension (high blood pressure). A review of Resident 112's MDS dated [DATE], indicated the resident was assessed with short and long- term memory problems. Resident 112 required extensive assistance (staff provide weight- bearing support) in bed mobility and transfer with one-person physical assist. A review of Resident 112's Physician Order Sheet dated 6/19/21, indicated an order for low bed with bilateral quarter length bed rails with bed alarm and floor mat 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 ensure narcotic (a kind of controlled drugs that produces pain relief, state of sleep and physical dependence on the drug) and hypnotic (sleeping pills) count sheet was signed in/out by licensed nurse during shift change for 2 of 14 days (1/2/2022 and 1/3/2022). This deficient practice had the potential risk for controlled medications get lost, diverted or accidental exposed. Findings: During an inspection of the facility's medication cart 1 for nursing station 2 on 1/14/2022 at 10:24 am, Narcotic Count Sheet for the month of January 2022 did not have sign in/out signature for 1/3/2022 from 3-11(pm) shift. Narcotic Count Sheet/PO E-kit (oral medication emergency kit), Narcotic Count Sheet/IM E-kit (intramuscular emergency kit), Narcotic Count Sheet/IV E-kit (intravenous emergency kit) and Narcotic Count Sheet/refrigerator E-kit (emergency kit inside refrigerator) did not have sign in/out signature for 1/2/2022 from 3-11 pm shift and 1/3/2022 for 3-11 pm shift. During an concurrent interview, Licensed Vocational Nurse 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify the physician of the pharmacist's recommendation for one of three sampled residents (Resident 57). Resident 57's physician was not notified of the pharmacist's recommendation for TSH (thyroid stimulating hormone) blood test since 12/19/2021. This deficient practice placed Resident 57 at risk for delayed care and appropriate treatment. Findings: A review of Resident 57's admission Record indicated the resident was readmitted to the facility on [DATE], with diagnoses including diabetes mellitus (high blood sugar) with diabetic neuropathy (a type of nerve damage that can occur with diabetes), obstructive sleep apnea (intermittent airflow blockage during sleep) and hypothyroidism (underactive thyroid). A review of Resident 57's Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 12/2/2021, indicated the resident had good short-and long-term memory recall ability. Resident 57 required total dependence (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of five percent or greater, as evidenced by the identification of two medication errors out of 26 opportunities for error. This yielded a medication error rate of 7.69 percent. These deficient practices had the potential to cause harm to the resident. Findings: A review of the facility's admission record indicated Resident 42 was readmitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), congenital malformations of heart and circulatory system (one or more problems with the heart structure that are present at birth) and hypertension (elevated blood pressure). A review of Resident 42's Physician's Order Summary for January 2022 indicated to give: - Metoprolol tartrate tablet 75 mg (milligram- unit of measurement), one tablet by mouth two times a day for hypertension/tachycardia (heart rate more than 100 beats per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 42) was free from significant medication errors (causes the resident discomfort or jeopardizes his or her health and safety) by failing to follow physician's order to check the resident's heart rate before administering metoprolol tartrate (medicine used to treat high blood pressure). This deficient practice had the potential to result in serious harm to Resident 42. Findings: A review of the facility's admission record indicated Resident 42 was readmitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), congenital malformations of heart and circulatory system (one or more problems with the heart structure that are present at birth) and hypertension (elevated blood pressure). A review of Resident 42's Physician's Order Summary for January 2022 indicated to give metoprolol tartrate tablet 75 mg (milligram- unit 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.