Sunset Manor Conv Hosp

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the care plan for one of three sampled residents (Resident 1) by failing to ensure Resident 1 did not have clutter around Resident 1's bed. This deficient practice placed Resident 1 at risk for falls and injuries from excessive clutter surrounding Resident 1's bed.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included COPD (Chronic obstructive pulmonary disease, a chronic lung disease causing difficulty in breathing), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily functioning), and depression (a persistent sadness, loss of interest in activities, and low energy, severely impacting daily life). During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of 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 interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) received mail and other packages within 24 hours of delivery.This deficient practice violated Resident 1's right to receive mail promptly (delivery of mail or other materials to the resident within 24 hours of delivery) and had the potential to impact Resident 1's well-being.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 4/25/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute pulmonary edema (rapid accumulation of fluid in the lungs) and anxiety disorder (a mental health condition characterized by excessive worry and fear that interferes with daily life). During a review of Resident 1's History and Physical (H&P) dated 8/13/2025, the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 10/31/2025, the MDS…

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

Based on interview and record review, the facility failed to ensure the nursing staff implemented person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of two sampled residents (Resident 2) by failing to monitor Resident 2's symptoms of increased confusion/physical abusive towards staff. These deficient practices had the potential to place Resident 2 at risk of not receiving the individualized care services to attain or maintain highest practicable physical, mental, and psychosocial well-being.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to facility on 2/17/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following nontraumatic intracerebral hemorrhage (bleeding within the brain, most commonly due to high blood pressure, trauma, or other blood vessel issues) affecting left non-dominant side, acute kidney failure (rapid loss of kidney function,…

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

Based on interview and record review, the facility failed to ensure the licensed nurse implemented the facility's Policy and Procedure (P&P) titled Medication Orders by failing to indicate the severity of the pain level for the pain medication order for one of two sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk of not receiving the optimal therapeutic effect (desirable and beneficial effects resulting from a medical treatment) of the medication, which had the potential to impair Resident 1's wellbeing.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/15/2025 with diagnoses including hemiplegia (total paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (as a result of disrupted blood flow to the brain due to problems with the blood vessels) affecting left non-dominant side, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)…

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 three of three sampled residents (Resident 30, 31 and 34) and/or their representatives were provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only go into effect if the person cannot communicate his/her own wishes) when: a. Resident 34 did not receive information regarding AD. b. Resident 30's AD Acknowledgement Form was filled out inaccurately. c. Resident 31's AD Acknowledgement Form was filled out inaccurately. These failures had the potential to result in Residents 30, 31, and 34 and/or their representatives to not be informed of their rights and receive unwanted and/or unnecessary life-sustaining care and treatment. Findings: a. During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was re-admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (elevated blood sugars), cirrhosis of the liver…

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 irregularities identified from the monthly drug regimen review reported by the facility's pharmacist were acted upon for two of five sampled residents (Residents 20 and 34): a. Resident 34's pharmacist recommendation to order laboratory test to monitor the increased risk of rhabdomyolysis (a serious medical condition of a breakdown of muscle tissue, releasing harmful substances into the bloodstream) was not acted upon. b. Resident 20's pharmacist recommendation to discontinue Benadryl (medication to treat pain and itching) was not acted upon. These deficient practices had the potential for unnecessary medication administration. Findings: a. During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was re-admitted to the facility on [DATE] with diagnoses that included diabetes (elevated blood sugar), cirrhosis of the liver (liver damage replaced by scar tissue) and dependence on renal dialysis (a treatment for people…

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 safe and sanitary conditions were maintained in one of one facility kitchen. During initial tour of the kitchen, a 22-ounce (oz) bottle of basil pesto sauce was observed with an unreadable best by or used by date. This deficient practice had the potential for improper food storage, which could lead to foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents who received food from the kitchen. Findings: During an initial tour and observation of the kitchen on 3/18/2025 at 8:58 am with the Assistant [NAME] (AC), a 22 oz. bottle of pesto sauce was observed inside the facility's freezer. The AC stated the pesto sauce bottle's use by or best by date was unreadable. The AC stated best by or used by dates were important to determine when the product was edible for consumption and when to discard to prevent possible food borne illnesses to the residents. During a review of the facility's Policy and Procedure (P&P) titled Date Marking for Food Safety, revised 1/31/2025,…

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 in need) was within reach for one of one sampled resident (Resident 55). This failure had the potential to result in resident not receiving assistance in a timely manner when needed. Findings: During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control) and tinea unguium (a fungal infection of the nails) During a review of Resident 55's Minimum Data Set (MDS, a resident assessment tool) dated 3/7/2025, the MDS indicated Resident 55 had clear speech, usually understood others and usually made self-understood. Resident 55 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half…

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 an effective communication method to one of two non-English speaking sampled residents (Resident 7). This failure had the potential for the resident not to receive necessary care and services. Findings: During a review of the Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control) dysphagia (difficulty swallowing) and pressure-induced deep tissue damage of the right heel (pressure ulcer/injury, PU/PI, localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 7's preferred language was Vietnamese. The MDS indicated Resident 7 had no speech, rarely/never understood others and made self-understood. The MDS indicated…

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 the physician's order to keep the resident's both heels to free float (technique where the heels were completely elevated off the surface) for one of three sampled residents (Resident 7). This failure had the potential risk for Resident 7 to develop pressure injury (PI, localized damage to the skin and/or underlying tissue usually over a bony prominence) and delayed healing of existing PI. Findings: During a review of the Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control) dysphagia (difficulty swallowing) and pressure-induced deep tissue damage of the right heel (pressure ulcer/injury, PU/PI, localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 7's Order Summary Report (OSR) dated 2/4/2025, the OSR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary care and services for one of one sampled resident (Resident 34), who required and received hemodialysis (treatment for kidney failure that removes waste and extra fluids from the blood) four times a week, by failing to ensure staff followed Resident 34's physician's order for fluid restrictions of 1200 milliliters (ml- unit of measurement) a day. This deficient practice had the potential for Resident 34 to experience fluid overload (excessive amount of fluid in the body) and difficulty breathing that can compromise the Resident 34's health. Findings: During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was re-admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (elevated blood sugars), cirrhosis of the liver (liver damage where healthy cells are replaced by scar tissue), and dependence on renal dialysis (a treatment for people whose kidneys are failing). During a review…

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 one of three sampled residents (Resident 6) whose primary language was Spanish, the binding arbitration agreement (AA, a private process where disputing parties agree that one or several other individuals can plan about the dispute) was fully understood by the resident and was presented in a language Resident 6 understand. This deficient practice had the potential for the resident to not be fully informed and make an informed decision on whether to enter into such agreement. Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included atrial fibrillation (irregular heart rate), hypertension (elevated blood pressure) and dependence on supplemental oxygen. During a review of Resident 6's History and Physical (H&P) dated 2/12/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a…

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

Based on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Hand Hygiene, and Management of C. Difficile (a type of bacteria that can cause diarrhea) Infection, by failing to ensure staff washed their hands with soap and water after providing care for one of five sampled residents (Resident 2), who had C. Diff. This deficient practice had the potential to result in cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) and the spread of infection throughout the facility. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 10/3/2024 and recently readmitted Resident 2 on 12/28/24 with diagnoses of dysphagia following cerebral infarction (a swallowing disorder that may occur after a stroke), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), and pleural effusion (a condition in which fluid builds up in the space between the lung and the chest…

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 recorded review, the facility failed to maintain the resident's bed remote control coil line (coiled remote-control cord) in safe operating condition for one of three sampled residents (Resident 1). The hard plastic covering of Resident 1's bed remote control coil line was damaged and pointed out. This failure resulted in a laceration (a wound when skin, tissue, and/or muscle was torn or cut open) on Resident 1's inner right hand between the thumb and index finger (also known as the pointer finger, or first finger) measuring 2 centimeters (cm-unit of measurement) in length, by 0.2 cm in width and by 0.2 in depth. Cross Reference : F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2024 with diagnoses that included type II Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition when the heart is not able to pump enough blood and oxygen to the body's organs) and respiratory failure (a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain its infection control/prevention surveillance program for two of two sampled residents (Resident 1 & Resident 2) by failing to: a. Initiate a scabies line list immediately after Resident 1 was confirmed to have scabies from a positive skin scrapping test result. b. Ensure that Infection Control measures were implemented when Resident 2 was identified to be highly suspicious of scabies. This deficient practice compromised infection control measures to prevent the potential spread of infections. Findings: a. During a review of Resident 1's admission Record (Face sheet), dated 8/16/2024, the facility admitted the resident on 6/6/2022, with diagnoses that respiratory failure, transient ischemic attack (a temporary disruption in the blood supply to part of the brain), epilepsy (a common condition that affects the brain and causes frequent seizures), and quadriplegia (a form of paralysis [the loss of the ability to move some or all of…

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

Based on observation, interview, and record review, the facility failed to adhere to professional standards of practice for one of five sampled residents (Resident 2), when Resident 2 ' s medication was left unattended at Resident 2 ' s bedside. This deficient practice had the potential to result in mismanagement of Resident 2 ' s medication for pain management and placed the resident at risk for adverse (untoward) consequences. Findings: During a review of Resident 2 ' s admission Record (AR) dated 8/13/2024, the AR indicated the facility admitted Resident 2 on 2/15/2024 with diagnoses including type 2 diabetes (persistent elevated blood sugar levels) and Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems). During a review of Resident 2 ' s History and Physical (H&P) dated 2/16/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set (MDS – a standardized assessment and care planning tool) dated 9/26/2023, the MDS indicated Resident 2 required setup 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain infection control practices as outlined in the facility ' s policy for Coronavirus Prevention and Response when one of two Certified Nursing Assistants (CNA 2) went inside a Covid-19 (Coronavirus, a highly contagious respiratory disease caused by SARS-CoV-2 virus that spreads from person to person and can cause mild to severe respiratory illness) isolation (to separate people who are sick) room of Resident 5 without wearing the required Personal Protective Equipment (PPE). This deficient practice had the potential to spread COVID-19 throughout the facility. Findings: During a review of Resident 5 ' s admission Record (AR) dated 8/6/2024, the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (persistent high blood sugar levels) and liver cirrhosis (condition in which the liver is scarred and permanently damaged) During a review of Resident 5 ' 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.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Nail Care, for one of three sampled (Resident 3) by failing to: 1. Ensure assigned Certified Nursing Assistants (CNAs) trimmed and cleaned the fingernails of Resident 3, who had contractures (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) to his left and right hands. 2. Ensure assigned CNAs notified assigned Licensed Vocational Nurses (LVNs) regarding Resident 3's long and overgrown toenails. 3. Ensure assigned LVNs notified the Social Services Director (SSD) that Resident 3 needed to be referred and seen by a podiatrist (medical specialists who help with problems that affect your feet or lower legs) for cleaning and trimming of Resident 3's long and overgrown toenails. These failures had the potential to cause injuries and infection to Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated, the facility admitted Resident 3 on 6/17/2024, 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 observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Resident 2 and Resident 270) by failing to: a. Ensure a call light to accommodate a resident's mobility limitations was provided when Resident 270 was unable to move Resident 270's bilateral upper arms and hands. b. Ensure call light was within reach for Resident 2 who was assessed as high risk for fall as indicated in the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response and the resident's care plan. These failures had the potential to result in Resident 270 and Resident 2 being unable to notify staff for needs and possibly, an emergency. Findings: a. During a review of Resident 270's admission Record (AR), the AR indicated Resident 270 was admitted to the facility on [DATE] with diagnoses that included but are not limited to myotonic muscular dystrophy (genetic condition that causes progressive muscle weakness 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 of Advance Directive (AD, written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) for two of two sampled residents (Residents 45 and 47) in accordance with facility's policy titled Residents' Rights Regarding Treatment and Advance Directives. These failures had the potential for Residents 45 and 47 to receive treatment and services against the residents' will. Findings: a. During a review of Resident 45's admission Record (AR), the AR indicated Resident 45 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 insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) with hyperglycemia…

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 the resident's suprapubic catheter (a hollow, flexible tube used to drain urine from the bladder through a cut in the abdomen) and indwelling catheter (a medical device that helped drain urine from the bladder) as ordered by the physician and as indicated in the resident's plan of care for two of four sampled residents selected for catheter care area (Resident 15 and Resident 11). These failures had the potential to result in catheter-related complications for Resident 15 and Resident 11. Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated, the facility admitted Resident 15 to the facility on 1/23/2003, and readmitted the resident on 11/6/2023, with diagnoses that included hydroureter (a condition where the ureter became larger than normal due to urine backup), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and retention 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 follow the facility's Policy and Procedure (P&P) for enteral feeding (tube feeding that supplies nutrients and fluids to the body if unable to safely chew or swallow) for two of three sampled residents (Residents 2 and 274 ) when: a. Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) dressing for Resident 2 was not changed per protocol. b. Enteral feeding was left ongoing while Resident 274 was lying flat on the bed. These failures had the potential for infection for Resident 2 and complication of aspiration (when food/liquid enter a resident's airway and lungs by accident) for Resident 274 . Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated, the facility admitted Resident 2 to the facility on [DATE], and readmitted the resident on 2/20/2024, with diagnoses that included dysphagia (difficulty swallowing) and attention to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 30 and 274) receiving oxygen therapy were provided respiratory care and resident safety in accordance with the facility's policy and procedure titled Oxygen Administration and Sudden Respiratory Distress Differential Diagnosis, by failing to: a. Ensure Resident 30's nasal cannula tubing (flexible plastic tubing used to deliver oxygen through the nostrils) was kept in covered in plastic bag when not in use and not rolled and inserted to the handle of the oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen). b. Ensure Resident 274 had a spare tracheostomy tube (tube inserted from an opening in the neck into the trachea [windpipe]) readily available at bedside. These deficient practices had the potential for infection for Resident 30 and failure to maintain a patent (open) airway during an emergency…

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 appropriate alternatives prior to installing a side or bed rail for two of two sampled residents (Residents 17 and 170). This deficient practice had the potential for accidents that could lead to injury. Findings: a. During a review of Resident 17's admission Record, the admission Record indicated the facility admitted the resident on 3/2/2023, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time) During a review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 3/5/2024, the MDS indicated Resident 17 had severely impaired cognitive (ability to understand) skills for daily decision making. The MDS indicated Resident 17 was totally dependent with all activities of daily living.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, sanitary and comfortable environment and prevent the development and transmission of communicable diseases and infection for five of five sampled residents ( Residents 35, 8, 61, 42 and 274), when the facility failed to: a. Ensure wound care was performed to Resident 35 in a manner that would prevent introduction of potentially contaminated material into the wound. b. Ensure curtains were changed during deep cleaning for two (Residents 8 and 61) of 28 rooms in the facility. c. Ensure the IPN changed gloves and perform hand hygiene after touching Resident 42's indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag). d. Ensure the Nurse Practitioner (NP) wore the required Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards and illnesses) prior to performing a physical assessment (examination) of Resident 274 who was placed on Enhanced Barrier…

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 and implement a care plan for one of one sampled resident (Resident 274) when Resident 274 has a left lateral (side) mid foot unstageable (bed sore that occurred when there was prolong pressure on a specific area to the skin resulting in an open wound. Tissue was lost and the depth of the wound was obscured by eschar [dry, dead tissue within the wound]) pressure injury (PI), left medial (toward middle or center) foot unstageable PI, left medial malleolus (ankle bone) stage two (shallow open ulcer with a red or pink wound bed) PI, left metatarsal (long bone in each foot) first toe unstageable PI, right heel deep tissue injury (DTI, pressure injury that are purple or maroon that appear on intact skin due to damage of underlying tissue), right lateral malleolus unstageable PI, right lateral mid foot stage two PI, left lateral lower leg unstageable PI, and right posterior lower leg PI. This failure had the potential to result in Resident 274's PIs…

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 two sampled residents (Resident 2) selected for language/communication care area was provided with Passy-Muir Valve (PMV, allow tracheostomy [a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck] patients to produce speech sounds) for effective communication. This failure had the potential for Resident 2 to not receive necessary care and services due to lack of effective communication aids. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, the facility initially admitted Resident 2 to the facility on [DATE], and readmitted the resident on 2/20/2024, with diagnoses that included tracheostomy and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 2'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 observation, interview, and record review, the facility failed to follow own policy and procedure (P&P) for pressure injury (PI, injuries to the skin and tissue below that are due to pressure on skin for long periods of time) prevention for one of one sampled residents (Resident 274). Resident 274's bilateral heel protectors (cushioned heel protectors that assist in reducing pressure in heels which can decrease the risk of pressure damage) were not on per Medical Doctor's (MD) order. Resident 274 who had a left lateral (side) mid foot unstageable (bed sore that occurs when there is prolong pressure on a specific area to the skin resulting in an open wound. Tissue was lost and the depth of the wound were obscured by eschar [dry, dead tissue within the wound]) PI, left medial (toward middle or center) foot unstageable PI, left medial malleolus (ankle bone) stage two (shallow open ulcer with a red or pink wound bed) PI, right heel deep tissue injury (DTI, pressure ulcers that were purple or maroon that…

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

Based on observation, interview, and record review, the facility failed to provide care and services for one of five sampled residents (Resident 48) with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) by failing to turn and reposition Resident 48 every two hours as indicated in the facility's policy and procedure (P&P) titled Turning and Repositioning and Resident 48's care plan. This failure had the potential to lead to further skin breakdown (damage to the skin's surface), infection, worsening, and/or delayed wound healing for Resident 48. Findings: During a review of Resident 48's admission Records (AR), the AR indicated, the facility initially admitted Resident 48 to the facility on 5/12/2023, and readmitted the resident on 10/13/2023, with diagnoses that included stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the right and left buttock, sacral region (at the bottom of…

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

Based on observation, interview, and record review, the facility failed to ensure the resident's right-hand splint (a medical device that supported and protected joints and its surrounding structures and worked by positioning the hand and wrist correctly) was maintained and properly applied in accordance with the facility's policy and procedure titled, Restorative Nursing Programs and resident's care plan for one of three sampled residents (Resident 16) selected for position mobility care area. This deficient practice placed Resident 16 at risk for contractures and had the potential to cause decline in Resident 16's physical function. Findings: During a review of Resident 16's admission Record (AR), the AR indicated, the facility admitted Resident 16 to the facility on 8/6/2020, with diagnoses that included muscle wasting (loss of muscle mass and strength) and contracture (shortening and hardening of muscles, tendons, skin, and other tissues that causes the joints to shorten and become stiff) of right and left hand. During a review of the Resident 16's untitled Care Plan (CP), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to supervise and follow policy and procedure (P&P) for Hoyer Lift (mechanical device that is operated by two people and used to lift and transfer residents safely) for one of one sampled resident (Resident 274) by failling to ensure 2 staff memberd operated the Hoyer lift to lift Resident 274 from the resident's bed. Resident 274 was left suspended in the air, unsupervised when Certified Nurse Assistant 2 (CNA 2) walked away from the Hoyer Lift to close the currtain. This failure had the potential to result in Resident 274 to sustain a serious injury. Findings: During a review of Resident 274's admission Record (AR), the AR indicated Resident 274 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pressure injuries (PI, injuries to the skin and tissues that were due to prolonged pressure) of the sacral region, right and left buttocks, right ankle, right heel stage one (intact skin with non-blanchable…

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 or touching assistance during meals for one of one sampled resident (Resident 19) with weight loss. This deficient practice had the potential to lead to further weight loss for Resident 19. Findings: During a review of Resident 19's admission Record(AR), the AR indicated the facility admitted the resident on 7/1/2022 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait.) During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 3/8/2024, the MDS indicated Resident 19 had severe cognitive impairment. The MDS indicated Resident 19 was dependent with sit to lying, lying to sitting on side 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 label and date the midline intravenous catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm used to administer medication into the bloodstream) for one of one sampled resident (Resident 45) in accordance with the facility's policy titled Peripheral Intravenous Catheter Insertion, Maintenance and Removal and resident's care plan. This failure had the potential to result in infection to Resident 45 and worsen the residents' health condition. Findings: During a review of Resident 45's admission Record (AR), the AR indicated Resident 45 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 insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) with hyperglycemia (high blood sugar). During a review of Resident 45's History and Physical (H&P), dated 3/20/2024,…

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

Based on interview and record review, the facility failed to ensure the medical record for one of five sampled residents (Resident 1) contained an accurate description of the actual experiences of Resident 1 by failing to ensure: 1. Details regarding an incident with the mechanical lift (a device used by staff to transfer residents from a bed to a chair or other similar places) which occurred on 1/19/24 were documented in Resident 1's medical record. 2. Details regarding dislodgement of Resident 1's intravenous line (IV; a soft, flexible tube placed inside a vein, usually in the hand or arm, and used by health care providers to give a person medicine or fluids) on 1/2/24 were documented in Resident 1's medical record. 3. The correct site of Resident 1's midline IV (an IV which is inserted into a larger vein using a longer catheter and can be left in the vein longer than a regular IV) was documented in Resident 1's medical record. These failures had the potential for Resident 1 to not receive appropriate care and treatment due to an incomplete/inaccurate medical record. Findings: 1.…

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

Based on interview and record review, the facility failed to follow its policy and procedure on reporting of alleged abuse violation, by failing to ensure one of one Certified Nursing Assistant (CNA 2) report abuse allegation on Resident 1 to the facility's abuse coordinator. This deficient practice resulted in the delay of investigation of the alleged abuse allegation and had the potential to result in violation of Resident 1's right to be free from abuse. Findings: During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 1/2/2024 with diagnoses that included vascular dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and wedge compression fracture (type of broken bone that can cause vertebrae to collapse, making them shorter) of the fifth lumbar vertebra. During a review of Resident 1's History and Physical (H&P), dated 1/2/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. 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 record review and interview, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1). Resident 1 ' s treatment orders for skin rashes were ordered on 10/12/23 and was not started until four days later on 10/16/23. This deficient practice resulted in delayed treatment and healing of Resident 1 ' s skin rashes. Findings: During a review Resident 1 ' s admission Record indicated the resident was admitted on [DATE], with diagnoses that included anoxic brain damage (caused by complete lack of oxygen in the brain) and diabetes mellitus (a chronic disease that occurs when the pancreas[an organ located in the abdomen] does not produce enough insulin [hormone that regulates blood sugar] or when the body cannot effectively use the insulin it produces). During a review of Resident 1 ' s Minimum Data Set (a standardized assessment and care planning tool) dated 10/20/23, indicated Resident 1 had memory recall…

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.