Elk Grove Post Acute

Based on observation, interview, and record review, the facility failed to ensure call lights were available to use for two of 30 sampled residents (Resident 100 and Resident 140), when:1. Resident 140's touch pad call light was not within reach; and2. Resident 100's regular call light was not within reach. These failures decreased the facility's potential to assist residents in a timely manner when needed.Findings: 1. A review of Resident 140's admission Record, dated 5/13/26, indicated Resident 140 was admitted to the facility in April 2014 with a diagnosis of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a concurrent observation and interview on 5/11/26 at 10:23 a.m. with Certified Nursing Assistant (CNA) 3 and Resident 140, Resident 140's touch pad call light was observed clipped to her gown and placed next to left hip. Resident 140 stated she was unable to reach her call light due to complete weakness in left arm and very little movement in right hand. CNA 3 confirmed Resident 140's call light was not within…

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 replace one of four sampled residents (Resident 1's) personal belongings in a timely manner when Resident 1's eyeglasses were lost.This failure had the potential to compromise Resident 1's vision.Findings:A review of Resident 1's face sheet (a summary of medical information) indicated he was admitted to the facility in late 2025 with diagnoses which included a brain disease that impaired memory. The facility listed Resident 1's family member as his responsible party (RP, person who is responsible for making health care and financial decisions).During a review of Resident 1's, Order Summary Report [OSR], dated 9/17/25, the ORS indicated Resident 1 did not have the capacity to make medical decisions.During an interview on 3/30/26 at 9:01 a.m. with Resident 1's Responsible Party (RP), the RP stated the facility had lost Resident 1's glasses and had not replaced the glasses or reimbursed for the cost to replace the glasses.During an interview on 3/30/26 at 11:51 a.m. with the Social Service Assistant (SSA), the SSA stated if 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 protect resident right to be free from physical abuse for two of five sampled residents (Resident 1 and Resident 2) when Resident 2 struck Resident 1 and Resident 1 scratched Resident 2 during an altercation on 2/21/26.This failure resulted in physical injury to Resident 1 and Resident 2 and had the potential to result in psychosocial harm for both residents.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction with hemiplegia and hemiparesis (oxygen and nutrients to part of the brain is blocked causing brain tissue death resulting in physical paralysis and physical weakness) and difficulty walking.A review of Resident 1's Minimal Data Set (MDS) (a standardized assessment tool used in nursing homes), dated 12/11/25, indicated Resident 1 had Brief Interview for Mental Status (BIMS) (short test used to check a person's memory and thinking) of 15/15 indicating intact cognition.Resident 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.

Based on observation, interview and record review, the facility failed to ensure a home like environment for facility residents for a census of 130 when three out of five shower rooms were unclean and unsanitary.This failure resulted in lack of provision for a home like environment for facility residents when the shower rooms were unclean. A review of Resident 1's admission record indicated Resident 1 was admitted in January of 2025 with a diagnosis of Type two Diabetes Mellitus (a chronic condition where the body does not regulate sugar levels in the body, that can cause slowed wound healing). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/21/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, tool that tests cognition) score of 15 out of 15 indicating Resident 1 was cognitively intact.During an interview on 2/6/26 at 10 a.m. with Resident 1, Resident 1 stated the facility shower rooms were dirty and unclean. Resident 1 further stated he felt uncomfortable at the facility and wanted to leave.During a concurrent observation and…

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

Based on observation, interview, and record review, the facility failed to ensure a clean environment for facility residents when three out of 4 shower rooms in use were left unclean for a census of 130.This failure had the potential to spread infections to facility residents.During a concurrent observation and interview on 2/6/26 at 10:17 a.m. with Licensed Nurse (LN 1) in the South Station Shower room (SS), LN 1 confirmed there was mold on the shower curtain, a used tan bandage on the floor of the shower, a ball of hair on the shower drain, a used bandage on the shelf adjacent to the shower, and the sharp container was full and had razors sticking out. LN 1 further confirmed there were broken tiles in the shower room.During a concurrent observation and interview on 2/6/26 at 10:35 a.m., with LN 1 in the East Station Shower Room (ES), LN 1 confirmed that there was an overflowing trash bin with soiled items bagged and no cover and an overfilled sharps container with razors overflowing. LN 1 further confirmed there was a dirty yellow Person Protective Equipment (PPE) gown on 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 provide a safe, clean, comfortable, and homelike environment for two out of six sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2's room was cluttered with multiple medium sized brown boxes, an empty soda can, two white towels, overripe bananas, and multiple personal items of their roommate. This failure had the potential to result in an unsafe and unsanitary environment for Resident 1 and Resident 2 to receive care and services and risk for the residents not to achieve their highest practicable well-being.Findings: 1a. A review of Resident 1's clinical record indicated Resident 1 was initially admitted January of 2026 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebrovascular disease (a group of conditions that affects the blood flow and the blood vessels in the brain) affecting right dominant…

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 protect the resident's rights for one of six sampled residents (Resident 1) when Certified Nurse Assistant (CNA) 1 kissed Resident 1's forehead without consent.This failure reduced the facility's potential to treat Resident 1 with dignity and respect.Findings:During a review of Resident 1's admission Record (AR), indicated, Resident 1 was admitted 9/25 with a diagnosis of wedge compression fracture (front part of the spinal bone collapses due to pressure, forming a wedge shape.)During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/12/25 indicated Resident 1 has intact cognition.During a review of Interdisciplinary conference (IDT - meeting where professionals from different fields come together to share knowledge and solve complex problems) dated 1/28/26 indicated, .allegation of inappropriate conduct by staff towards him (Resident 1). Additionally, IDT met with Resident 1 and gave more details including, .that a staff member kissed his forehead and push his behind…

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 safety of residents when they failed to provide adequate monitoring and supervision for Resident 1 identified as at risk for elopement for a census of 129 residents. This failure resulted in Resident 1 wandering out of the facility to a coffee shop unaccompanied by staff. A review of Resident 1's clinical record indicated Resident 1 was admitted in November 2025 with a diagnosis of end stage renal disease (a condition where waste and fluid buildup in the body because the kidneys cannot remove them properly). A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 12/1/25 indicated Resident 1 had moderately impaired cognition (memory or thinking problems). During a review of Resident 1's progress note dated 12/10/26, the progress note indicated Resident 1 . discussed during IDT (interdisciplinary, group of professionals) due to being identified as a risk for elopement due to history.During a review of Resident 1's progress note dated 1/3/26, the note indicated, .Staff saw the resident at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to protect the right to be free from physical/mental abuse for one of six sampled residents (Resident 1), when Resident 2 forcefully grabbed Resident 1 by his throat during an altercation on 12/26/25. This failure had the potential to cause significant physical and emotional injury to Resident 1. Findings:Resident 1 was admitted to the facility in January of 2023 with diagnoses that included generalized weakness and Alzheimer's disease (a disease that causes a decline in cognitive function that interferes with daily life).A review of Resident 1's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 11/26/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating Resident 1 had severe mental and cognitive impairments.Resident 2 was admitted to the facility in December of 2024 with diagnoses that included dementia (a loss of thinking, remembering, and reasoning skills).A review of Resident 2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was free from abuse when Resident 2 threw a water pitcher towards Resident 3.This failure had the potential to result in physical injury and psychosocial distress to Resident 3. Findings:A review of Resident 3's record indicated resident 3 was admitted in September of 2025 with a diagnosis of Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest in activities). A review of Resident 3's Minimum Data Set (MDS- an assessment tool) dated 9/26/25 indicated Resident 3 was cognitively intact.A review of Resident 2's record indicated Resident 2 was admitted in September of 2025 with a diagnosis of Paraplegia (a condition that affects the spinal cord affecting use of half the body or lower legs).A review of Resident 2's MDS dated [DATE] indicated Resident 2 was cognitively intact.A review of Resident 2's progress noted dated 2/21/25 indicated Resident 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.

Based on interview, and record review, the facility failed to provide a written bed hold notice upon transfer to the hospital to Resident 4 or her family.This failure had the potential risk to deny Resident 4 re-admission to the facility. Findings:During a review of Resident 4's clinical record, the record indicated Resident 4 was admitted in August 2025 with a diagnosis of Diverticulitis (inflammation of the intestinal wall) of the large intestine.During a review of resident 4's MDS (Minimum Data Set-a assessment tool) dated 8/21/25 indicated Resident 4 was cognitively intact.During a review of Resident 4's clinical record, the progress notes dated 9/13/25 indicated, .resident admitted to hospital.During a review of Resident 4's clinical record, the progress noted dated 9/14/25 indicated, .received a call from resident daughter. she verbally understanding the situation and agrees with plan of care to send her to ER (emergency room) for evaluation.During an interview and concurrent record review on 9/24/25 at 3:55 p.m. with Director of Nursing (DON), the DON confirmed there was no…

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

Based on interview and record review the facility failed to ensure one of four sampled patients (Patient 1) with a known elopement risk had adequate supervision to ensure safety when Patient 1 could not be located by facility staff. This failure resulted in Patient 1 leaving the facility unaccompanied on 9/13/25 and 9/14/25.Findings:A review of Patient 1's clinical record indicated Patient 1 was admitted in September of 2025 with a diagnosis of Type 2 Diabetes Mellitus (a condition where the body is unable to regulate blood sugar levels). A review of Patient 1's Minimum Data Set (MDS- an assessment tool) dated 9/14/25 indicated Patient 1 was cognitively intact and the functional abilities section indicated Patient 1 was independent for wheelchair mobility up to 150 feet.During a review of Patient 1's care plan titled, The resident is non compliant., dated 9/13/25 indicated, .Frequent safety checks, Monitoring residents' whereabouts and any attempts to leave facility without staff knowledge.A review of Patient 1's progress note dated 9/13/25 indicated, . receptionist saw the resident…

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

Based on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from abuse when Resident 2 pushed Resident 1 during an altercation.This failure resulted in Resident 1 falling into the ground and had the potential for Resident 1 to experience fear or distress.Findings:During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in October 2025 with diagnoses that included left femur shaft fracture (a break in the thighbone), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body), and malignant neoplasm of occipital lobe (a cancerous tumor in the part of the brain that controls vision). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment.During a review of Resident 2's admission records, the records indicated Resident 2 was admitted to the facility in March 2025 with diagnoses that included dementia (a…

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

Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for one of 5 sampled residents (Resident 3) when Resident 3's medication was not administered as ordered and was left at bedside.This failure had the potential to result in contamination of the medication and for Resident 3 not having the desired effects of the medication.Findings:During a review of Resident 3's admission records, the records indicated Resident 3 was admitted to the facility in November 2025 with diagnoses that included complete lesion of thoracic spinal cord (a severe injury where there is a total loss of all feeling and all ability to control movement resulting in paralysis), paraplegia (loss of movement and/or sensation, to some degree, of the legs), depression (persistent feelings of sadness and loss of interest that interfere with daily life) , and retention of urine (the inability to completely empty the bladder). Resident 3's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 3 had intact…

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 services according to professional standards of quality for one of four sampled residents, Resident 1, when:1. Licensed Nurse 1 (LN 1) did not follow the physician's order; and2. LN 1 and Treatment Nurse (TN) demonstrated different techniques and knowledge in applying [NAME] wraps (adjustable compression wraps used to manage swelling associated with lymphedema, [swelling of a body part, usually an arm or leg, due to a buildup of fluid]) to Resident 1.These failures decreased the facility's potential to safely implement the physician's orders and possibly risk Resident 1's safety.Findings:A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility in June 2024 with the diagnosis that included Chronic Venous Hypertension (CVH, high pressure in the leg veins, symptoms can include pain, swelling, varicose veins, and heaviness in the legs) and difficulty in walking.A review of Resident 1's Brief…

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 guidelines for Enhanced Barrier Precaution (EBP, an infection control intervention to reduce transmission of multi-drug-resistant organisms) that utilize the use of gown, glove and to practice hand washing/sanitizing for one of four sampled resident, Resident 1 when:1. Licensed Nurse 1 (LN 1) did not wear gloves when she handled Resident 1's inhaler canister; and 2. LN 1 did not sanitize her hands before donning on clean gown and gloves.This deficient practice had the potential to spread multi-drug-resistant organisms (MDRO's, bacteria that resist treatment with more than one antibiotic) among residents, staff and visitors.Findings:1. During a review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility in June 2024 with the diagnosis that included Pressure Ulcer of Sacral Region, Stage 4 (severe deep wound that extends to the muscle, tendon or bone) and difficulty in walking. 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.

Based on interview and record review, the facility failed to provide Resident 1 with information regarding her medical condition and plan of treatment and failed to notify Resident 1's Family Member (FM) of change in condition, when Resident 1 had an episode of decreased responsiveness due to hypoglycemia (low blood sugar). This failure resulted in Resident 1 and Resident 1's FM being unaware of Resident 1's medical condition and treatment plan with the potential for worsening medical condition. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in October 2024 with multiple diagnoses including left acetabulum fracture (hip fracture), right pelvic fracture, osteoporosis (condition in which bones become weak and brittle), diabetes (high blood sugar levels), and obstructive sleep apnea (sleep disorder characterized by breathing pauses causing decreased oxygen levels). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 10/24/24, indicated Resident 1 had a Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (Resident 1) when resident left the facility unnoticed, for a census of 134. This failure resulted in Resident 1 not receiving nursing care and was exposed to unsafe environment for over 24 hours. Findings: A review of the clinical record indicated Resident 1 was admitted [DATE] with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 4/22/25 indicated Resident 1 was cognitively intact. A review of Resident 1's Nurses Progress Note dated 6/3/25 at 3:30 p.m. indicated, Received…

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 resident safety for one resident (Resident 1) out of a census of 130 when Resident 1 eloped the facility premises even with a Wanderguard monitor bracelet in place. This failure resulted in Resident 1 missing and eloping from the facility and has reduced the facility's potential in keeping Resident 1 safe from harm. Findings: During a review of Resident 1's admission Record (AR), the AR indicated that Resident 1 was admitted [DATE] with diagnosis including Alzheimer's Disease (a disease characterized by progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated May 7, 2025, indicated Resident 1 had severe cognitive impairment. During a review of Nurses Progress Note dated 6/1/25 at 4:45 p.m., indicated, .at 1630 .patient not found .facility staff located patient sitting at 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 provide effective pain management for one of three sampled residents (Resident 1) when upon admission to the facility, Resident 1's pain medication for moderate to severe pain was not available. This failure resulted in Resident 1 experiencing decreased comfort and participation with physical and occupational therapy. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2025 with multiple diagnoses including intertrochanteric fracture of left femur (hip fracture), pneumonia, chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), protein-calorie malnutrition (does not eat enough protein and calories to meet nutritional needs), and schizoaffective disorder (mental health condition characterized by symptoms of schizophrenia such as hallucinations and delusions, and symptoms of mood disorder). A review of Resident 1's Minimum Data Set (MDS-…

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

Based on record review and interview the facility failed to timely assess a change of condition (COC) in accordance with professional standards and practices for one of three sampled residents, Resident 1. This failure resulted in a delay in Resident 1 being transferred to an acute care hospital for decreased oxygen saturation and increased lethargy (a lack of energy and diminished mental alertness). Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2025 with multiple diagnoses including intertrochanteric fracture of left femur (hip fracture), pneumonia, chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), protein-calorie malnutrition (does not eat enough protein and calories to meet nutritional needs), and schizoaffective disorder (mental health condition characterized by symptoms of schizophrenia such as hallucinations and delusions, and symptoms of mood disorder). During a review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool),…

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 infection control practices for one of four sampled residents (Resident 2), when the Certified Nursing Assistant 2 (CNA 2) did not apply the required Personal Protective Equipment (PPE, gloves, gown and/or goggles/face shield) while changing linen in Resident 2 ' s room placed on an Enhanced Barrier Precaution (EBP, infection control intervention to reduce transmission of resistant organisms). This failure had the potential to spread infection among the facility ' s residents. Findings: A review of Resident 2 ' s admission Record, dated 5/6/25, indicated Resident 2 was admitted to the facility in 2020 with a diagnosis of renal and ureteral calculous obstruction (blockages prevent the normal flow of urine from the kidneys to the bladder, leading to the kidneys swelling up with urine). A review of Resident 2 ' s Order Summary Report, dated 5/6/25, indicated Resident 2 had an order for an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine). During a concurrent 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 ensure three out of five sampled residents (Resident 1, Resident 2, and Resident 3) were assisted with nail care as part of their Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), when Resident 1, Resident 2, and Resident 3 were found with long untrimmed nails. This failure had the potential for Resident 1, Resident 2, and Resident 3 to sustain injury and to acquire an infection. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility in Winter 2025 with multiple diagnoses including need for assistance with personal care, type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and paraplegia (partial or total loss of function in all four limbs and the torso). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated…

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

Based on observation, interview, and record review, the facility failed to ensure professional foot care was delivered to one of five sample residents (Resident 1), when Resident 1 did not receive podiatry (foot) services in a timely manner. This failure had the potential for Resident 1 ' s toenails remaining uncut and overgrown. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility in Winter 2025 with multiple diagnoses including need for assistance with personal care, type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and paraplegia (partial or total loss of function in all four limbs and the torso). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/15/25, indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 4/17/25 at 9:39 a.m. in Resident 1 ' s room, Resident 1's toenails were long with visible debris underneath right and left foot. Resident 1 ' s feet were dry with visible crusted areas on toes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 threw a cup filled with coffee towards Resident 1 splashing hot coffee onto Resident 1's right arm causing an injury. This failure reduced the facility's potential to protect Resident 1's right to be free from any type of abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE] with diagnoses including single subsegmental thrombotic pulmonary embolism (blood clot has blocked a small artery in the lungs), embolism and thrombosis of arteries of lower extremities (thrombosis-blood clot forms in the blood vessels; embolism-when a clot travels and blocks artery in leg), chronic kidney disease (kidneys are damaged and cant clear blood. Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 3/10/25, indicated, Resident 1 had a very mild…

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 meet professional standards of care for four of 32 sampled residents (Residents 21, 27, 92 and 82), when: 1. Resident 21 had no physician's order and no plan of care for self-catheterization (a procedure that involves inserting a hollow tube into one's own bladder). 2. Resident 27 did not receive an antibiotic (a drug used to treat infections caused by bacteria) order as prescribed. 3. Resident 92 had no plan of care for the use of a mouth guard. 4. Resident 82 did not have consistent and accurate documentation for urine output monitoring. These failures had the potential to compromise the residents' care and could have resulted in serious health complications. Findings: 1. A review of the admission Record indicated the facility admitted Resident 21 in 2018 with multiple diagnoses which included paraplegia (the inability to voluntarily move the lower parts of the body), a history of urinary tract infections and neuromuscular dysfunction…

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 pharmacy services were maintained for two of 129 residents when: 1. An expired resident's controlled medications (prescription medications with more risk of addiction and harm) were not removed from the medication cart for seven days, which had the potential to result in drug diversion. 2. Resident 27's Physician Order was not followed, and six omitted doses were still in the medication room without notifying the physician or pharmacy which had the potential to negatively affect Resident 27's treatment of infection. Findings: 1. During a concurrent interview and record review on 2/25/25 at 11:52 a.m. with the Director of Nursing (DON), the facility's Patient Narcotics Log was reviewed. The DON acknowledged 20 controlled medications for a resident that had expired on 2/17/25 were not brought to her office for destruction until 2/24/25. The DON stated, we created an opportunity for diversion by delaying removal of medications from the medication cart. The DON further stated the expectation was for all…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly when: 1. An opened multi-dose bottle of oseltamivir oral suspension (an antiviral medication used to treat or prevent influenza) was found in the refrigerator without an expiration date. 2. Staff personal belongings were kept in the medication storage room. These failures had the potential for unsafe or ineffective medication use, spread of infectious pathogens, and drug diversion. Findings: 1. During a concurrent observation and interview on 2/24/25 at 2:12 p.m. with Licensed Nurse (LN) 1 in the North station medication storage room., an opened 60 ml (milliliter, unit of measure) bottle of medication was found. LN 1 acknowledged there was a bottle of oseltamivir being stored in the refrigerator with no opened or expiration date. LN 1 stated, the expectation is for staff to label all medications with appropriate open/expired dates because it can affect the potency and effectiveness of the medication. During an interview on 2/25/25 at 12:09 p.m. with the Director 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 kitchen staff had appropriate competencies and skill sets to safely carry out certain functions of the food and nutrition service when: 1. Staff were not sure of the appropriate dish machine temperature needed to appropriately clean, 2. Staff were not sure how to appropriately test the red buckets (often called sanitizer buckets, used to hold sanitizer solutions, ensuring proper sanitization of surfaces and equipment, and are easily identifiable to prevent cross-contamination) to see if the sanitizer was at the correct concentration, 3. Hand hygiene not done according to policy, 4. A cook was observed using a yellow cutting board (used for raw poultry) to cut cooked roast beef, instead of the brown board. These failures had the potential to leading to food borne illness for the 125 Residents eating facility prepared meals. Findings: 1. During an observation and interview in the kitchen on 2/25/25 at 12:50 p.m. with Dietary Aide (DA 1). DA 1 described the steps needed to effectively run the dish…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Food labels were lacking or mislabeled, 2) Kitchen areas found dirty and/or rusty, 3) Smallware not discarded when no longer able to be sanitized, 4) Bin of clean plates found with food residue and a sugar packet on a plate, 5) Three steam table pans were stored wet, and one had food residue in the pan, 6) Hairnets not used consistently used in the kitchen, 7) Resident tray containing chocolate pudding was brought down the hall without a cover on top, and 8) Sprinkler cleaning occurred over food production and clean dishes that were drying. These failures had the potential to lead to food borne illness for the 125 Residents eating facility prepared meals. Findings: 1) During the initial kitchen tour on 2/24/25 beginning at 9:24 a.m., two ice cream cups were found with no label in the reach-in freezer. The refrigerator…

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 and maintain an effective infection prevention and control program for a census of 129 when: 1. Three facility staff did not wear required personal protective equipment (PPE) when assisting Resident 44 and Resident 22 whom were both on enhanced barrier precautions (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); 2. Resident 22's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labelled and properly stored when not in use; 3. Resident 17's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not labelled and properly stored when not in use; 4. A facility staff did not…

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

Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when: 1. Walk-in freezer found with ice build-up on the floor, 2. The ice machine leaked, and a bucket was placed underneath the unit to catch the water, 3. The dish machine temperature gauge was not moving and did not indicate the temperature of the water, and 4. Food service (tray line) rack did not hold position and was held in position with plastic wrap. These failures had the potential of leading to food borne illness for the 125 Residents eating facility prepared meals. Findings: 1.During a concurrent observation and interview on 2/24/25 at 10:01 a.m., with the Dietary Manager (DM) in the walk-in freezer, ice build-up was on the floor. DM stated that the ice machine had leaked earlier in the day and some water had gone into the freezer and had frozen on the floor. During an observation on 2/25/25 at 2:50 p.m., the walk-in freezer still had ice build-up on the floor. During an interview on 2/26/25 at 3:00 p.m., with the DM, DM stated that he thought the ice…

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 call light system was accessible for four out of 32 sampled residents (Resident 41, Resident 11, Resident 52, and Resident 20), when call light buttons were observed not within reach. This failure had the potential to result in residents' needs not being met and prevent communication for assistance when needed. Findings: A review of Resident 41's clinical record indicated Resident 41 was admitted to the facility June 2024 with multiple diagnoses which included hemiplegia (loss of ability to move one side of the body) and hemiparesis (weakness or paralysis on one side of the body). A review of Resident 11's clinical record indicated Resident 11 was originally admitted to the facility March 2008 with multiple diagnoses which included muscle weakness and other reduced mobility. A review of Resident 52's clinical record indicated Resident 52 was originally admitted to the facility January 2025 with multiple diagnoses which included muscle weakness and need for assistance with personal care. 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 protect two out of 32 sampled residents' (Resident 8 and Resident 20) right to be treated with respect and dignity when facility staff were standing over Resident 8 and Resident 20 while feeding them during the 2/24/25 lunch meal. This failure resulted in Resident 8 to experience emotional distress and felt disrespected and potential for Resident 20 to feel that he was not being treated with respect and dignity. Findings: 1a. A review of Resident 8's clinical record indicated Resident 8 was admitted April of 2021 and had diagnoses that included chronic pain syndrome (condition that involves persistent pain that lasts for weeks to years), weakness, contracture (permanent shortening of muscles, skin, and nearby soft tissue that results in limited range of motion and stiffness), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 8's Minimum Data Set (MDS- a federally mandated resident assessment tool)…

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 reasonable accommodation of resident needs for one of 32 sampled residents (Resident 20) when Resident 20's call light system was not appropriate and was not within reach. This failure placed Resident 20's safety at risk and had the potential for Resident 20's needs to be not met. Findings: A review of Resident 20's clinical record indicated Resident 20 was admitted January of 2025 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) affecting left non-dominant side, dementia (a progressive state of decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion), muscle weakness, and need for assistance with personal care. A review of Resident 20's MDS Cognitive Patterns, dated 1/8/25, indicated Resident 20 had BIMS score of 2 out of 15 which indicated Resident 20 had a severely impaired cognition. A review of Resident 20's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two out of 32 sampled residents (Resident 24 and Resident 47) were assisted with nail care as part of their Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when both residents were found with long untrimmed nails. This failure had the potential for Resident 24 and Resident 47 to sustain injury and to acquire an infection. Findings: Resident 24 was admitted to the facility October 2022 with multiple diagnoses which included multiple sclerosis (disease where nerve damage disrupts communication between the brain and the body which can result in muscle weakness, numbness and impaired coordination) and quadriplegia (partial or total loss of function in all four limbs and the torso). A review of Resident 24's Minimum Data Set (MDS, an assessment tool) dated 1/15/25, indicated, Resident 24 had moderate cognitive impairment (a stage 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 one of 32 sampled residents (Resident 13) were offered resident centered activities. This failure decreased social interactions and increased the potential for negative impact on the physical, mental and psychosocial well-being of Resident 13. Findings: Resident 13 was admitted to the facility in Winter 2023 with diagnoses that included senile degeneration of brain (a progressive state of decline in mental abilities). During a concurrent observation and interview on 02/24/25 at 10:57 a.m., with Resident 13, Resident 13 was observed sitting on their bed. Resident 13 expressed a desire to communicate with others and reported loneliness and difficulty due to her hearing impairment. Resident 13 stated that a request for hearing assistance was made to the facility. There were no magazines, music players, game boards, amplifiers or any other activity tools observed in Resident 13's room. During an observation, on 02/24/25 at 2:15 p.m., Resident 13 was observed lying in bed, eyes opened. She was not…

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 two out of seven sampled residents (Resident 44 and Resident 59) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 44 and Resident 59 physician's order for low-air loss mattress (LALM- a medical-grade mattress designed to prevent and treat pressure injuries by reducing moisture and heat buildup) monitoring of settings and functioning was not consistently done. This failure had the potential for Resident 44 and Resident 59's wounds to get worse, and for the residents to not achieve their highest practicable well-being. Findings: 1a. A review of Resident 44's clinical record indicated Resident 44 was admitted April of 2020 and had diagnoses that included dementia (a progressive state of decline in mental abilities), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), weakness, and malnutrition (state of poor nutrition that occurs when…

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

Based on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 32 sampled residents (Resident 8) when Resident 8's physician's order for oxygen therapy was not followed. This failure had the potential to result in unsafe delivery of oxygen to Resident 8 and for Resident 8 to not achieve her highest practicable well-being. Findings: A review of Resident 8's clinical record indicated Resident 8 was admitted April of 2021 and had diagnoses that included respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), weakness and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 8's Minimum Data Set (MDS- a federally mandated resident assessment tool)…

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

Based on interview and record review, the facility failed to ensure one out of 32 sampled residents (Resident 17) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 17's pain medication order was not followed. This failure had the potential for Resident 17 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, and not attain his highest practicable well-being. Findings: A review of Resident 17's clinical record indicated Resident 17 was admitted May of 2023 and had diagnoses that included diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and low back pain. A review of Resident 17's Minimum Data Set (MDS- a federally mandated…

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 food in accordance with the physician's prescribed diet for one out of 32 sampled residents (Resident 16) when Resident 16 whom was on No Added Salt diet (NAS- a dietary restriction that limits the intake of salt) received two salt packets during the 2/25/25 lunch meal. This failure had the potential to negatively affect Resident 16's medical condition and for Resident 16 to not achieve his highest practicable well-being. Findings: A review of Resident 16's clinical record indicated Resident 16 was admitted July of 2024 and had diagnoses that included dementia (a progressive state of decline in mental abilities), malnutrition (state of poor nutrition that occurs when the body does not receive enough or the right nutrients to function properly), hypokalemia is a condition where the potassium levels in the blood are abnormally low), and hypertension (high blood pressure) A review of Resident 16's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 12/24/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician's orders were followed in accordance with professional standards of care for one of three sampled residents (Resident 1) when PRN (given as needed or requested) Clonidine hydrochloride (Clonidine HCl-medication used for high blood pressure) was not given as per physician order. This failure had the potential to negatively affect Resident's 1 health condition and well-being. Findings: During a review of Resident 1's admission Record (AR) , the AR indicated, Resident 1 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebrovascular disease (CVA-stroke, loss of blood flow to a part of the brain), Chronic Kidney Disease (long-term condition when kidneys don't work properly) and hypertensive heart disease (group of heart conditions caused by long-term high blood pressure.) During a review of Resident 1's Order Summary Report…

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 pain management was provided consistent with professional standards of practice, the comprehensive care plan, and the resident's choices for one of 3 residents (Resident 1) when Resident 1's pain was not assessed and managed timely. This failure resulted in Resident 1 not experiencing adequate pain relief and not attaining the highest possible level of comfort. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in July 2016 with diagnoses that included depression, anxiety, lumbar intervertebral disc degeneration (occurs when the discs in the lower back wear down), and chronic pain syndrome (pain that lasts for longer than 3 months). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had intact cognition. During a review of Resident 1's care plan, initiated on 4/22/19, the care plan indicated, The resident has (chronic) pain .On the dot asking for pain Medication. Never misses a dose. Watches clock for next…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s right to be free from sexual abuse by a resident, when one of four sampled residents (Resident 1) had her breast touched and massaged by Resident 2. This failure had the potential to negatively impact Resident 1 ' s psychosocial well-being. Findings: A review of Resident 1 ' s admission record, indicated she was admitted in 9/22 with a diagnosis of Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities). The record also indicated Resident 1 was not her own responsible party. A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS, a federally mandated assessment tool), dated 8/8/24, indicated Resident 1 had severely impaired memory. A nursing note, dated 10/26/24, indicated Resident 1 had been sitting in her wheelchair at the nurses ' station when staff witnessed Resident 2 grabbed Resident 1 ' s hands, touched her left breast and began to massage…

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 proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for two out of five sampled residents (Resident 4 and Resident 6) when Resident 4 and Resident 6's physician's orders for oxygen therapy were not followed and their oxygen therapy was not care planned. These failures had the risk to result in unsafe delivery of oxygen to Resident 4 and Resident 6 and potential for Resident 4 and Resident 6 to not receive appropriate respiratory care and not achieve their highest practicable well-being. Findings: 1a. A review of Resident 4's clinical record indicated Resident 4 was admitted June of 2024 and had diagnoses that included congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body), diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing), and anemia (a condition of not having enough healthy red…

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 accurate and safe pharmaceutical services to meet the needs of 22 residents for a census of 124, when: 1. Licensed Nurses (LN 6 and LN 3) administered residents' medications scheduled for 9 a.m., more than an hour later than the scheduled time; 2. Resident 153 missed her morning dose of medication to treat restless leg syndrome (involuntary leg movement which causes uncomfortable sensation in legs) and 3. Resident 203's pain medication was not signed as given in a timely manner. These failures had the potential for ineffective medication therapy. Findings: During a concurrent observation and interview on 2/13/24 at 10:28 a.m., LN 6 was observed passing medications in North East Hall. LN 6 stated she was passing medications scheduled for 9 a.m. LN 6 stated she had four (4) more residents to give the 9 a.m. medications, and stated it would be close to 11 a.m. by the time she completed medication administration for her assigned residents. LN 6 acknowledged she was late with medication administration and…

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

Based on observation, interview and record review, the facility failed to ensure food was served with an appetizing temperature for 8 out of 31 sampled residents (Resident 34, Resident 88, Resident 1, Resident 403, Resident 10, Resident 49, Resident 43 and Resident 37). This failure had the potential for the residents not consuming their meals and may cause weight loss. Findings: During an interview on 2/13/24 at 9:15 a.m. with Resident 34, Resident 34 stated, food is unacceptable, the temperature was cold. During an interview on 2/13/24 at 10:23 a.m. with Resident 88, Resident 88 stated, food is sometimes cold. During an interview on 2/13/24 at 10:30 a.m. with Resident 1, Resident 1 stated, food is cold .temperatures are hit or miss. During an interview on 2/13/24 at 10:51 with Resident 403's Family Member 1 (FM1), FM 1 stated, food is not always hot. During an interview on 2/13/24 at 1:03 p.m. with Resident 10, Resident 10 stated, food is sometimes cold. During an interview on 2/13/24 at 1:10 p.m. with Resident 49, Resident 49 stated, food is cold most days. During an 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.

Based on observation, interview, and record review the facility failed to ensure the resident rights to personal privacy and confidentiality of his or her personal medical information was maintained for a census of 124 residents when: 1.Meal tray tickets with resident identifiers were found in the general trash and 2.A computer screen was left unattended with Protected Health Information (PHI) visible to anyone walking by. These failures had the risk potential to compromise resident privacy and confidentiality for a census of 124 residents residing in the facility. Findings: 1. During a Kitchen Tour on 2/14/24, at 1:57 p.m., tray tickets with resident names and room numbers were observed in a garbage can. The Dietary Manager (DM) confirmed there were resident's tray tickets in the garbage can and had Protected Health Information (PHI). During a concurrent observation and interview on 2/14/24, at 1:58 p.m., with the DM, the DM confirmed the tray tickets contained information such as resident name, room number, diet order and food likes/dislikes which should not have been disposed 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 provide a homelike environment for the residents when the sliding door curtains in rooms 46, 47, 53, and 54 were torn, had holes, loose threads, brown stains and the walls in rooms 33, 46, 47, 53 and 54 had gouges, scratches, and peeling wallpaper. These failures resulted in the residents residing in these rooms not being provided a homelike environment and had the potential to negatively impact their psychosocial well-being. Findings: During the Initial Pool observation on 2/13/24, rooms 46, 47, 53 and 54 sliding door curtains were found to have tears, holes, loose thread and brown stains. The walls to rooms 33, 46, 47, 53 and 54 were observed to have gouges, scratches and peeling wallpaper. During an interview on 2/15/24 at 7:17 a.m., with Housekeeper (HK 1), HK 1 stated torn and dirty sliding door curtains are not nice for [residents] to look at and does not provide a homelike environment. During an interview on 2/15/24 at 7:20 a.m. with the Housekeeping Manager (HM), the HM stated, we have ordered new…

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 their policies and procedures to ensure professional standards of quality was maintained for one of 31 sampled residents (Resident 34) when the attending physician was not notified of a delay in obtaining STAT (immediately) laboratory samples for Resident 34. This failure had the potential to cause delay in the management of Resident 34's change of condition. Findings: A review of Resident 34's 'admission Record' indicated Resident 34 was admitted in 12/2023 with diagnoses which included sepsis (body's extreme response to an infection), Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar), kidney failure, obesity and hyperlipidemia (high cholesterol). A Brief Interview for Mental Status (BIMS, a tool used to test cognition) dated 1/3/2024, indicated Resident 34 was cognitively intact. During a review of Resident 34's progress notes, dated 2/9/24, the notes indicated, Charge nurse reports res [resident] cont [continue] to c/o [complain of] SOB [shortness of breath] and wheezing after…

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 each resident received the necessary care and services in accordance with professional standards of quality and their individualized person-centered care plans for five of 31 sampled residents (Resident 76, Resident 82, Resident 60, Resident 58, and Resident 54), when the staff failed to respond to their call lights (alerting devices to call nursing staff) for assistance with personal care in a timely manner; leaving residents in wet or soiled briefs for extended periods of time. These failures resulted in the delay in providing the necessary care, causing physical discomfort, frustration, and had the potential to affect the resident's dignity, health and well-being. Findings: A review of the facility's policy titled, Quality of Life, Accommodation of Needs, dated 1/2020 indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe .functioning,…

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 effective pain management was provided for one of 31 sampled residents (Resident 62) who was on hospice (end of life care that includes pain management), when the facility's licensed staff did not notify Resident 62's hospice team that his pain medication was ineffective. This failure resulted in Resident 62's enduring uncontrolled pain and suffering. Findings: A review of Resident 62's clinical record indicated, Resident 62 was admitted to the facility in 2022 with multiple diagnoses that included low back pain and rheumatoid lung disease with rheumatoid arthritis (an autoimmune disease that causes pain, inflammation and damage to the joints and other body parts). His Minimum Data Set (MDS, an assessment tool) indicated he had moderate cognitive impairment. A review of Resident 62's Order Summary Report, indicated the following: RESIDENT admitted INTO [NAME OF HOSPICE] HOSPICE CARE AS OF 1/24/24 . and was on the following medications for pain: Dilaudid Oral Liquid 1 MG/ML [milligram/milliliter, 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.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of 31 sampled residents, (Resident 91) who received hemodialysis (HD, a medical procedure that helps remove waste and excess fluid from the blood when the kidneys are unable to perform this function), when his intake, output and weights were not accurately measured as ordered. These failures increased Resident 91's risk in developing fluid overload. Findings: A review of the clinical record indicated Resident 91 was admitted to the facility end of 2023 with multiple diagnoses that included kidney failure. A review of Resident 91's Order Summary Report indicated the following: Indwelling Catheter [a tube inserted to drain urine from the bladder and left in place] .to closed drainage for Neurogenic Bladder [lack of bladder control]. Monitor I/O [intake and output] every shift. Monitor weights daily in am [morning] at same time, same clothing, same scale. If weight variance is greater than or equal to 2 lbs [pounds, unit of measurement] in 1 days[sic] or, greater…

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

Based on observation, interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 68) was free from unnecessary medications when a psychotropic medication (any drug that affects brain activity associated with mental processes and behavior) was ordered in the absence of a diagnosis of depression. This failure placed Resident 68 at risk for adverse effects from use of a psychotropic medication. Findings: A review of Resident 68's clinical record indicated he was admitted to the facility late 2023 with multiple diagnoses that included high blood pressure. His diagnosis list did not include a diagnosis of depression. A review of Resident 68's Minimum Data Set (MDS, an assessment tool), dated 11/21/23, indicated he was cognitively intact, and he did not have an active diagnosis of depression. A review of Resident 68's Order Summary Report indicated, Trazodone HCI [hydrochloride] Oral Tablet 50 MG [milligram, unit of measurement] .Give 1 tablet by mouth at bedtime for Inability to sleep M/B [manifested by] wandering around facility at night .order date…

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 food safety requirements when: 1. two cutting boards were found to have a sticky substance on the cutting surface that could get in contact with food being served to 120 residents eating food prepared at the facility; 2. Resident 37's food tray was left at bedside when he was out on an appointment; and 3. Resident 403's food tray was left at bedside when she was out at dialysis treatment. These failures had the potential to contaminate food and cause illness. Findings: During a concurrent observation and interview on 2/14/24 at 2:25 p.m. with the Dietary Manager (DM) in the kitchen, two cutting boards were found to have a sticky substance on their surface. The DM touched the substance on the boards and stated the sticky substance should not be present. The DM confirmed resident food can be contaminated if it is in contact with the sticky substance. During a review of the facility's policy and procedure (P&P) titled, Sanitization, dated 2001 and revised November 2022, the P&P indicated, equipment is…

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 effective infection prevention and control measures were followed for a census of 124 when: 1. the toilet in room [ROOM NUMBER] had white linen on the floor with brown stains, the toilet bowl had brown splashes and the hand washing sink had a used paper towel on the side of the faucet; 2. the laundry room ceiling had brownish discoloration and the vents were covered with black substances; and 3. the laundry machine pipes had a gray and whitish build up and the sides had white, and brown build up. These failures had the potential to spread germs and cause infections among residents and staff. Findings: 1. During an observation on 2/13/24 at 10 a.m., the toilet in room [ROOM NUMBER] had a white linen on the floor with brown stains, the toilet bowl had brown splashes and the hand washing sink had a used paper towel on the side of the faucet. During a concurrent observation and interview on 2/13/24 at 10:14 a.m., the Licensed Nurse (LN…

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 the walk-in freezer in a safe operating condition for a census of 120 residents who received meals prepared by the facility when ice build-up was found on the entire ceiling, walls and food storage racks, and the freezer door seal was modified with black insulation tape. These failures had the potential to alter the food quality and safety for 120 residents who received meals prepared in the facility's kitchen. Findings: During a concurrent observation and interview on 2/13/24 at 8:45 a.m. with the Dietary Manager (DM), in the walk-in freezer, the DM confirmed there was a thick layer of ice build- up on the ceiling, walls and on the metal storage racks. The DM stated, this has been an ongoing issue .ice buildup .maintenance removes ice weekly .can damage food served to residents. During a concurrent observation and interview on 2/14/24 at 2:15 p.m. with the DM outside the walk-in freezer, the DM stated maintenance placed black insulation tape on the door frame to keep air from getting in [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.

Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, an assessment tool used to identify resident needs) was completed in a timely manner for 1 of 31 sampled residents (Resident 1) when the MDS was not completed no less than once every 3 months as required by the regulations. This failure had the potential to delay Resident 1's care planning process. Findings: During a review of Resident 1's clinical record, Resident 1 was admitted to the facility in 5/2019 with diagnoses which included muscle weakness, paraplegia (unable to move legs or lower body parts), and atrial fibrillation (a condition characterized by an irregular and rapid heart rate). A review of Resident 1's electronic medical record indicated the last quarterly MDS assessment was completed in 10/2023. During a concurrent interview and record review on 2/16/24 at 1:00 p.m., with the MDS Coordinator, the MDS Coordinator stated Resident 1's quarterly MDS assessment was overlooked and should have been completed in a timely manner. The MDS coordinator confirmed Resident 1's…

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

Based on observation, interview, and record review, the facility failed to accurately document and identify food preferences for one of 31 sampled residents (Resident 305), when Resident 305 liked ice cream, but the meal ticket indicated he disliked ice cream. This failure had the potential to result in Resident 305's food preferences not being honored and followed. Findings: During a review of Resident 305's admission record, the record indicated Resident 305 was admitted in February of 2024 with diagnoses that included Parkinsonism (condition that causes slowed movements, stiffness, and tremors), Pulmonary embolism (occurs when a blood clot blocks and stops blood flow in a blood vessel in the lungs), seizures (sudden, uncontrolled burst of electrical activity in the brain), and major depressive disorder (disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 305's Mini-Nutritional Assessment, dated 2/8/24, the assessment indicated Resident 305 scored 3 points equivalent to malnourished. During a concurrent 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.

Based on observation, interview, and record review, the facility failed to ensure the call light system was accessible for one of 31 sampled residents (Resident 303), when Resident 303's call light was placed hanging on the curtain and not within reach. This failure had the potential to negatively affect Resident 303's safety by preventing the resident from communicating a request for assistance when needed. Findings: During a review of Resident 303's admission records, the records indicated Resident 303 was admitted in February of 2024 with diagnoses that included pneumonia (inflammation and fluid in the lungs), pain in left hip, asthma (airways get narrow and swollen and are blocked by excess mucus), severe dementia (a condition that affects memory, thinking and social abilities), delirium (altered state of consciousness, characterized by episodes of confusion), and difficulty walking. During a review of Resident 303's care plan, revised on 2/12/24, the care plan indicated, Resident is at risk for falls: Impaired mobility, weakness .Assist resident getting in and out of bed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide required supervision for one of three sampled residents (Resident 1), when Resident 1 was left on the toilet, fell, and hit her head. This failure resulted in Resident 1 spending five days in the hospital to receive treatment for an acquired subdural hemorrhage (a severe and sudden loss of blood from a damaged blood vessel). Findings: A review of Resident 1's admission record indicated admission to the facility on [DATE], with diagnoses which included a displaced right femur (thigh bone) fracture after a fall, Parkinson's disease (a degenerative brain condition which results in problems with balance and movement) with dyskinesia (involuntary and erratic movement of the face, arms, and legs), difficulty in walking, and a need for assistance with personal care. A review of a fall risk assessment dated [DATE] at 10:11 p.m., indicated Resident 1 had a high risk for falls and was, .Unable to independently come to a standing position . [and] Requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate assistance in a timely manner when: 1. Resident 3 requested assistance to the restroom, waited an hour for assistance from the proper number of CNAs, and ended up soiling his clothes in front of his family members; and, 2. Resident 2's dinner tray was dropped off onto his bedside table without assistance to eat or communication as the Certified Nurse Assistant (CNA) was going on a break. This failure decreased the facility's potential to provide prompt assistance to residents for their activities of daily living when they need it. Findings: 1. A review of an admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included stroke (a blockage of an artery in the brain which can result in difficulty with thinking, speech, and movement and sensation), overactive bladder, need for assistance with personal care, and difficulty in walking. A review of a care plan…

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

Based on observation and interview, the facility failed to ensure two dumpsters and a trash bin were covered. This failure decreased the facility's potential to prevent the attraction of pests which eat of disposed food and taking refuge within facility property. Findings: In an observation of the facility's large dumpsters located in the back of the facility on 10/5/23 at 4:04 p.m., a blue dumpster's lid was pulled back which exposed clear plastic bags of trash visible. Adjacent to the blue dumpster was a green dumpster with its lid pulled back, allowing its contents to be accessible to pests. Near an entrance door on the northern perimeter of the facility was a large, light-colored trash bin. Its lid was propped on its side between the bin and the outside wall of the facility. Blue soiled gloves, a crumpled cigarette package, 25 yellow-brown cigarette butts, and a mouse trap were observed within two feet outside of the trash bin. In an interview on 10/5/23 at 4:54 p.m., the Maintenance Director (MD) verified the blue and green dumpsters were open. The MD stated all trash…

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 resident medical information was safeguarded from public view for one resident (Resident 1) of three sampled residents. This failure decreased the facility's potential to protect confidential resident information. Findings: In an observation and concurrent interview on 10/5/23 at 4:34 p.m., the Certified Nurse Assistant 1 (CNA 1) confirmed the presence of Resident 4's telephone order on the counter of the North-East nurses' station. The CNA 1 verified Resident 4's name and telephone order. The CNA 1 also verified Resident 4's telephone order was visible and readable if a visitor were to pass the nurses' station or stand in front of the nurses' station. A review of Resident 4's telephone order, dated 10/5/23, indicated Resident 4's name, physician's name, prescription number, medication, and lab result. The telephone order also indicated, This document .is private and may contain Protected Health Information (PHI) .Any unauthorized review, use, disclosure, distribution of this information is prohibited.…

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.