Fair Oaks Healthcare Center

Based on interview and record review, the facility failed to ensure one of 34 sampled residents (Resident 103) was free from chemical restraints and unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 103's Lorazepam (medication used to treat anxiety) was given without appropriate target behavior and side effects monitoring, and no care plan was developed for Resident 103's use of antianxiety medication.These failures decreased the facility's potential to provide appropriate care and monitoring of Resident 103's target behaviors and increased Resident 103's risk and exposure to side effects associated with psychotropic medications.Findings:During a review of Resident 103's admission records, the records indicated Resident 103 was admitted to the facility in January 2026 with diagnoses that included anxiety disorder (excessive, persistent fear or worry that interferes with daily life). Resident 103's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/3/26, indicated…

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

Based on observation and interview, the facility failed to ensure nursing services were provided in accordance with professional standards of practice for two of two, sampled residents (Residents 185 and 172), when:1. Nursing staff did not follow safe handling standards for hazardous medications.2. A Nurse did not obtain or verify required vital signs prior to administering medications with physician hold parameters.These failures placed residents at risk for medication-related adverse effects and placed staff at risk for exposure to hazardous medications.During an observation and review of hazardous medication administration for Resident 185, on 2/4/26 at 8:38 a.m., LN 1 prepared and administered the following hazardous medications without wearing gloves:Mycophenolate Sodium 180 mg, and Tacrolimus 1 mg medications to treat a previous kidney transplant. LN 1 handled the medications with bare hands during preparation and administration.During an observation of medication administration for Resident 172 on 2/4/26 at 9:05 a.m., LN 2 administered Metoprolol 100 mg by mouth without…

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 Activities of Daily Living (ADLs: fundamental self-care tasks that individuals perform daily to maintain independence and hygiene) to residents dependent with ADL care for one of 34 sampled residents (Resident 30), when the facility failed to trim Resident 30's toenails after multiple requests from nursing staff.This failure had the potential for Resident 30 to experience dignity concerns related to not being groomed properly, and with the potential for fungal infection due to long toenail length. During an observation on 2/10/25, at 10:02 a.,m., in Resident 30's room. Resident 30 was observed to have long, thickened, discolored toe nails.During an interview on 2/10/26, at 10:45 a.m., with Licensed Nurse (LN) 6, LN 6 stated, Resident 30 does have long nails. During a review of Reisdent 30's Shower Sheet dated 1/15/26, sheet indicated, Toe Nails Need Clipping was checked as Yes. During a review of Reisdent 30's Shower Sheet dated 2/1/26, sheet indicated Toe Nails Need Clipping was checked as Yes.…

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 necessary treatment and services were implemented to promote healing and prevent worsening of the pressure injury (PI, area of damaged skin caused by prolonged pressure on a specific area of the body or friction) for one of 34 sampled residents (Resident 26), by failing to utilize a low air loss mattress (LAL, a special mattress designed to circulate a constant airflow used for residents who have pressure injuries) as indicated in the policy and recommended by wound care physician.This failure had the potential to impede and delay the healing for Resident 26's pressure injury and placed Resident 26 at risk for worsening of PI.A review of the admission record indicated the facility admitted Resident 26 in October of 2024 with multiple diagnoses, which included heart and kidney disease, chronic pain syndrome, and widespread edema (swelling).A review of Resident 26's admission nursing assessment dated [DATE] indicated the resident had coccyx…

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

Based on interview and record review, the facility failed to ensure a resident with bowel incontinence received appropriate treatment to restore normal bowel function for one of 34 sampled residents (Resident 66) when Resident 66 received a laxative [substance that relieve constipation by softening stool or stimulating bowel movements] while having diarrhea (loose, watery stools occurring three or more times daily) and loose stools caused by C. Difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection.This failure had the potential to result in prolonged fecal incontinence, decreased skin integrity, dehydration, and frustration for Resident 66.Findings:During a review of Resident 66's admission records, the records indicated Resident 66 was admitted in January 2026 with diagnoses that included cellulitis of right lower limb (bacterial infection of the skin and underlying tissues in the right lower leg), severe sepsis with septic shock (a life-threatening infection that causes widespread inflammation leading to organ failure), and depression (persistent…

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 respiratory care was provided according to professional standards for three of 34 sampled residents (Resident 124, Resident 144, and Resident 188) when: Resident 124's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was on the floor;Resident 144's continuous positive airway pressure (CPAP, a medical device that is used to deliver pressurized air directly into the airways) was not placed in an infection control bag after use;Resident 188's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was left on top of the nightstand and was not placed in an infection control bag after use.These failures had the potential to result in unsafe and unsanitary delivery of respiratory care to Resident 124, Resident 144 and Resident 188. 1. A review of the admission Record indicated Resident 124 was admitted [DATE] with diagnoses…

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 residents are free of significant medication errors for one of 34 sampled residents (Resident 56) when Resident 56's antibiotic (medication used to treat infections) doses were not administered as ordered by the physician.This failure had the potential to result in Resident 56's prolonged use of antibiotics and not having the desired effects of the medication.Findings:During a review of Resident 56's admission records, the records indicated Resident 56 was admitted to the facility in January 2026 with diagnosis that included osteomyelitis of vertebra (infection of the spine). Resident 56's MDS indicated Resident 56 had intact cognition.During a review of Resident 56's care plan, initiated 1/6/26, the care plan indicated, .[Resident 56] is on antibiotic therapy Cefazolin [an antibiotic] 2 grams (g, a unit of measurement) every 8 hours until 2/27/26.Administer ANTIBIOTIC medications as ordered by physician.During a review of Resident 56's Medication Administration Record (MAR - a daily documentation record used by 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 maintain a safe and sanitary environment when:The glass windows were cracked and shattered in the laundry room; and,The clean linen cart cover had a rip/tear.These failures had the potential for moisture build up leading to growth of molds in the laundry area and clean linens to be exposed to contaminants such as dust. During a concurrent observation and interview with the Laundry Staff 1 (LS 1) in the clean side of the laundry area on 2/11/26 at 10:07 a.m., a cardboard was taped over a broken glass window, another window was cracked with blue tape on the cracks, and the clean linen cover had a rip (linear tear) on the top portion. The LS 1 stated she placed the cardboard to prevent cold air from coming in the room and the windows had been like this for 2-3 months. The LS 1 further stated [name of Environmental Director] knew about the rip on the clean linen cover. During an interview with the LS 2 on 2/11/26 at 10:14 a.m. in the laundry room, the LS 2 stated if the cover of the clean linen cart had a rip,…

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 investigate a complaint of mistreatment for one of five sampled residents (Resident 1), when Resident 1's Family Member (FM) notified facility staff of Resident 1's complaint and facility did not conduct an investigation including resident and staff interviews and, staff education.This failure had the potential to place Resident 1 and other residents at risk for mistreatment leading to psychosocial distress. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in August 2025 with multiple diagnoses including malignant neoplasm of the cauda equina (a cancerous tumor affecting nerves at end of the spinal cord), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), neuromuscular dysfunction of the bladder (nerves and muscles that control bladder function are impaired), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety or fear that interfere with daily life). A review of Resident 1's Minimum Data…

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 a safe and protective environment to be free from physical abuse was provided for one of three sampled residents (Resident 1), when Resident 1 was hit in the back of the head by Resident 2. This failure resulted in Resident 1's feeling scared of Resident 2 and had the potential to expose Resident 1 and other residents from further possible physical abuse from Resident 2. During a review of Resident 1's admission Record (AR) dated 5/2018, the AR indicated Resident 1 had diagnoses which included major depression. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/29/25, the MDS indicated Resident 1's memory was intact.During a review of Resident 2's AR dated 5/2018, the AR indicated Resident 2 had diagnoses which included dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition…

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 four sampled residents (Resident 1) from injury when Resident 1 slid off the edge of the bed to the floor when a Certified Nursing Assistant (CNA) was assisting with dressing. This failure resulted in Resident 1 sustaining a right hip fracture causing pain, decreased mobility and functional level. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in December 2019 with multiple diagnoses including senile degeneration of the brain (progressive decline in cognitive abilities that occurs with aging characterized by loss of memory and thinking skills), fibromyalgia (a condition causing widespread body pain), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- interrupted blood flow to the brain causing brain tissue death), and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 1'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 interview and record review, the facility failed to provide nursing services in accordance with professional standards of practice to meet the needs of one of four sampled residents (Resident 1), when the facility did not follow a physician order to perform laboratory blood tests. This failure had the potential to result in worsening of Resident 1 ' s bladder infection and subsequent need to transfer to a hospital. Findings: A review of the facility ' s policy titled, Request for Diagnostic Services, with the last revision date of 2007, indicated, All orders for diagnostic services must be entered into the resident ' s medical record .Orders for diagnostic services will be promptly carried out as instructed by physician ' s order .Emergency requests must be labeled stat [now] to assure that prompt action is taken. A review of Resident 1 ' s admission record indicated the facility admitted the resident in 2023 with multiple diagnoses which included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), lung and heart diseases. 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 maintain complete and accurate medical records for one of four sampled residents (Resident 1), when there was documentation that the blood tests ordered by physician were performed and there was no documentation the physician was notified of resident's refusal of the lab tests. In addition, the order to reschedule blood tests for later date was not entered into Resident 1 ' s records. These failures resulted in the confusion among the facility ' s staff whether the tests were performed as ordered and had the potential to result in Resident 1's continued deterioration of health. Findings: A review of Resident 1 ' s admission record indicated the facility admitted the resident in 2023 with multiple diagnoses which included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), lung and heart diseases. A review of Resident 1 ' s clinical records contained documentation dated 12/16/24 which indicated that the resident had been diagnosed with urinary tract infection (UTI, a bladder infection). 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 pharmacy services were maintained to ensure a system that will account for and maintain accurate reconciliation (count of pills matches documentation for administration of medication) of all pharmaceutical products for a census of 134 residents when: 1. Loose medication found in the bottom of the medication drawer. 2. Packaged medication with a resident label found in the back of medication drawer. 3. The controlled medication (drug that is regulated by the government for its manufacture, possession, and use) audit for Resident 131 did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet in the narcotic book that keeps record of the usage of controlled medications) but was not documented on the Medication Administration Record (MAR, a legal document used to record medications given to the residents) on two occasions to indicate it was given to Resident 131. These failures resulted in the potential risk for diversion of the loose medication (use 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 accurate labeling and storage of drugs for a census of 134 residents when: 1. An expired medication was stored in a treatment cart with all active medications. 2. An emergency medication did not have a label with resident's name affixed to medication. 3. An open date label (a label that captures the date a new bottle was opened) was not affixed to an open bottle of glucose test strips (small, disposable plastic strips that collect a blood sample to measure blood sugar levels). These failures increased the risk to administer medication that had lost its potency due to being expired or give medication to the wrong resident and to have inaccurate readings of glucose. Findings: 1. During a concurrent observation and interview of medication cart 1 in D-wing on 10/14/2024, at 4:02 p.m., with Licensed Nurse (LN) 4, 1 glucagon emergency kit (a medication kit used to treat severe low blood sugar containing one vial with dry glucagon powder and a prefilled syringe with liquid to mix with the powder) was found in…

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

Based on observation, interview and record review, the facility failed to properly store raw meat and dry foods in accordance with safe food practices and failure to wear hair restraints in the kitchen for a census of 134 residents when: 1. raw ground beef was found stored above the vegetables; 2. uncooked lasagna pasta, polenta powder and chocolate chips stored unsealed; 3. Restorative Nursing Assistant (RNA) did not wash his hands, wear a hair and facial hair restraint before entering the kitchen; and 4. Dietary Aide's (DA) facial hair was not covered with hair restraints. This deficient practice had the potential to cause cross contamination of harmful bacteria; attract pests or rodents to unsealed dry foods; and transfer harmful germs onto food. Findings: 1. During a concurrent observation and interview with the Dietary Manager (DM), in the kitchen's walk-in freezer on 10/14/24 at 9:10 a.m., raw ground beef was observed on a shelf, stored above the vegetables. The DM acknowledged and stated, the raw meat should be stored with other meats below the vegetables to avoid…

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 134 residents when: 1. Two facility staff removed their N95 mask respirators (a type of mask that filters up to 95% of particles in the air) inside a droplet isolation precaution room (an isolation precaution implemented when a patient infected with a pathogen which is transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing) before exiting the room; 2. Two resident visitors entered a COVID (an infectious disease) isolation precaution room without using all the required personal protective equipment (PPE); 3. Four out of five sampled facility staff did not have a current N95 mask fit test (a test protocol conducted to verify that the specific type and model of N95 mask is both comfortable and provides the wearer with the expected protection) done. 4. Resident 395's nasal cannula (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 interview and record review, the facility failed to have an accurate Minimum Data Set (MDS- an assessment tool used to guide care) assessment for one out of 28 sampled residents (Resident 131) when Resident 131's admission MDS pain management was inaccurate. This failure caused the facility to have inaccurate health status data for Resident 131 and potential for Resident 131 to not achieve his highest practicable well-being. Findings: A review of Resident 131's clinical record indicated Resident 131 was admitted September of 2024 and had diagnoses that included encounter for other orthopedic aftercare (a care provided after a surgery that involves bones, muscles, and joints), pain in right lower leg, and diabetes mellitus (a chronic condition causing too much sugar in the blood). A review of Resident 131's MDS Cognitive Patterns, dated 9/9/24, indicated Resident 131 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 131 had intact cognition. A review of Resident 131's MDS Health Conditions, dated 9/9/24,…

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.

Based on observation, interview, and record review, the facility failed to ensure one out of 28 sampled residents (Resident 396) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 396's physician's order for intake and output monitoring for tube feeding was not consistently followed. This failure increased the potential for inadequate monitoring of Resident 396 intake and output, failure to recognize early signs of fluid imbalance, and for Resident 396 to not achieve the highest practicable well-being. Findings: A review of Resident 396's clinical record indicated Resident 396 was admitted October of 2024 and had diagnoses that included cerebral infarction (damage to a part in the brain due to a disrupted blood flow), muscle weakness, and aphasia (a language disorder that affects a person's ability to understand and express written and spoken language). A review of Resident 396's Minimum Data…

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 28 sampled residents (Resident 69) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 69's physician's order of pain medication was not followed. This failure had the potential for Resident 69 to not achieve relief from pain and not attain her highest practicable well-being. Findings: A review of Resident 69's clinical record indicated Resident 69 was admitted August of 2024 and had diagnoses that included cerebral infarction (damage to a part in the brain due to a disrupted blood flow), muscle weakness, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and osteoarthritis (a disease that causes the cartilage and bone in joints to break down over time causing pain). A review of Resident 69's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns,…

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 three sampled residents (Resident 1's) rights were exercised timely when the facility discontinued an antipsychotic medication (used for treating psychosis or disconnection from reality) for Resident 1 without notifying the resident's representative (RR). This failure resulted in Resident 1's family members being frustrated and baffled by the resident's change in behaviors. Findings: Review of Resident 1's medical record, admission Record , indicated Resident 1 was a long term resident in the facility with diagnoses that included memory problem with agitation, anxiety disorder and legal blindness. In the admission Record, three family members were listed as the emergency contacts, one of them being the RR for Resident 1. In a telephone interview on 7/15/24 at 1:36 p.m., Resident 1's family member stated that the facility discontinued Seroquel, an antipsychotic medication, that had worked well for the resident without notifying the RR or any of the resident's family members. He stated the resident changed in…

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

Based on interviews and record review the facility failed to promptly notify Resident 1's Responsible Party (RP) or Family Member (FM) when Resident 1 experienced burns to two fingers. This failure resulted in Resident 1 feeling as if the facility did not take her injury seriously. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in May 2020 with diagnoses including parkinsonism (brain conditions that cause tremors) and ataxia (loss of muscle control in arms and/or legs). A review of a nurse progress note dated 4/22/24 at 2:33 p.m. indicated, [Resident 1] was attempting to feed self this AM [morning] without CNA assistance. Due to tremors [Resident 1] spilled hot cereal over and burn 2 fingers to left hand. Index finger blister measuring apprx [approximately] 2.5x1 .middle finger 2x2. [Resident 1] was advised to wait for staff to assist w [with] feeding. NP [Nurse Practitioner] .wrote new orders to monitor site. There was no documented evidence Resident 1's RP or FM was notified of Resident 1's injury when it occured. 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 interviews and record review the facility failed to ensure the accuracy of assessments for one resident (Resident 1) when Resident 1 did not receive timely and adequate assessments of her injuries. This failure resulted in Resident 1's inaccurate and inconsistent assessments of her injuries, a lack of diagnosis for her injuries, and a delay in appropriate treatment. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in May 2020 with diagnoses including parkinsonism (brain conditions that cause tremors) and ataxia (loss of muscle control in arms and/or legs). A review of a nurse progress note dated 4/22/24 at 2:33 p.m. written by Licensed Vocational Nurse 1 (LVN 1) indicated, [Resident 1] was attempting to feed self this AM [morning] without CNA [Certified Nursing Assistant] assistance. Due to tremors [Resident 1] spilled hot cereal over and burn 2 fingers to left hand. Index finger blister measuring apprx [approximately] 2.5x1 .middle finger 2x2. [Resident 1] was advised to wait for staff to assist w [with] feeding. NP…

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

Based on interviews and record review the facility failed to revise Resident 1's care plan within a timely manner after Resident 1 sustained an injury after an accident. This failure decreased the facility's potential to ensure residents receive appropriate and person-centered care. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in May 2020 with diagnoses including parkinsonism (brain conditions that cause tremors) and ataxia (loss of muscle control in arms and/or legs). A review of a nurse progress note dated 4/22/24 at 2:33 p.m. indicated, [Resident 1] was attempting to feed self this AM [morning] without CNA assistance. Due to tremors [Resident 1] spilled hot cereal over and burn 2 fingers to left hand. Index finger blister measuring apprx [approximately] 2.5x1 .middle finger 2x2. [Resident 1] was advised to wait for staff to assist w [with] feeding. NP [Nurse Practitioner] .wrote new orders to monitor site. During a review of Resident 1's care plan initiated on 4/26/24 indicated, [Resident 1] has actual impairment to skin…

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 reviews the facility failed to ensure physician orders were followed when Resident 1 did not receive wound care treatment as ordered. This failure decreased the facility's potential to assist Resident 1's wound to heal. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including open wounds to right and left lower legs, diabetes mellitus (inadequate control of sugar in the blood stream) and atherosclerosis of arteries (narrowing and hardening of the blood vessels) in the legs and feet. During a review of Resident 1's Order Summary Report (OSR, physician orders) printed on 6/5/24, Resident 1 had orders for the following wound care: 1. Starting on 4/15/24, licensed nurses were to monitor Resident 1's left and right lower extremities, lower leg to toes, diabetic foot ulcer for sing or symptoms of infection, every shift. 2. Starting on 4/16/24, licensed nurses were to clean Resident 1's left lower extremity to…

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

Based on interview and record review, the facility failed to ensure an Infection Preventionist (IP: a nurse responsible for the facility's Infection Prevention and Control Plan) was available to meet all the requirements of the position for a census of 141 residents. This failure decreased the facility's potential to prevent the spread of infection among staff and residents. Findings: An interview on 3/1/24 at 9:10 a.m., the Executive Director (ADM) stated the facility's full time IP left in January 2024 and indicated the IP continued to work part-time during February 2024. The ADM added, the facility was hoping to hire a full time IP soon. An interview on 3/1/24 at 2:37 p.m., the Assistant Director of Nursing (ADON) stated the facility is in between IPs and was unable to confirm the facility had anyone working in the IP role. An interview and concurrent record review on 3/1/24 at 4:30 p.m., the ADM provided time sheets for the facility's IP. The time sheet for dates 2/1/24-2/15/24, indicated the IP had worked zero hours. Additionally, there was no time sheet provided for the dates…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention program for one resident (Resident 1) out of three sampled residents, when the Treatment Nurse 1 (TN 1): did not clean bandage scissors prior to or after cutting a soiled wound dressing, placed treatment supplies directly on Resident 1's bed and returned supplies to the treatment cart, and did not perform hand hygiene (simple act of cleaning hands to present the spread of germs) during a wound treatment. These failures increased the risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another) and the potential for infection. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease (PVD: a narrowing of a blood vessel which decreases circulation of blood to a body part) and diabetes (DM2: a chronic condition that affects the way the body processes blood sugar, which slows the body'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 interview and record review, the facility failed to implement policies and procedures for the prohibition and prevention of abuse for a census of 142 residents when 22 out of 26 sampled facility staff hired in December 2023 (Certified Nurse Assistant [CNA] 3, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, CNA 16, CNA 17, CNA 18, CNA 19, CNA 20, CNA 21, Licensed Nurse [LN] 4, LN 5, and Housekeeping Staff [HKS]) started working with residents in the facility without an employee background check (a formal process that verifies an upcoming employee's personal and professional information such as identity, work history, criminal record, and any other relevant information) done. This failure placed all the residents in the facility at risk for possible serious physical and/or psychosocial harm and decreased the facility's potential to protect residents from exposure to an employee with a criminal history of abuse, neglect, and/or exploitation. Findings: During a concurrent interview and record review on 2/6/24 at 2:16 p.m. with the Human…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and complete a baseline care plan (BCP) within 48 hours of admission for one of two sampled residents (Resident 1). This failure decreased the ability to address Resident 1's specific health needs and communicate his initial plan of care. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure, pneumonia due to inhalation of food and vomit, gastrostomy tube (G-tube, opening into stomach), and dysphagia (difficulty swallowing). Resident 1 was discharged home on [DATE]. A review of a document titled, 48 Hour Baseline Care Plan, indicated Resident 1's BCP was completed on 12/19/23. During an interview on 1/17/24 at 1:02 p.m. with Director of Nursing (DON), DON confirmed Resident 1's BCP was completed on 12/19/23. DON stated BCP should have been completed within 48 hours of admission, because staff needed the BCP to understand the plan of care Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physician's Nothing By Mouth (NPO) diet order for one of two sampled residents (Resident 1), when Resident 1 was served and fed a meal at dinner time. This failure increased Resident 1's potential to inhale food into his lungs and develop pneumonia (lung infection). Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure, pneumonia due to inhalation of food and vomit, gastrostomy tube (G-tube, opening into stomach), and dysphagia (difficulty swallowing). A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 12/14/23, indicated Brief Interview of Mental Status (BIMS) score was 15 of 15 with good memory. A review of Resident 1's Order Summary Report, dated 1/17/24, indicated Resident 1 received a bolus feeding via his G-tube and his diet was NPO. The report further indicated a stat (urgent) chest x-ray (CXR) was ordered for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medication as ordered for one resident (Resident 1) of three sampled residents. This failure had the potential for Resident 1 to have complications related to hypertension. Findings: During a review of Resident 1's Physician Order Report (POR), the POR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertension (high blood pressure). The POR also indicated an order for amlodipine (a medication that helps lower blood pressure) 5 mg (milligrams , a unit of measurement), give two tablets orally for hypertension one time a day; hold if systolic blood pressure (the pressure in the arteries when the heart beats) is less than 100. During a review of Resident 1's Care Plan (CP), dated 11/7/23, the CP indicated Resident 1 was at risk for complications related to hypertension, administer amlodipine, and monitor blood pressure every shift and as needed, to prevent complications related to hypertension. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow infection control guidelines for the residents of the facility, when: 1. Certified Nursing Assistant (CNA 1) did not wear required Personal Protective Equipment (PPE- mask, gown and gloves) while inside a resident's room that was under contact isolation precautions; and 2. An uncovered linen cart from laundry with resident's clean personal clothes was seen parked in the A wing hallway. These deficient practices had the potential to spread infection and disease among residents, staff and visitors. Findings: 1.During a review of Resident 2's clinical record he was last admitted to the facility on [DATE]. According to Resident 2's progress notes as documented by his physician [physician's name] with custodial visit date of 11/28/23, with Assessment and plan for Pneumonia (inflammation and fluid in lungs) and C. Difficile Diarrhea (C-Diff-highly contagious bacterial infection). During a concurrent observation and interview with CNA 1 on…

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

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one resident (Resident 1) of two sampled residents when: 1. Resident 1's pain medication was not administered timely and per physician order; and, 2. A lidocaine patch (a topical patch that applies pain relief) was documented as administered when it was not. This failure had the potential to increase Resident 1's pain above a tolerable threshhold and allow for accurate pain remedies to be administered. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in September 2023 with diagnoses including fractures and neoplasms (abnormal growth of tissue). A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 10/17/23, indicated Brief Interview of Mental Status (BIMS) score was 15 of 15 with good memory. 1. During an interview on 10/30/23 at 9:26 a.m. with Resident 1, Resident 1 stated it took Licensed Nurse 3 (LN 3) more than three hours to give her oxycodone (drug that relieves pain) 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.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for nine of 130 residents when: 1. Residents' identification was not verified at the time of medication administration for Resident 31, Resident 81, and Resident 83, which put residents 31, 81 and 83 at risk of receiving the wrong medication, 2. Disposed non-controlled medications (prescription medications with less risk of addiction and harm) were retrievable or were destroyed in sharp containers (a hard plastic container that is used to safely dispose of hypodermic needles and other sharp medical instruments), which could result in drug diversion, 3. Two expired medications were available for use for Resident 44 and 99 in the medication cart, which put residents 44 and 99 at risk of receiving expired medication, 4. Resident 99's opened inhaler (used to administer medication by breathing in) in the medication cart was not dated, which put Resident 99 at risk of receiving expired or outdated medication, 5. Loose pills were found in the medication carts, which could…

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 medications were stored correctly for the census 130, when: 1. A medication cart was not locked and left unattended during medication pass, 2. Two medication bottles were left on top of the medication cart unattended and accessible to unauthorized personnel, 3. Disposed non-controlled medications (prescription medications with less risk of addiction and abuse) were retrievable and not properly destroyed, 4. Loose pills were found in the medication carts on wing B, C and D, and; 5. Temperature of a medication refrigerator on wing C was out of range. 6. A medication cart drawer was left open and unattended, These failures had the potential for medication misuse, drug diversion and medication ineffectiveness. Findings: 1. During a medication pass observation with Licensed Nurse (LN) 10 on 11/1/21 at 9:07 a.m., LN 10 entered room [ROOM NUMBER] to check Resident 100's blood pressure. LN 10 left the cup with medications on top of the…

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

Based on observation, interview, and record review, the facility failed to prepare meals that conserve nutritive value, flavor, and appearance when recipes were not followed for meal production. This failure had the potential for 124 residents of a census of 130 not receiving the nutritional value of their meals. Findings: During an observation and interview on 11/2/21, at 8:50 a.m., [NAME] 2, took a pan out of the oven containing olive color peas. She added an unmeasured amount of the peas to the food blender to blend. She added an unmeasured amount of milk and butter to the mixture and continue to blend. This mixture was then placed in a pan, covered with aluminum foil and placed inside the steamer oven for lunch. During an interview on 11/2/21, at 9:34 a.m., [NAME] 2, stated she did not used a recipe (step-by-step preparation procedures, cooking details, portion sizes to maintain nutrient contents) to puree the peas. She eye-balled the ingredients, used about half a bag of peas, blended with milk and butter to an apple sauce consistency. During an interview on 11/2/21, at 3:21…

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

Based on observation, interview, and record review, the facility failed to ensure safe food production and minimize the potential for food borne infections when: 1. Open food packages (various cereals, dill weed seasoning, and sliced cheese) were not labeled with open dates; and, 2. Kitchen equipment and floors were dirty and/or worn (steam table pans, fan, cutting boards and meat slicer), and metal shelves were rusty. These failures had the potential to expose 124 residents of a census of 130 to expired foods and placed these residents at risk for food borne infections (illness caused by consuming contaminated foods or beverages). Findings: 1. During an observation of the initial kitchen tour on 11/1/21, at 8:32 a.m., an opened 35 ounce bag of Toasted Oats, an opened 35 ounce bag of Corn Flakes, and an opened 28 ounce box of Farina hot wheat cereal in the dry storage area were not labeled with an open date. An opened 5.5 ounce bottle of dill weed in the prep area of the kitchen was not labeled with an open date. An opened 5 pound bag of sliced cheese in the refrigerator was found…

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 infection prevention practices to prevent the development and transmission of communicable (contagious) diseases and infections when: 1. Five Residents (Resident 44, Resident 49, Resident 89, Resident 185, and Resident 320) were not offered hand hygiene prior to meals; and, 2. One staff entered the kitchen and did not wash hands prior to touching equipment. These failures had the potential to spread germs and make the residents ill in the facility for a census of 130. Findings: 1. During an observation on 11/2/21, at 11:51 a.m., Resident 49, Resident 89 and Resident 44 were not offered hand hygiene when lunch meal trays were passed out by staff. During an observation on 11/3/21, at 12:30 p.m., Resident 320 and Resident 185 were not offered hand hygiene when lunch meal trays were passed out by staff. During a concurrent observation and interview on 11/2/21, at 12:23 p.m., Resident 44 was noted to be holding his urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage…

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

Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the Department, for a census of 130. This failure had the potential for abuse allegations to not be investigated thoroughly and in a timely manner. Findings: Review of Resident 3's clinical records indicated Resident 3 was admitted to the facility in mid 2018 with diagnoses that included anxiety disorder. Review of Resident 3's MDS (Minimum Data Set, an assessment tool) Section C, dated 7/9/21, indicated Resident 3 had a BIMS (Brief Interview of Mental Status) score of 8 out 15 which indicated moderate impaired cognitive function. During a concurrent observation and interview conducted on 11/1/21 at 1:30 p.m., Resident 3 was observed to have a reddish to purplish discoloration on her right forearm measuring approximately 12 centimeters (cm, a unit of measurement) x 4 cm, and on her left forearm measuring approximately 6 cm x 4 cm. Resident 3 stated someone hit her. A review of Resident 3's clinical records did not indicate any documentation of discoloration on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet the professional standards of nursing practice when Licensed Nurse (LN) did not ensure Resident 183 swallowed the medications after administration for a census of 130. This failure placed the resident at risk for ineffective medication therapy and increased the potential for choking. Findings: Resident 183 was a short term resident in the facility with diagnoses which included a history of bleeding in the space that surrounds the brain and was at an advanced age. In a concurrent observation and interview on 11/1/21 at 10:25 a.m., Resident 183 was lying in her bed and stated she needed some juice to swallow her medications. LN 6 who administered the medications to the resident was in the hallway right outside the resident's room. LN 6 came into the resident's room and gave the resident water in a plastic cup with a straw. When the resident opened her mouth to drink the water, multiple pills, approximated 6 to 7 pills, were observed on…

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

Based on observation, interview, and record review, the facility failed to ensure a skin assessment was conducted and documented for one resident (Resident 3), for a census of 130. This failure had the potential for Resident 3 to not receive adequate care and monitoring. Findings: Resident 3 was admitted to the facility in mid-2018 with diagnoses that included anxiety disorder. During an observation conducted on 11/1/21 at 1:30 p.m., Resident 3 was observed to have a reddish to purplish discoloration on her right forearm measuring approximately 12 centimeters (cm, a unit of measurement) x 4 cm, and on her left forearm measuring approximately 6 cm x 4 cm. A review of Resident 3's clinical records did not indicate any documentation of discoloration on Resident 3's forearms. Review of Resident 3's Progress Notes dated 11/1/21 at 3:19 p.m. by Licensed Nurse (LN) 2, indicated, IT WAS BROUGHT TO MY ATTENTION THAT [Resident 3] HAD A LARGE DISCOLORED AREA AROUND HER WRIST . During an interview with the LN 2 on 11/3/21 at 8:53 a.m., LN 2 stated she did not document the left arm discoloration…

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 environment remained free from accident hazards as possible when Resident 5's smoking materials were not kept in a secure location, for a census of 130. This failure had the potential for residents to have access to smoking materials without supervision. Findings: Resident 5 was admitted to the facility in late 2019 with diagnoses that includied cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain). During an observation conducted on [DATE] starting at 8:31 a.m., Resident 5 was smoking outside in the patio. At 8:49 a.m., Resident 5 came back inside the facility, returned cigarettes and a lighter which were inside a small plastic container by pushing it down behind the nurses' station counter. The Licensed Nurse (LN) 2 took the container and placed it further back on the counter. The nurses' station did not have any doors. In an interview with the LN 2 on [DATE] at 8:50 a.m., the 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 ensure a medication error rate of less than 5 percent with 27 observed opportunities for one of six sampled residents (Resident 49), when: 1.Resident 49 was administered calcium carbonate (used to treat gas and stomach pain) 750 mg (milligram is a unit of measuring weight) instead of prescribed calcium carbonate 500 mg, 2. Resident 49's lidocaine patch (medication used to treat pain) was administered instead of notifying the physician when the nurse knew that the previous patch was not removed as prescribed the night before. These failures resulted in 2 medication errors identified out of 27 opportunities during Medication pass observation. This resulted in the facility having a medication error rate of 7.41 percent. Findings: 1. A review of Resident 49's admission record, indicated Resident 49 was admitted late 2021 with multiple diagnoses that included Rhabdomyolysis (a serious medical condition due to a direct or indirect muscle injury). During a review of Resident's 49's physician order for November 2021,…

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.