Fowler Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment for one of two sampled residents when Resident 12's low air loss machine (designed to distribute patient's body weight over a broad surface area and help skin breakdown) was turned off. This failure had the potential for Resident 12 to develop skin breakdown which could result in pressure ulcer development. Findings: During a concurrent observation and interview on 3/5/25 at 9:40 a.m. in Resident 12's room, Resident 12 was seen lying in bed, covered with blanket and yelling out. Resident 12 did not answer questions asked. Resident 12's bed was positioned in lowest position and had a low air loss mattress. Resident 12's low air loss mattress was turned off and was unplugged from the wall. During a review of Resident 12's admission Record, (AR) dated 3/6/25, the AR indicated Resident 12 was re-admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) have the specific competencies, and skill sets necessary to ensure residents who required Enhanced Barrier Precaution (EBP) were properly managed to prevent the risk for infections for seven of seven sampled residents (Residents' 10, 30, 39, 40, 29, 37 and 28) when the IP demonstrated a breakdown in following critical infection control policies and procedures. These failures placed Residents' 10, 30, 39, 40, 29, 37 and 28 at increased risk for infection. Findings: During a review of Resident 10's admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical…

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 three sampled residents (Resident 27) were provided special eating equipment when Resident 27's lunch was not served on an adaptive equipment scoop plate per her meal ticket. This failure resulted in Resident 27's individualized care needs not met which led to difficulty eating, delayed in finishing her meals and the potential risk for decreased oral intake. Findings: During a review of Resident 27's admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (complete and partial weakness on the left side of the body following a stroke [blood flow to the brain is decreased, causing brain cells to die]) , chronic obstructive pulmonary disease (COPD-air flow obstruction and inflammation of the airways, leading…

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 residents received adequate supervision to prevent elopement for one of three sampled residents (Resident 1) who was a high risk for elopement (when a resident, who is incapable of adequately protecting themselves, departs the facility unsupervised and undetected) when Resident 1 eloped from the facility on 11/6/24. This failure placed Resident 1 ' s safety at risk when Resident 1 was found on the side of the road a mile and a half away from the facility by staff. Findings: During record review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 had diagnoses which included .TRAUMATIC BRAIN INJURY (alteration in brain function caused by an external force such as a blow, bump or jolt to the head) .ALCOHOL DEPENDENCE .SEIZURES (a sudden uncontrolled burst of electrical activity in the brain) .HISTORY OF FALLING .ANXIETY DISORDER (mental health condition that causes excessive and persistent feelings of worry and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 9/2/24. This Failure placed Resident 1's safety at risk when Resident 1 was found on the side of the road half a mile away from the facility by a passing motorist. Findings: During an observation on 9/18/24, at 8:20 a.m., the facility building was surrounded with an 8-foot-tall metal fence. The fence extended entirely around the building and staff & visitors entered and exited the facility through a single locked gate which opened with a key. During a concurrent observation and interview on 9/18/24, at 8:40 a.m., with Sitter 1, in Resident 1's room, Sitter 1 was sitting at Resident 1's bedside. Sitter 1 stated she was assigned to provide one-on-one monitoring and supervision for Resident 1. Sitter 1 stated Resident 1 recently eloped. During a review Resident 1's Progress Notes (PN) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 6/16/24. This Failure placed Resident 1's safety at risk when Resident 1 was found walking on the side of the road ½ a mile away from the facility. Findings: During a review of Resident 1's admission Record (AR- a document containing resident profile information) dated 6/27/24, the AR indicated Resident 1 was a [AGE] year-old male admitted to the facility with diagnoses included traumatic brain injury (TBI, serious injury to the brain that affects problems with how a person thinks, understands, moves, communicates, and acts), and mild cognitive impairment (impaired ability to remember, think, or make decisions). During a review of Resident 1's Care Plan (CP), dated 6/26/24, the CP indicated Resident 1 is an elopement risk/wanderer related to impaired safety awareness, Resident wanders…

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 adequate supervision for one of two sampled residents (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 5/15/24 at 7:40 PM and was found by the Sheriff's Department on 5/16/24 at 4 AM in the orchard a mile away from the facility. This failure resulted in Resident 1 leaving the facility without supervision for over eight hours which had the potential to cause injuries. Findings: During an observation on 7/7/24 at 2:35 PM Resident 1 was sitting in the lobby smiling and waving hello to visitors. Resident 1 had an approximately 1-millimeter dot size scabbed on the forehead and on the forearm. During a review of Resident 1's admission Record (AR-contains important information about a patient such as their personal details, the reason for admission and medical history), dated 6/10/24, the AR indicated Resident 1 was admitted to the facility with diagnoses that included traumatic brain injury (TBI, serious injury to the brain that affects problems with how a person…

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

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with the facility's policy and procedure and professional standards for food safety when: 1. [NAME] and gray particles were found in the windowsill (ledge on bottom of window) next to the food preparation sink. 2. [NAME] build up was found on the exterior of the dish washing machine. 3. The ice machine and food preparation sink had no air gaps (a vertical space usually one inch or more between the end of a pipe or faucet and the top of a sink which creates a separation between the water supply and contaminated water). 4. The temperature of the dish washing machine was under the minimum 120° Fahrenheit (F- unit of measurement) requirement. 5. Oven mitts used to handle hot foods were soiled with orange and brown grime and debris. 6. Food stored in the resident's refrigerator was not labeled with resident's name and use-by-date (the last day for the consumption of food item while at peak quality). These failures had the potential to cause cross-contamination and food…

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 clean and safe environment for residents, staff and the public when: 1.The kitchen dry storage floor had areas of brown stains, missing and cracked linoleum, exposing the cement underneath with accumulation of dark gray debris. 2.The facility floors in the common areas and resident rooms, had black-colored stains, uneven surfaces, cracked linoleum with accumulation of black and brown debris and missing baseboards. This failure to ensure the physical environment was maintained in a safe, clean, and sanitary manner as evidenced by multiple contact surfaces in disrepair placed residents, staff, and the public at potential risk for falls and cross contamination (the process by which bacteria are unintentionally transferred from one substance or object to another with harmful effect) which could lead to foodborne illness (caused by food contaminated with bacteria). Findings: 1. During an observation on 3/12/24 at 9:26 a.m. in the kitchen's dry food storage room, the floor had multiple areas of brown…

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 their grievance policy and procedure for five of 15 sampled residents (Residents 18, 27, 28, 37, and 39) when the facility did not ensure Resident 18, 27, 28, 37 and 39 were able to submit grievances anonymously. This failure resulted in Residents 18, 27, 28, 37, and 39 not able to exercise their rights to submit grievances anonymously regarding the facility and their care and could negatively affect their pyschosocial well-being. Findings: During the resident council meeting on 3/14/24 at 9:10 a.m. with Residents 18, 27, 28, 37, and 39, Residents 18, 27, 28, 37, and 39 stated they did not know how to file anonymous grievances. Resident 39 stated he did not know how to submit grievances anonymously. During an interview on 3/14/24 at 4:23 p.m. with the Social Services Director (SSD), the SSD stated residents must ask staff members for grievance forms. The SSD stated he kept grievance forms in his office, in a drawer behind the nurses' station and in a drawer locked in the Activities Director's (AD)…

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 maintain an accurate medical record consistent with professional standards and practices for four of 10 sampled residents (Resident 1, 4, 13, and Resident 34) when Resident 1, 4, 13, and 34's Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. These failures resulted in a medical record that did not reflect Resident 1, 4, 13, and 34's treatments for end-of-life care and services. Findings: During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with Medical Records Director (MRD), Resident 1's POLST, dated 8/2/23 was reviewed. MRD stated Resident 1's POLST was not completed. MRD stated Resident 1's POLST was missing all the physician's information, which included the physician's name, physician's address, physician's phone number, physician's license number…

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 services provided met professional standards of quality for one of 27 residents (Resident 28), when Resident 28 was not offered water to rinse her mouth after aerosol oral inhaler (a medication used to prevent difficulty breathing administered by way of inhalation both oral and nasal) administration as ordered by the physician. This failure had the potential for the inhaler medication to accumulate in Resident 28's mouth and placed Resident 28 at risk to developed oral thrush (fungal infection). Findings: During an observation on 3/13/24 at 8:37 a.m., in Resident 28's room, the Director of Staff Development (DSD) administered aerosol oral inhaler to Resident 28. The DSD did not offer Resident 28 water to rinse her mouth after medication administration. During a review of Resident 28's Order Summary Report, dated 3/13/24 indicated, . 2 puffs inhale orally . rinse mouth with water and spit back into cup after use . During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used 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 observation, interview, and record review, the facility failed to ensure drugs were labeled with resident identifier and expiration date in accordance with the facility's policy and procedure Labeling Medications and Biological's (a substance such as vaccines or drugs derived from a living organism used for treatment) when one Fluticasone propionate salmeterol inhaler (medications used to treat respiratory disease, a mist or spray that the patient breathes in the nose or mouth) and one nasal spray ( liquid medicine spray into the nose) medication was stored in medication cart 1 without a resident identifier label (resident's name and date of birth ) and expiration date. This failure placed residents at potential risk for receiving the wrong medication and expired medications, which could lead to medication ineffectiveness and medication adverse reaction. Findings: During a concurrent observation and interview on 3/14/24 at 11:13 a.m. with the Infection Preventionist (IP), in front of the nurse's station, medication cart 1 stored one inhaler medication and one nasal spray…

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 policy and procedure to monitor and maintain essential equipment in a safe operating condition for one of six residents, (Resident 4), when Resident 4's oxygen concentrator (a medical device to deliver oxygen) was not routinely monitored and maintained in accordance with facility policy and procedure. This failure had the potential for Resident 4's oxygen concentrator to break down and fail which could result in Resident 4 going without oxygen. Findings: During a concurrent observation and interview on 3/13/24 at 8:54 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 4's room, Resident 4's oxygen concentrator had gray particles on the surface. CNA 1 stated the oxygen concentrator had a lot of dust and should be cleaned. CNA 1 stated maintenance was responsible to ensure the oxygen concentrator was clean. During a concurrent observation and interview on 3/14/24 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 4's room, LVN 1 opened the oxygen concentrator filter cover and LVN 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.

During an observation, interview, and record review, the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance from nursing staff) for 17 residents bed (3 C,4 B, 7 D, 9 A,B,D 10 C,D 11 A,B,C 12 A,B,C 14 A,B,C) out of 46 residents bed when the patient call light system warning lights above residents doorway and monitoring panel located in the nurses station to indicate when patients have perceived needs requiring attention were not functioning properly. This failure resulted for residents in the facility not able to call for help and receive immediate assistance from nursing staff which placed residents ' health and safety at risk. Findings: During an interview on 1/16/24 at 10:10 a.m., with Maintenance Supervisor (MS), the MS stated he conducted daily inspections for all the call lights in residents ' room for proper functioning. The MS stated when residents pressed the call light button, the warning lights above resident ' s doorway and the monitoring panel located in the nurse ' s station must…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistant (CNA) 1 met the specific certification requirements when CNA 1 was working in the facility without an active CNA certification. This failure had the potential for Residents not being provided adequate and quality care according to their needs. Findings: During a concurrent interview and record review on [DATE] at 11:15 a.m. with the Director of Nursing (DON), the facility document titled, Active Employees (AE) dated [DATE] was reviewed. The AE indicated, CNA 1 ' s Certified Nursing Certificate had an expiration date of [DATE]. The DON stated CNA 1 ' s certificate expired on [DATE] and CNA 1 was not scheduled to work until her certificate was active. During a review of the facility document titled CNA NOC Shift [DATE], the document indicated, CNA 1 was on the schedule to work on [DATE], [DATE], [DATE] [DATE], and [DATE] for the night shift. During a review of the facility document titled Daily…

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

Based on observation, interview and record review, the facility failed to ensure food service staff were able to carry out the functions of the food and nutrition service safely and effectively when Kitchen staff (CKA 1, CKA 2, and KA 1) did not air dry bowls and cups prior to storage, did not label opened food products with use by date, did not place a drip pan on thawed uncooked frozen meat inside the refrigerator, and did not perform appropriate glove use in the kitchen. Failure to have staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services can result in foodborne illnesses from cross contamination or the growth of microorganisms for the 44 residents eating food prepared in the facility. (Cross Reference F812) Findings: During a concurrent observation on 5/1/23, at 9:15 a.m., inside the kitchen, with Cook/Kitchen Aide (CKA), CKA 1 placed a tray of wet bowls inside the cabinet. CKA 1 lifted the bowls and water dripped from the bowls, and stated, the bowls were wet. During a concurrent observation and interview on 5/1/23, 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.

Based on observations, interviews and record review, the facility failed to ensure professional standards for food safety guidelines were followed when, 1. Cake stored inside the kitchen refrigerator was not fully covered and placed on top of a torn cardboard boxes with moisture stains. 2. Cheese slices and whipped cream were placed inside unsealed plastic bags stored inside the kitchen refrigerator. 3. Wet bowls and cups were stacked and stored inside the cabinet. 4. Cooking spices were stored unsealed and in containers with debris. 5. Opened bag of frozen sausage patties was in the freezer without an opened date. 6. Five meal tray carts were stored in the kitchen storage room with 44 uncovered meal trays, and a bag of plastic forks placed on the top of a plate, more than two hours before meal service. 7. The kitchen backdoor was fully open without a closed-door screen during food preparation. 8. Uncooked frozen chicken thighs inside a cardboard box was thawed in the bottom of the refrigerator without a drip pan (a pan placed underneath thawed frozen food to catch the drippings 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 observations, interviews, and record review, the facility failed to maintain an effective pest control program, when a dead cockroach was found on a glue trap (a trap that uses glue, adhesive material as the mode of capture to trap rodents and insects) in the food storage room and dead insects were found on the kitchen windowsills above the food preparation area and dish sink. These failures had the potential to cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) in a medically vulnerable resident population of 44 residents who consumed food prepared in the kitchen. Findings: During an observation on 5/1/23, at 9:15 a.m., in the kitchen, the back door is fully open without a door screen while food is being prepared. During an observation on 5/1/23, at 9:42 a.m., inside the food storage room, one dead cockroach was captured in the glue trap. During a concurrent observation and interview on 5/1/23, at 9:52 a.m., in the food storage room, with the Dietary Aide (DA) 1, DA 1 stated, the cockroach should not be inside the food…

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, during the survey period of 5/1/23 to 5/8/23, the facility failed to provide the minimum of at least 80 square feet per resident in 10 out of 17 rooms (Rooms 1, 2, 5, 6, 11, 12, 14, 15, 16 and 17). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered. Findings: During a concurrent observation and interview with the Director of Maintenance (DOM) and Housekeeping Supervisor on 5/4/23, at 10:58 a.m., the DOM stated he was aware ten rooms did not meet the minimum square footage required. The room measurements were as follows: Room # Square Feet Number of residents 1 156.18 2 2 157.20 2 5 215.68 3 6 214.27 3 11 216.02 3 12 216.56 3 14 217.96 3 15 156.83 2 16 156.96 2 17 157.20 2 During multiple observations made between 5/3/23 to 5/8/23, and the residents had a reasonable amount of privacy. The residents had closets and bedside tables which provided adequate storage space. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet…

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 was treated with respect and dignity for one of three sampled residents (Resident 2) when staff shaved Resident 2 in the hallway without providing privacy. This failure violated Resident 2's right to be treated with respect and dignity and had the potential to cause embarrassment. Findings: During a review of Resident 2's face sheet titled, admission Record, (document containing resident personal information), undated, the face sheet indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included, cerebral infarction (stroke caused by disrupted blood flow to the brain), urinary tract infection (infection in any part of the urinary system [kidneys, bladder, or urethra]), contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes deformity of the joints), type 2 diabetes mellitus (a long-term metabolic disorder that is characterized by high blood sugar levels),…

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 written notification to the Long-Term Care Ombudsman (LTCO- a person who routinely visits the facility and advocates for the residents) when one of two sampled residents (Resident 47) was transferred to the acute care hospital. This failure had the potential to result in Resident 47 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a concurrent interview and record review, on 5/8/23, at 10:46 a.m., with the Director of Medical Records (DMR), Resident 47's Transfer Form (TF), dated 2/28/23 was reviewed. The DMR stated, he was unable to find documentation of LTCO notification when Resident 47 was transferred to the acute care hospital. The DMR stated, during the time when Resident 47 was transferred to the acute care hospital the facility did not have a Director of Social Services (DSS). The DMR stated, it was the responsibility of the DSS to notify the LTCO when Resident 47 was transferred to the acute care hospital. During an interview 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 interview and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for one of four sampled residents (Resident 23) when Resident 23 who was nonverbal and was coded as comatose (a state of deep unconsciousness for a prolonged period, the person's eyes will be closed and unresponsive to their environment) in the MDS assessment. These failures resulted in an inaccurate assessment of Resident 23's mental status and had the potential for Resident 23's needs to go unmet. Findings: During an observation on 5/1/23, at 10:30 a.m., Resident 23 was lying in bed with eyes open. Resident 23 did not respond when spoken to. During an observation on 5/1/23, at 12:48, in Resident 23's room, a nursing staff was feeding Resident 23 with a puree diet (food with a pudding-like consistency). During a review of Resident 23's MDS, dated 3/21/23, the MDS section B, (a section in the MDS which assessed hearing, speech, and vision), indicated Resident 23 was . Comatose . 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a person-centered comprehensive care plan was implemented timely for one of 23 sampled residents (Resident 30) when Resident 30 had a diagnosis of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and had a physician order for a left hand splint (a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain) with no implementation of a comprehensive care plan. This failure had the potential to result in Resident 30's care needs going unmet. Findings: During a review of Resident 30's face sheet, titled admission Record (document containing resident personal information), undated, the face sheet indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included, Hereditary and idiopathic (unknown cause) neuropathy (nerve problem that causes pain, numbness, tingling,…

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 quality for two of three sampled residents (Resident 18 and Resident 30) when: 1. Licensed Vocational Nurse (LVN 1) used an unapproved medication administration technique while using an insulin flex pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) during a medication pass observation. This failure placed Resident 18 at risk for dosing errors and had the potential for adverse side effects such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). 2. License Nurse (LN) failed to perform a change of condition assessment and documentation for Resident 30's complained of burning with urination. This failure had the potential for Resident 30's change of condition not being addressed by the nursing staff which could lead to delayed in treatment and services. Findings: During a medication pass observation on 5/2/23, at 9:27…

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 three sampled residents (Resident 30) received appropriate equipment to prevent further decline in mobility and range of motion when Resident 30 had a diagnosis of contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and nursing staff failed to apply Resident 30's left hand splint (a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain) according to physician's order. This failure resulted in the potential risk for Resident 30's left hand contracture to worsen, which could lead to further declined in mobility and range of motion, and increased dependence for activities of daily living. Findings: During a review of Resident 30's face sheet titled, admission Record,(AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical…

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 drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were labeled in accordance with accepted professional standards of practice for five of 23 sampled residents (Resident 1, Resident 5, Resident 15, Resident 18 and Resident 21) when: 1. Resident 5's linaclotide (a medication used to treat irritable bowel syndrome [an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation] with constipation) with an expired date of 1/23/23 was stored in Medication Cart 1 ready for residents used. 2. Resident 15's insulin glargine open date and use by date was incomplete and did not indicate the year. Resident 15's medication Phenylephrine-Cocoa Butter (a medication used to temporarily relieve swelling burning, pain and itching caused by hemorrhoids [a swollen vein or group of veins in the region of the anus]) with an expired date of 4/23/23 was stored in Medication Cart 1 ready for residents used. These failure had the potential 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 interview and record review, the facility failed to ensure medical records were complete, accurately documented in accordance with accepted professional standards of practice for one of eight sampled residents (Resident 26) when Resident 26's Physician Order for Life Sustaining Treatment (POLST-a specific medical orders for resident treatment and wishes in the case of a medical emergency) for Do Not Resuscitate (DNR- is a medical order written by a doctor which instructs health care providers not to do resuscitation [the action of reviving someone from unconsciousness or apparent death] if a patient's breathing stops or if the patient's heart stops beating) was not signed. This failure had the potential risk for Resident 26's decisions regarding his healthcare and treatment options not being honored. Findings: During a review of Resident 26's admission Record (AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient'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 maintain an effective infection control and prevention program when one of two sampled residents (Resident 29) nasal cannula (a device used to deliver supplemental oxygen or increase airflow through the nose to a person in need of respiratory help) was on the floor and not stored inside a plastic bag. This failure placed Resident 29 at risk for cross-contamination (the physical transfer of harmful germs from person, object or place to another) and to developed respiratory infection (when germs enter the body, usually through the mouth or nose) from using contaminated nasal cannula. Findings: During a review of Resident 29's admission Record(AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), dated 5/2/23, the AR indicated, Resident 29 had the diagnoses of Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways 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.