Vineyards At Fowler

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 6Number of residents cited: 2 Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration of medications to meet residents needs for two of six sampled residents (Resident 46 and Resident 5) when Resident 46's psychotropic (medications that alter brain chemistry to affect mood, thoughts, and behavior) medication brexpiprazole (used to treat Alzheimer's Disease-a disease characterized by a progressive decline in mental abilities) and Resident 5's inhaler (a small, handheld medical device that delivers medicine as a mist or spray directly to the lungs for treating respiratory conditions like asthma) medication fluticasone propionate/salmeterol (used for treatment of breathing problems in patients with asthma) were not available to administer on 1/7/25.These failures resulted in Resident 46 and Resident 5 not receiving their routine medications, which could have led to serious health conditions.…

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 Number of residents sampled: 4Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure food preferences were accommodated for one of four sampled residents (Resident 16) when Resident 16's standing physician order for strawberry shake was not served to Resident 16 during lunch on 9/30/25. This failure had the potential risk to result in Resident 16 not meeting nutritional needs, which could lead to unplanned weight loss. During a concurrent interview and record review on 9/30/25 at 12:20 p.m. in the dining room, Resident 16 was sitting in her wheelchair with her lunch tray positioned in front of her. Resident 16's lunch tray did not include a strawberry health shake. Certified Nursing Assistant (CNA) 1, was observed seated next to Resident 16 and assisting with lunch. CNA 1 stated Resident 16 needed assistance with meals to ensure adequate intake and prevent weight loss. CNA 1 reviewed Resident 16's meal ticket and stated, There should be a milk shake with her…

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 Number of residents sampled: 4Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure adaptive equipment was provided for two of four sampled residents (Resident 14 and Resident 16) when:1.During a meal observation in the dining room on 9/30/25, Rehabilitative Nursing Assistant (RNA) used plastic straws instead of spoon for Resident 14's liquids.This failure had the potential for Resident 14 to aspirate while drinking fluids.2.Resident 16 was not provided sippy cup on her meal tray during lunch on 9/30/25. This failure had the potential to limit Resident 16's ability to drink independently and safely. 1.During a concurrent observation and interview on 9/30/25 at 12:12 p.m. in the dining room, Resident 14 was observed seated in a geriatric chair (large, padded, reclining room with wheels, designed for individuals with limited mobility, offering comfort and support for relaxing, dining or medical procedures) assisted by RNA with his meals. Resident 14's drinks…

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 residents were treated with dignity and respect for one of seven residents (Resident 1) when two Certified Nurse Assistants (CNA 2, CNA 3) spoke loudly and disrespectfully to Resident 1 and accused her of taking her roommate's remote control and adjusting the television to face Resident 1.This failure placed Resident 1 at potential risk for emotional distress, depression, mental instability, and decline in overall health. During an interview on 11/25/25 at 9:38 a.m., Resident 1 reported two CNAs (CNA 2, CNA 3) accused her of turning her roommate's TV and taking the remote control. Resident 1 stated the CNAs spoke loudly and angrily, calling her a liar, which she found unprofessional and hurtful. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 1 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to protect residents' rights and ensure they were free from misappropriation of property, medications were administered as prescribed, and controlled drugs were properly accounted for and discarded according to facility's policy and procedure for two of three sampled residents (Resident 5 and Resident 6) when License Vocational Nurse (LVN) 5 diverted controlled medications (drugs regulated by law for potential abuse, addiction, or dependence) prescribed for Resident 5 and Resident 6 for personal use and failed to properly document, discard discontinued medications according to facility's policies and procedures. These failures resulted in Resident 5 and Resident 6 not receiving their prescribed medications as ordered which placed them at risk for inadequate pain management and anxiety. During an interview on 11/25/25 at 12:09 p.m. with Registered Nurse (RN), the RN stated controlled substances were stored in the controlled substance…

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 observations, interviews and record review, the facility failed to maintain accurate controlled substance records, documentation and reconciliation in accordance with facility's policies and procedures for two of three sampled residents (Resident 5, 6) when the license nurses (LNs) failed to accurately document and account Resident 5 and Resident 6 controlled substance on the Controlled Drug Records and Medication Administration Record to accurately reflect the controlled substance disposition or resident administration.These failures resulted in the facility's delayed detection of controlled substances diversion for Residents 5 and 6, and placed residents at potential risk for medication errors, untreated pain, and overdose, compromising residents' safety and quality of care. During an interview on 11/25/25 at 12:09 p.m. with the Registered Nurse (RN), The RN stated when controlled substances were delivered, the licensed nurse (LN) checked the medications against the pharmacy manifest to ensure the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure residents were free from unnecessary medications administration for three of three sampled residents (Resident 1, 5, and 6) when license nurses (LN) assessed Resident 1, Resident 5, and Resident 6's pain levels as mild to moderate and administered pain medications prescribed for severe pain, not in accordance with the physician's order. These failures had the potential to place Resident 1, Resident 5, and Resident 6 at risk for over-medication, respiratory distress, impaired cognition, falls, and inadequate pain control. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which includes type 2 diabetes mellitus (DM2-- a condition where the body has trouble controlling blood sugar levels, causing blood sugar to become high)…

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 notify the residents responsible party (RP- an individual who has the authority to act on behalf of the patient)/family/emergency contact of a change in condition for two of three sampled residents (Resident 1, 6) when Resident 1 experienced seizures (abnormal electrical activity in the brain) and Resident 6 reported chest pain and were transferred to acute care hospital. This failure had the potential to result in Resident 1 and Resident 6's RP/family/emergency contact being unaware of the acute health conditions, hospital transfers, and treatment decisions, which could negatively impact continuity of care and right to have their representatives involved in care decisions. During a concurrent interview and record review on 8/22/25 at 1:41 p.m. with the Director of Nursing (DON) in the DON office, Resident 1's Situation Background Assessment Recommendation Form (SBAR-a tool used to improve the clarity and efficiency of information exchange) form 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 interview, and record review, the facility failed to ensure residents received adequate supervision to prevent elopement for one of six sampled residents (Resident 1) when Resident 1 left the faciity on 2/17/25 without facility staff's knowledge and did not return. This failure resulted for Resident 1 at a higher risk of harm such as dangerous weather exposure, getting hit by a car or being assaulted. Finding: During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that include . Non displaced intertrochanteric( area between the two trochanters (thigh bone) of the femur) fracture (complete of partial break in a bone) of left femur(bone of the thigh) Alcoholic cirrhosis (a chronic liver disease characterized by the formation of scar tissue) .Bipolar Disease (sometimes called manic-depressive disorder; mood swings that range from the lows of depression…

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 Licensed Nurses have the competencies necessary to meet the needs and safety of the residents for one of six sampled residents (Resident 1) when Licensed Vocational Nurses (LVN) 3 and LVN 4 failed to notify the facility Administrator (ADM), Director of Nursing (DON) and the authorities when Resident 1 left the facility and did not return. This failure resulted in delayed in emergency response and placed Resident 1 at increased risk for harm such as dangerous weather exposure, getting hit by a car or being assaulted. Findings: During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that include . Non displaced intertrochanteric( area between the two trochanters (thigh bone) of the femur) ( fracture (complete of partial break in a bone) of left femur(bone of the thigh) Alcoholic…

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, facility document review, and facility policy review, the facility failed to ensure the facility-wide assessment was updated and reviewed annually. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Facility Assessment, implemented 06/2024, revealed, 10. The facility assessment will be reviewed and updated as necessary and at least annually. A Facility Assessment Tool, revealed the sections for Date(s) of assessment or update and Date(s) assessment reviewed with QAA [Quality Assurance Assessment]/QAPI [Quality Assurance and Performance Improvement] committee, were dated 08/31/2023. During an interview on 09/17/2024, the Administrator stated the facility assessment had not been reviewed prior to 08/31/2023. The Administrator stated they planned to review the facility assessment the last week of 09/2024. During an interview on 09/20/2024 at 2:21 PM, the Administrator stated the facility assessment was done on 09/10/2024, but it had not been reviewed or revised. The…

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

Based on interview and facility policy review, the facility failed to maintain an effective infection control program. Specifically, the facility failed to establish and implement a surveillance plan to identify, track, and monitor infections. This had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Infection Prevention and Control Program, implemented 10/2022, revealed, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The section titled Policy Explanation and Compliance Guidelines, included, 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual…

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, record review, and facility policy review, the facility failed to support a resident's choice to be out of bed by not providing the necessary specialized wheelchair needed for the resident to be out of bed for 1 (Resident #26) of 16 sampled residents. Findings included: A facility policy titled, Resident Rights, with a copyright date of 2024, revealed, 5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has the right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. An admission Record revealed the facility admitted Resident #26 on 12/05/2023. According to the admission Record, 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, record review, and facility policy review, the facility failed to ensure activities of daily living (ADLs) were provided for 1 (Resident #4) of 16 sampled residents. Specifically, Resident #4's fingernails were not properly trimmed. Findings included: A facility policy titled, Nail Care implemented 10/2022, revealed, 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. An admission Record revealed the facility originally admitted Resident #4 on 10/04/2002. According to the admission Record, the resident had a medical history that included diagnoses of quadriplegia, contracture of muscle at multiple sites, generalized muscle weakness, pain in an unspecified limb, and wrist drop. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #4 had upper and lower extremity impairments on both sides. The MDS indicated Resident…

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

Based on observation, interview, record review, and facility policy review, the facility failed to have a physician's order for the use of supplemental oxygen for 1 (Resident #98) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, implemented 10/2022, revealed, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy further indicated, Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. An admission Record revealed the facility originally admitted Resident #98 on 04/14/2023 and readmitted the resident on 09/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia, acute pulmonary edema, and chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment…

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, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was on duty daily for eight consecutive hours. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Nursing Services-Registered Nurse (RN), implemented 10/2022, revealed, 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. A facility nursing schedule for September 2024, indicated there were no RNs scheduled to work on 09/05/2024. However, RN #5's Employee Time Cards, dated 09/05/2024, revealed she worked 1.40 hours that day. A facility nursing schedule for September 2024, indicated there were no RNs scheduled to work on 09/08/2024. However, a Nursing Staffing Assignment and Sign-in Sheet, dated 09/08/20024, revealed RN #7 worked nonconsecutively for 7 hours that day. During an interview on 09/20/2024 at 1:07 PM, the Director of Nursing (DON) stated she was out sick from 09/01/2024 through 09/05/2024,…

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

Based on interview, record review, and facility policy review, the facility failed to ensure a PRN (pro re nata, as-needed) psychotropic medication had a 14-day stop date for 1 (Resident #12) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Use of Psychotropic Medication, implemented 10/2022, indicated, 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. [id est, that is] 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. An admission Record revealed the facility initially admitted Resident #12 on 07/06/2023 and readmitted the resident on 08/08/2024. According to the admission Record, the resident had a medical history that included a diagnoses of schizoaffective…

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, record review, and facility policy review, the facility failed to accurately transcribe hospital discharge medication orders for 1 (Resident #12) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Transcribing Physician Orders and Consulting Physician/Practitioner Orders, implemented 10/2022, revealed, 2. For consulting physician/practitioner orders received in writing or via fax [facsimile], the nurse in a timely manner will: c. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. An admission Record revealed the facility initially admitted Resident #12 on 07/06/2023 and readmitted the resident on 08/08/2024. According to the admission Record, the resident had a medical history that included a diagnosis of schizoaffective disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score…

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 two residents (Resident 1) had a correctly completed Minimum Data Set Assessment (MDS, a comprehensive, standardized assessment tool) when a review indicated six (6) incorrect entries. These six (6) errors indicated a pattern of incorrect assessment results, resulting in Resident 1's MDS that was not reflective of her status at the time of the assessment, and had the potential for Resident 1 to have unmet care needs that did not address her status, needs, strengths, and areas of decline. Findings: During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS indicated at Question A2300 as having an Assessment Reference Date of [DATE], which indicated a look back period of 7 days (unless another time period is indicated). For Resident 1's MDS assessment, the 7-day time period was [DATE] through [DATE]. The MDS contained six (6) errors at the following questions: Question C1310C Question E900 Question I2300 Question J1800…

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 implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when Resident 1 had a new onset of confusion, hallucinations (seeing and/or hearing things that are not real) and was yelling. This failure resulted for Resident 1's new onset of altered level of consciousness needs such as monitoring and safety to go unmet. Findings: During a review of Resident 1's admission Record, dated 4/17/24, at 4:08 PM, the admission Record indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE]. During a review of Resident 1's Minimum Data Set (MDS, a standardized, comprehensive assessment tool), dated 3/26/24, the MDS indicated at Section C500, Brief Interview for Mental Status, a score of eight out of 15, which indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. During…

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 services provided met professional standards of quality for one of three sampled residents (Resident 1) when Resident 1 was assessed with a new onset of confusion and hallucination (seeing and/or hearing things that are not real) and a physician's order for urine culture and sensitivity test (lab test to check for bacteria and germs in the urine) was not done to determine if an infection was present and the cause of the confusion. This failure resulted for Resident 1's urinary tract infection (UTI-a condition in which bacteria invades and grow in the urinary tract) to go untreated which led to Resident 1's new onset of confusion and hallucination. Findings: During a review of Resident 1's admission Record (AR), dated 4/17/24, at 4:08 PM, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE]. During a review of Resident 1's Progress Notes (PN), dated 3/19/24, at 10:52 PM, the PN indicated Resident 1 was…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a history of psychological problems and previous attempts to leave the facility on 4/11/24, received the necessary supervision from staff during another attempt to leave the facility on 5/12/24. This failure resulted in Resident 1 being unattended while in the parking area of the facility, who then quickly left the facility without supervision and was found 20 minutes later wandering on a nearby street. This failure had the potential for injury to Resident 1. Findings: During a review of Resident 1's admission Record (AR), dated 5/29/24, the AR indicated Resident 1 was admitted to the facility with diagnoses that included psychosis (refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality, a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), and Strange and Inexplicable Behavior. During a review of Resident 1's Care Plan (CP), dated 3/18/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 48 sampled residents (Resident 1) received Trauma Informed Care Evaluation (a process that acknowledge the need to understand patients ' life experiences to deliver effective care and treatment) performed when the Social Services Director (SSD) did not complete a Trauma Informed Care Evaluation for Resident 1. This failure had the potential for the facility ' s inability to identify triggers which could result in Resident 1 ' s re-traumatization (the reactivation of trauma symptoms by way of thoughts, memories, or feelings related to past experienced). Findings: During a review of Resident 1 ' s admission Record, dated 4/17/24, at 4:08 PM, the admission Record indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE]. During a review of Resident 1 ' s Progress Notes, dated 3/21/24, at 1:50 PM, the Progress Notes indicated a care conference meeting was held with Resident 1 ' s Family Member (FM 1). During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 48 sampled residents (Resident 1) had a Social Services Evaluation completed. This failure had the potential for unmet care needs for Resident 1, who was recently admitted to the facility, including care for mood and behaviors, adjustment to the new environment, mental health history, support systems, and behavioral interventions. Findings: During a review of Resident 1 ' s admission Record, dated 4/17/24, at 4:08 PM, the admission Record indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE]. During a concurrent interview and record review on 4/24/24, at 10 AM with the Social Services Director (SSD), Resident 1 ' s clinical record was reviewed. The SSD stated Resident 1 did not have a Social Services Evaluation. The SSD stated Resident 1 was admitted on [DATE] and the Social Services Evaluation should have been done. The SSD stated she was responsible to complete Resident 1 ' s Social Services Evaluation. 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 make information available for three of seven sampled residents (Residents 23, 25 and 29) when residents were unaware of how to file a grievance or complaint. This failure had the potential to result in Resident 23, 25 and 29 to have their concerns or grievances unaddressed. Findings: During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the Director of Social Services (DSS) was the grievance official. Resident 23 stated, I do not know how to file a grievance . During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 5/12/21, at 10:30 a.m., with Resident 29, Resident 29 stated, I don't know how to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for three of three sampled residents (Residents 5, 13, and 39) when: 1. Resident 5's MDS assessment of hearing and cognition were not coded accurately; 2. Resident 13's dialysis (use of machine to remove wastes from the body and keep body in balance) status was not coded (a system of signals used to represent letters or numbers in transmitting messages) accurately in Section O (Special Treatments, Procedures, and Programs) of the MDS assessment; and 3. Resident 39's MDS assessment for identification information was not coded accurately to indicate the accurate discharge status. These failures had the potential of the facility to not provide the necessary care and services to meet the residents' individualized needs. Findings: 1. During a concurrent observation and 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.

During an observation, interview, and record review the facility failed to provide an ongoing activities program for three of seven sampled residents (Residents 1, 11, and 23) when the facility did not support residents in their choice of activities. This failure had the potential to result in Resident 1, 11, and 23 being bored and verbalizing the facility did not have activities to do daily. Findings: During an interview on 5/11/21, at 2:58 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated the Activities Director (AD) was on leave. CNA 4 stated she was the Activities Assistant (AA). CNA 4 stated the AD was to come back after her leave but had not returned. CNA 4 stated she had been working in the facility since June 2019. CNA 4 stated she started doing activities in June 2020. During a concurrent observation and interview on 5/11/21, at 3:21 p.m., with CNA 4, in the hallway, a calendar dated May 2021 was reviewed. CNA 4 stated she would follow the calendar as scheduled. CNA 4 stated on 5/11/21 at 1 p.m. Aroma Therapy was scheduled. CNA 4 stated she did not do the Aroma…

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 served met the daily nutritional needs for 21 of 37 residents (Residents 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190) when residents on regular and large portion diets were served more than the required portion size of the main dish [meatballs]. This failure had the potential to result in Resident 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190 to receive more than the recommended daily calorie intake based on residents nutritional dietary needs. Findings: During a review of facility document titled, Order Listing Report, dated 5/11/21, the order listing report indicated, .Status: Current, Order Category: Diet, Order Status: Current. Resident Name: Resident 31, Order Summary: Controlled Carbohydrate diet Regular texture .Resident 13, Renal Diet, Regular Texture .Resident 29, Regular Large Portion diet Regular texture .Resident 3, Regular diet Regular texture .Resident 16, Regular diet Regular texture .Resident 20,…

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 suitable, nourishing snacks for four of seven sampled residents (Residents 1, 11, 23, and 29) when facility staff did not provide a variety of snacks for residents in the facility. This failure resulted in Resident 1, 11, 23, and 29 verbalizing and requesting different types of snacks from staff and staff did not notify the Dietary Service Manager (DSM). Findings: During an interview on 5/12/21, at 10:20 a.m., with Resident 23, Resident 23 stated the facility staff did not pass out evening snacks. During a review of Resident 23's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 3/29/21, the MDS assessment indicated, Resident 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 5/12/21, at 10:30 a.m., with Resident 29, Resident 29 stated the facility staff…

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 and serve food in accordance with professional standards for food safety when the Dietary [NAME] (DC) did not document the temperatures of the food served on 5/10/21 and 5/11/21. This failure had the potential to cause foodborne illness (caused by consuming contaminated foods or beverages) in 37 of 39 residents who consumed food prepared the kitchen. Findings: During a review of the facility document titled, Spring Cycle Menus, dated 5/10/21, the spring cycle menus indicated, . Temp [blank] Grape juice .Temp [blank] breakfast meat . Temp [blank] Broccoli salad .Temp [blank] egg salad sandwich . During a review of the fancily document titled, Spring Cycle Menus, dated 5/11/21, the spring cycle menus indicated, .Temp [blank] Apple Juice .Temp [blank] Toasted Oats .Temp [blank] Ham and Egg Scrambles .Temp [blank] Bran Muffin .Temp [blank] Milk . During a review of the facility's document titled, Order Listing Report, dated 5/11/21, the order listing indicated, .Status: Current, Order Category: Diet,…

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 provide a safe, clean, and homelike environment when: 1. One of one bathroom (Bathroom [ROOM NUMBER]) had baseboards there were peeled, the walls had even paint, and tiles were missing and broken near the shower tub; 2. One of one bathroom (Bathroom [ROOM NUMBER]) had a soap dispenser that was not functional; and 3. One of 35 Residents (Resident 34) had a gap between the window and the window seal. These failures created an environment that was not homelike and had the potential to result in a decreased quality of life for residents in the facility. Findings: 1. During an observation on 5/11/21, at 10 a.m., in Bathroom [ROOM NUMBER], the baseboard by the wall in the shower area was peeled off. The walls had uneven paint. There were missing tiles pieces and broken tile pieces by the shower tub. During a concurrent observation and interview on 5/11/21, at 4:49 p.m., in Bathroom [ROOM NUMBER], with Certified Nursing Assistant (CNA) 3, CNA 3…

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 a baseline (starting point) care plan for one of six sampled residents (Resident 188), when Resident 188 did not have a care plan for hospice (care focuses on terminally ill patient's pain and symptoms and emotional and spiritual needs at the end of life) care within 48 hours of admission. This failure had the potential to result in Resident 188's hospice needs to go unmet. Findings: During a review of Resident 188's admission Record (AR-document that gives a resident's information at a quick glance) dated 5/6/21, the AR indicated, .admission Date 05/01/2021 .Diagnosis Information .OTHER SEQUELAE (condition which is the consequence of a previous disease or injury) OF CEREBRAL INFARCTION (blockage in the brain) . During a review of Resident 188's Order Summary Report undated, the Order Summary Report indicated, .Admit to [name of company] Hospice for Dx (diagnosis): End stage Sequelae of cerebral vascular . order date: 5/2/202 . During a…

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

Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 187), when Resident 187's did not have a care plan to address his hard of hearing and Resident 187's care plan for activities of daily living (ADL- routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, mobility, and continence) was incomplete. This failure had the potential to result in Resident 187's hard of hearing and ADL care needs to go unmet. Findings: During a concurrent observation and interview on 5/10/21, at 8:35 a.m., with Resident 187, Resident 187 was observed leaned forward to try to hear what was said. Res 187 stated he did not hear well from both ears. Resident 187 stated he had a hearing aid prior to admission to the facility on 4/29/21. Resident 187 stated he did not use his hearing aid because it make loud noises and it made him unable to hear what people said. During a concurrent interview and record review on 5/12/21, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented for two of two sampled residents (Resident 7 and Resident 20) when: 1. Resident 7 was provided a house supplement (beverage containing protein and other performance substances as ingredients mixed with milk or water for the purposes of improved nutrition) for weight loss and did not have a physician's order for a house supplement; and 2. Resident 20 suffered a fall on 2/12/21 and the licensed nurse on duty did not complete an assessment of Resident 20. Resident 20 had an x-ray (type of radiation called electromagnetic waves, creates pictures of the inside of your body, the images show the parts of the body in different shades of black and white to checking for broken bones) completed on 2/17/21 which indicated a fracture of the long middle finger. These failures resulted in Resident 7 and Resident 20 not receiving professional care and presented with delayed treatment and care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident's abilities of daily living did not diminish for two of twelve sampled residents (Resident 5 and Resident 29) when: 1. Resident 5 requested a grooming services for a haircut from staff and there was not staff available to provide him with a haircut; and 2. Resident 29's Restorative Nurse Assistant (RNA-helps residents gain/improve strength and mobility) exercises and ambulation were not provided per the physician's order. These failures resulted in Resident 5 expressing and verbalizing not liking his long hair on multiple occasions and had the potential for Resident 29 to decline in her ability to carry out activities of daily living (ADL-skills required to manage one's basic physical needs including personal hygiene or grooming, dressing, toileting , transferring or ambulating, and eating), strength, and mobility. Findings: During a concurrent observation and interview on 5/10/21,…

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 implement and maintain a safe environment with an effective infection prevention and control program for the prevention of Corona Virus (COVID-19- a contagious serious respiratory infection transmitted from person to person) transmission when one of one sampled Licensed Vocational Nurses (LVN 4) did not follow the use of a fit tested (a fit test determines if a tight-fitting respirator can be worn without having any leaks) N95 respirator (protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) when caring residents identified as PUI (person under investigation- someone on observation for symptoms of COVID-19 [a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]) COVID-19. This practice potentially placed the residents and staff at risk for the spread and transmission of COVID-19, complications from COVID -19 and death. Findings: During a concurrent observation…

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