Community Subacute and Transitional Care Center

Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information and was posted in a prominent readily accessible place to residents and visitors when:1. Daily nurse staffing information was posted behind nursing station 1 and nursing station 2, which was inaccessible to residents and visitors.2. Daily nurse staffing information did not include the actual hours worked by Registered Nurse (RN)s, Licensed Vocational Nurse (LVN)s, and Certified Nursing Assistant (CNA)s.This failure resulted in restricted public access to posted nurse staffing information for 99 out of 99 residents admitted within the facility which had the potential to result in residents not knowing how many total or actual direct care hours were provided.During an observation on 12/19/25 at 11:26 a.m. at nursing station 1, Transitional Care, the facility's posted daily nurse staffing information titled, Report of Nursing Staff Directly Responsible for Resident Care, dated 12/19/25, was observed behind nursing station 1. The document…

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 establish and maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable (contagious) diseases and infections for four of ten sampled residents (residents 107,7, 39, and 42) when:1. A dignity bag was not correctly put on Resident 107's urine catheter bag and the urine catheter bag was touching the floor. This failure placed Resident 107 at risk to develop a Catheter-Associated Urinary Tract Infection (CAUTI -a serious infection occurring when germs enter the urinary system through a urinary catheter).2. A medication tray was not cleaned or disinfected in between use and contact with Resident 42, Resident 7 and Resident 39, whom were on Enhanced Barrier Precautions (EBP-- an infection control intervention designed to reduce transmission of resistant organisms using gown and glove use during high contact resident care activities).This failure placed Resident 42, Resident 7, and Resident 39 at risk for the spread and introduction of Multidrug-Resistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the dignity and privacy for one of 11 sampled residents (Resident 50) when Resident 50 was observed from the hallway of his room without any clothing on two occasions. This failure violated Resident 50's right to maintain his privacy.Findings:During a concurrent observation and interview on 12/16/25 at 10:20 a.m. in Resident 50's room, Resident 50 was observed in bed covered with a sheet, holding the sheet to his chin with both hands. Resident 50 was asleep but woke up when knocked on the door and introduction made. Resident 50 stated he had been at the facility for three weeks, because he went to Mexico. Resident 50 did not answer any further questions.During a review of Resident 50's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/18/25, the AR…

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

Based on observation, interview, and record review the facility failed to ensure one of nine sampled residents (Resident 5) received personal privacy and confidentiality of his personal and medical records when Licensed Vocational Nurse (LVN) 4 left Resident 5's Medication Administration Record (MAR) computer screen visible in the hallway while administering medications. This failure resulted in Resident 5's personal and medical records being visible to staff, residents and visitors, which could lead to unauthorized access to confidential personal and medical records. During an observation on 12/17/25 at 12:18 p.m. Medication Cart 3 (MC 3) was observed next to Resident 5's room with the drawers and computer screen facing out toward the facility hallway. Licensed Vocational Nurse (LVN) 4 was observed removing medication from MC 3. LVN 4 was observed donning personal protective equipment (PPE) and entering Resident 5's room. LVN 4 was observed closing Resident 5's room door. MC 3 was observed unattended in the hallway, next to Resident 5's room, with the drawers and computer screen…

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 two out of 22 residents (Resident 38 and Resident 87) received a level II Pre-admission Screening and Resident Review (PASRR- evaluation for individuals suspected of having a Serious Mental Illness (SMI) or Intellectual/Developmental Disability (I/DD)/Related Condition (RC), triggered by a positive Level I screen, to determine if they need specialized services, ensuring placement in the least restrictive setting) evaluation by the designated entity to determine if SMI, ID/DD/RC conditions were present when: 1. Resident 38 had a PASRR level I screening result positive for SMI, and the facility did not ensure a PASRR level II screening was completed. 2. Resident 87 had a PASRR level I screening result positive for SMI, and the facility did not ensure a PASRR level II screening was completed.These failures resulted in Resident 38 and Resident 87 not receiving the required PASRR level II screening which had the potential to result in missed…

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 had a well-balanced diet that meets their daily nutritional and special dietary needs when the facility's approved therapeutic diet manual:1. Was not based on current standard of practice or nationally recognized diet for residents with diabetes when the facility had a Reduced Concentrated Sweets (RCS) diet order for nutrition care with diabetes for one sampled resident (Resident 107); and 2. Did not contain a small portion diet or menu for one sampled resident (Resident 29) when the physician's diet order was for a small portion diet.These failures had the potential to result in inconsistent nutritional management related to therapeutic diet planning, limiting resident choices and failure to have all the diet choices in the diet manual could result in resident's receiving incorrect portions of food items. 1. During kitchen observation on 12/16/25 at 10:49 a.m. with Dietary Aid (DA) 1, DA 1, was observed preparing Resident 107's lunch tray. DA 1 stated his job was to place condiments, 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.

Based on observations, interviews, and record reviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when two of three kitchen staff (Dietary aid 1 and 2) did not have hair and facial hair fully restrained or covered during meal preparation and service. This failure had the potential to compromise food sanitation and resident safety.During an observation of lunch meal service on 12/16/25 at 12:35 pm, in the kitchen, Dietary Aid (DA)1 was wearing a baseball cap with longer hair in back and hair was not fully covered. DA 1 was not wearing hairnet. DA 1 was calling out trays, checking out meal tickets and meal trays with food, putting cold beverages on meal trays and placing meal trays into food carts.During a concurrent observation and interview on 12/17/25 at 12:32 pm with DA 2 in the kitchen, DA 2 was wearing surgical mask, the side of face had facial hair and was uncovered. DA 2 stated that he was mixing Juven (medical drink mixture with vitamins and minerals), diet cranberry beverages in cups 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. The cook failed to follow the diet order for three of three residents (Residents 56, 69, and 88). 2. The facility failed to have an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. These failures had the potential to result in residents being exposed to contaminated food which could lead to food born illness for all residents who receive food prepared in the kitchen and had the potential for Resident 56, Resident 69 and Resident 88 to have weight gain or loss by diet orders not being followed. Findings: 1. During a concurrent observation and interview on 8/27/24 at 12:20 p.m. with the Dietary Manager (DM), in the facility's kitchen, the [NAME] (DA), did not follow the recipe for three residents with small portion diet orders during the lunch service…

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 were treated with dignity and respect for three of 11 sampled residents (Resident 37, Resident 43, Resident 69) when: 1. Registered Nurse (RN) 1 administered medication to Resident 37's and did not provide privacy. This failure resulted in Resident 37 not being provided with respect and dignity while taking her medication. 2. RN 1 checked Resident 69's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. This failure resulted in Resident 69 not being provided with respect and dignity while her B/P was checked. 3. Resident 43's privacy curtain was tied in a knot. This failure resulted in Resident 43 not being provided his right for a respectful and dignified existence and denied Resident 43 the right to have an environment that promotes maintenance or enhancement of his quality of life. Findings: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain medical records which were complete, and accurately documented in accordance with accepted professional standards and practices for three of seven sampled residents (Resident 6, Resident 55 and Resident 41) when Resident 6, Resident 41 and Resident 55's copy of Physician Orders for Life-Sustaining Treatment (POLST-a medical document which outlines a patient's preferences for end-of-life care) were incomplete and not readily available as part of Resident 6 and 55's current medical records. These failures had the potential risk for Resident 6, Resident 41 and 55's decision regarding their healthcare treatment options not being honored. Findings: During a review of Resident 6's admission Record, (AR-document containing resident profiles) dated 8/29/24, the AR indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (occurs when the kidneys are no longer able to function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 6) when Resident 6's antipsychotic medication (used to treat severe mental disorder in which a person loses the ability to recognize reality or relate to others) use was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 6's care needs not met. Findings: During a review of Resident 6's admission Record (document with resident demographic and medical diagnosis information), dated 8/29/24, indicated Resident 6 was admitted in the facility on 8/30/23 with diagnoses which included unspecified psychosis (mental health problem that causes people to perceive or interpret things differently from those around them) and end stage renal disease (terminal illness that occurs when kidneys can no longer function on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure drugs and biologicals were labeled in accordance with current accepted professional principles and facility policy and procedures for one of two medication carts in Transitional Unit when medication cart contained Resident 53's (Fluticasone Propionate brand name- used to relieve allergic and non-allergic nasal symptoms) 50 mcg (microgram-unit of measurement) was found to not have an open date and beyond use date (BUD-the last date you can safely use a medication). This failure had the potential for Resident 53's medication to be administered past the discard date which could result in loss of effectiveness of medication leading to poor management of Resident 53's condition. Findings: During a concurrent observation and interview on [DATE] at 2:06 p.m. at the medication cart in Transitional Unit with Licensed Vocational Nurse (LVN) 1, Resident 53's (Fluticasone propionate brand name) was found with no open date and BUD. LVN 1 stated…

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 one of 11 residents an accessible call system when Resident 43's call light (a device that is used by a resident to call staff for assistance) was out of reach and wrapped around the television arm behind the resident's bed. This failure resulted in Resident 43 being unable to call for assistance and had the potential to delay care during an emergency and cause adverse outcomes. Findings; During a review of Resident 43's admission Record (AR), dated 8/29/24, the AR indicated Resident 43 had been admitted on [DATE]. Resident 43's admitting diagnoses included: nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), chronic obstructive pulmonary disease (COPD- lung disease that causes restricted airflow and makes it difficult to breathe) with acute exacerbation (a sudden worsening of respiratory symptoms), epilepsy (a chronic brain disorder that causes seizures, which are episodes of…

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