Horizon Health & Subacute Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to prevent residents from receiving unnecessary medications for three out of seven sampled residents (Residents 8, 38, and 126) when: 1.Resident 8 and 126's did not have liver function test labs (LFT- blood tests that measure how well your liver is functioning) completed or monitored while taking valproic acid (a medication used to treat seizure disorders [sudden burst of electrical activity in the brain], certain psychiatric conditions [a wide range of conditions that affect a person's thoughts, emotions and behavior]). These failures resulted in the status of Resident 8 and 126's liver function being unknown and had the potential to cause serious negative effects including toxic levels of valproic acid leading to increased sedation (a state of calmness, relaxation or sleepiness), confusion, seizures, tremors, and liver failure which may become life threatening. 2.Resident 38 was administered oxycodone (opioid pain killer)-acetaminophen (combined pain…

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 medication error rate was less than five percent when the facility ' s medication error rate was 14.81 percent. There were 27 opportunities for errors and four medication errors occurred with two of four sampled residents (Residents 25 and 85) when: 1. Resident 25 was administered an fluticasone propionate and salmeterol inhalation (medication that is inhaled and helps reduce swelling in the airways) and did not rinse mouth after use as indicated in the prescriber order. 2. Resident 85 was administered one Bumetanide tablet (medication that can treat fluid retention and high blood pressure [force exerted by blood on the walls of the arteries as it is pumped by the heart throughout the body]) at 9:32 a.m. when it was scheduled to be administered at 8:00 a.m. (over an hour past the administration time). 3. Resident 85 was administered Carvedilol (medication to treat heart failure [condition in which the heart cannot pump enough…

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, interview, and record review, the facility failed to properly store and label medications in two of six medication carts when: 1. Eight of fifteen liquid bottled medications did not have an open date in the long-term wing medication cart. Seven of these nine medications were for Residents 1, 25, 34, 62 and 100. This failure had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications 2. Five of 11 eye drop bottles did not have patient labels for Residents 1, 62, and 94 in the long-term wing medication cart. This failure had the potential to result in misidentification of a medication, patient safety risks, and incorrect dosage. 3. One of six medication carts had eye drop medication for three of three residents (residents 76, 115, and 145), that were not labeled with resident name or date the medication was opened. This failure had the potential for residents to receive other residents' medications and/or expired medication that…

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 food was stored, prepared and distributed in accordance with professional standards when: 1. Kitchen staff (KS 3) did not monitor had not recorded the temperature during the cooling process after preparing tuna salad that was at ambient temperature (room temperature) ; 2. Kitchen staff (KS 4) did not wear a beard net while preparing resident juice cups nor did kitchen staff (KS 5) wear a beard net while putting away equipment and wiping down surfaces; 3. Two robot coupes were stored wet with water inside, pooled on bottom and condensation on the lid; 4. A black serving scoop was stored inside a dry storage bin containing thickener; and 5. A box containing hash brown potatoes was on the floor inside the walk-in freezer. The facility's failure to maintain professional standards for food service safety had the potential to expose highly susceptible residents who received food from the kitchen to foodborne illness (an illness that…

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 accurate and complete medical records in accordance with professional standards of practices were maintained for seven of twelve sampled residents (Residents 15, 16, 33, 45, 52, 106, and 126), when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) were not accurate and complete. This failure had the potential for Resident 15, 16, 33, 45, 52, 106, and 126's decisions regarding treatment options and end of life wishes to not be honored. Findings: During a review of Resident 15's Physician Orders for Life Sustaining Treatment (POLST-is a medical order that helps give people with serious illness more control over their care during a medical emergency) dated [DATE], the POLST indicated, . Date Form Prepared . (no date written) . During a concurrent interview and record…

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 respect and dignity in an environment that promotes and enhances quality of life for two of six sampled residents (Residents 1 and 74) when Certified Nursing Assistants (CNA's 2 and 3) stood to fed them lunch. This failure violated Residents 1 and 74's right to be offered a dignified dining experience and made Resident 1 feel uncomfortable and disrespected. Findings: During an observation on 3/3/25 at 1:25 p.m. in the dining room, CNA 2 stood while she fed Resident 74 during lunchtime. CNA 2 spoke to Resident 74 while she stood over her, not sitting at eye level. During an interview at 3/3/25 at 1:46 p.m. with CNA 2, CNA 2 stated she should have sat down with Resident 74 during mealtime. CNA 2 stated she should have sat down on a chair next to Resident 74 and made sure she was at eye level when she fed him. CNA 2 stated Resident 74 could have felt uncomfortable and rushed when she stood to fed him. CNA 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of six sampled residents (Resident 53) had the right to make choices about aspects of his life in the facility when his choice to have a shower on a Saturday instead of a Friday was not honored. This failure resulted in Resident 53's skin on his upper cheat and left upper arm becoming red, dry and itchy leading to him scratching himself opening the skin and the potential for an increased risk for infection. Findings: During a review of Resident 53's admission Record (AR- document containing resident demographic information and medical diagnosis) dated [DATE], the AR indicated, Resident 53 had diagnoses of end stage renal disease (condition where the kidneys have permanently lost their ability to function properly), diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) level), heart failure (when the heart muscle doesn't pump blood as well as it should) , hypertensive heart disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for one of eight residents (Resident 55), when the facility did not respond to Resident 55's complaint of air from the vent in his room blowing on his face. This failure resulted in Resident 55 feeling cold, frustrated, and uncomfortable in his bed. Findings: During a concurrent observation and interview on 3/3/25 at 11:16 a.m. with the caregiver of Resident 55 in his room, a small white trash bag taped to the side of the over the bed table (a rolling table designed to be positioned over a bed, providing a stable surface for activities like eating, reading, or working while in bed), was observed waving back and forth as if being blown by the wind. The table was placed over the bed where the resident's upper body and head would have been if the resident had been in the bed. Resident 55 was sitting at the end of his bed in a wheelchair watching the television that belonged to the A bed 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 interview and record review the facility failed to notify the Ombudsman (a public official who advocates for residents' rights, health, safety, and well-being, investigating and resolving complaints and concerns), and the resident representative, (RP-person designated to make decisions for a resident), in writing of a resident's transfers to the hospital for one of six sampled residents (Resident 66) when the facility did not inform the ombudsman of Resident 66's transfer to the hospital and the RP was not given written notice of Resident 66's transfer to the hospital. This failure violated Residents 66's right to have his RP and Ombudsman properly informed of his hospitalization on 7/8/24. Findings: During an interview on 3/5/25 at 11:43 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 66's RP was only called for his transfer to the hospital on 7/8/24 and was not given the notification in writing. RN 1 stated she did not know residents and their RP's needed to be notified in writing of their…

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 practice for two of seven sampled residents (Residents 52 and 113) when: 1. Resident 52's tube feeding bag (TF - a liquid form of nutrition that is carried through your body through a flexible tube) was not labeled with the date it was hung (set up for administration). 2. Resident 113's TF bag was not labeled with the time the TF bag was hung. These failures had the potential to result in Residents 52 and 113 to receive nutrition that was outdated or expired and put them at risk of food borne illness (any illness resulting from eating contaminated/spoiled foods). Findings: During an observation on 3/3/25 at 9:35 a.m. in Resident 52's room, Resident 52 was dressed, lying in bed asleep with her head elevated. Resident 52 had a TF attached to a feeding pump (a machine that delivers specific amount of fluids per hour of nutrition) that was not administering TF to Resident 52. Resident 52's TF bag had no date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain routine dental services to meet the needs each for one of two residents when Resident 76 had treatment recommendations for a bone spur (an abnormal bony growth that forms on or around joints or along the edges of bones) removal and a new full set of dentures (a removable plate or frame holding one or more artificial teeth) and no action taken by the facility since 9/15/23, leaving the resident without dental service intervention for 17 months and three weeks. These failures resulted in Resident 76 wearing dentures that did not fit properly and caused her pain had the potential to result in poor oral health, difficulty eating and speaking, and decreased quality of life that could lead to depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one ' s 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 two out of twenty-three kitchen staff (KS 1 and 2) had appropriate competencies and skill sets to safely and effectively carry out the functions of food and nutrition services when: 1. KS 1 used a #12 scoop (1/3 cup, 2.67 ounces) to portion chopped meat when the menu did not indicate portion sizes for chopped meat; and 2. KS 2 did not use the correct portion size when preparing tuna and egg salad sandwiches. These failures had the potential to result in residents receiving inadequate protein which could result in frailty (decreased energy), weight loss, delayed wound healing, loss of muscle, and increased risk of fractures (broken bones). Findings: 1. During an observation of the lunch meal service on 3/4/25 at 12:37 p.m. KS 1 was plating chopped hamburger for residents on prescribed chopped diets. Hamburger patties were pre-chopped and paced in a container on the steam table prior to the start of meal service. Hamburger pieces were approximately ½ inch in size. KS 1 used a full #12 scoop to portion…

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 six sampled residents (Resident 35) area was maintained a safe, functional, sanitary and comfortable environment for residents staff and the public when, Resident 35's room had a bag of adult diapers, multiple t-shirts, sweaters and jackets stacked on top of a walker and wheelchair at the foot of the hospital bed, blocking access to the window. These failures had the potential to cause injuries, falls and a fire safety hazard for Resident 35 and her roommate. Findings: During a review of Resident 35's admission Record (AR- document containing resident demographic information and medical diagnosis) dated 3/6/25 the AR indicated, Resident 35 was admitted to the facility on [DATE]. Resident 35's diagnosis included, chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), pain, hypertension (high blood pressure), anxiety, depressive…

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 each resident received adequate supervision to prevent accidents for one of three residents (Resident 1), when Resident 1 required two person assist for turning and repositioning but was turned by Certified Nursing Assistant (CNA) 1 during briefs (adult diaper) change alone (without another person to assist) on [DATE]. This failure resulted in Resident 1 falling out of bed and onto the floor on [DATE] and the potential for Resident 1 to be injured. Findings: During a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted on [DATE] with a history of Anoxic Brain Damage (when the brain is completely deprived of oxygen, which can lead to brain cell death), Persistent Vegetative State (a condition in which a person is awake but lacks awareness of themselves or their surroundings), Tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy to ensure Injuries of Unknown Origin (any injury without a reason the injury could have or did occur) were reported to all Local and State Officials in the required time frame, as defined by law, for one of three sampled residents (Resident 1) when, the facility discovered Resident 1, a non-verbal and non-mobile resident, had a closed fracture of his left humerus (a brake in the bone of the upper left arm) and did not report it to the Police Department or Ombudsman. This failure resulted in the delay of investigation by outside agencies, assistance in the facility ' s investigation, and had the potential to result in resident abuse not being discovered, putting all residents at risk of abuse. Findings: During an interview on 2/7/25 at 8:30 a.m. with the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), the Ombudsman stated, he had not been informed of any injuries of…

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

Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 1) was free from abuse, neglect, and exploitation when Licensed Vocational Nurse (LVN) 1 used profane language (language that is considered offensive, vulgar, or irreverent) toward Resident 1 and instructed staff not to assist Resident 1 after an unwitnessed fall (when an individual falls to the ground or a lower surface without anyone seeing it) on 11/17/24. These failures had the potential for Resident 1 to experience agitation, intimidation, disrespect, and fear. Findings: During a review of Resident 1's admission Record (AR), dated 11/22/24, the AR indicated, Resident 1 had a history of Schizophrenia (a chronic mental illness that affects a person's ability to think, feel, and behave normally) and Anxiety Disorder (a condition that causes excessive and persistent feelings of fear, dread, and uneasiness). During a concurrent observation and interview on 11/22/24 at 3:10 p.m. with Resident 1, in Resident 1's room, Resident 1 stated, on 11/17/24 he was sitting on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when two boxes containing 48 [brand name] Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) self-test kits were expired on 8/23/24 in the clean utility supply room (a space for storing, preparing, and distributing clean and sterile supplies for patient care). This failure had the potential to produce inaccurate Covid-19 test results. Findings: During a concurrent observation and interview on 10/4/24 at 12:10 p.m. with Infection Preventionist (IP; a healthcare professional designated to prevent the spread of infections in healthcare facilities) in the clean utility room supply room, two boxes of [brand name] Covid-19 self-test kits were on the shelf. Each box contained 12 kits with four individual tests inside. The label on the boxes indicated the expiration date was 1/23/24. IP 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.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from physical abuse when one Mental Health Worker (MHW) placed both of his hands on Resident 1's shoulders and shoved him backwards. This failure resulted in Resident 1 stumbling backwards and experiencing mental anguish, including intimidation, feeling threatened, frightened, and increased agitation. Findings: During a review of the document titled SOC341 – Report of Suspected Dependent Adult/Elder Abuse (submitted to the Department from the facility), dated 6/24/24, the SOC341 indicated that on that date between 5 PM and 5:15 PM, Resident 1 was observed in his bathroom yelling. [MHW] attempted to de-escalate the patient. Resident [1] then pushed [MHW. MHW] responded by pushing patient with two hands on each shoulder causing resident to stumble back. During a review of Resident 1's admission Record (AR), dated 7/9/24, the AR indicated he was admitted to the facility with diagnoses that included Schizoaffective Disorder (a mental disease that affects the person's ability…

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 check the references of one of three employees (Mental Health Worker, or MHW) prior to employment. This failure resulted in the potential for one unqualified employee (MHW) to provide care to residents [Cross Reference with F600]. Findings: During a review of the document titled SOC341 – Report of Suspected Dependent Adult/Elder Abuse (submitted to the Department from the facility), dated 6/24/24, the SOC341 indicated that on that date between 5 PM and 5:15 PM, Resident 1 was observed in his bathroom yelling. [MHW] attempted to de-escalate the patient. Resident [1] then pushed [MHW. MHW] responded by pushing patient with two hands on each shoulder causing resident to stumble back. During an interview on 7/9/24, at 11:40 AM, with the Administrator, the Administrator stated the MHW's employment with the facility was terminated. The Administrator stated, As a Mental Health Worker, I really don't think he was a good fit. He was triggering residents. During a review of the facility document titled, Employee Warning/Discipline…

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 report the findings of an investigation of an abuse allegation to the Department within five days. This failure had the potential for an allegation of abuse to not be thoroughly investigated and result in further abuse [Cross Reference with F600]. Findings: During a review of the document titled SOC341 – Report of Suspected Dependent Adult/Elder Abuse (submitted to the Department from the facility), dated 6/24/24, the SOC341 indicated that on that date between 5 PM and 5:15 PM, Resident 1 was observed in his bathroom yelling. [Mental Health Worker, or MHW] attempted to de-escalate the patient. Resident [1] then pushed [MHW. MHW] responded by pushing patient with two hands on each shoulder causing resident to stumble back. During an interview on 7/9/24, at 4:30 PM, with the Administrator, the Administrator stated, We don't have a 5-day follow up report. During a review of the facility's policy and procedure (P&P) titled, Reporting of Alleged Violations, dated 3/18, the P&P indicated, A completed copy of all investigation…

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.

2. A review of Resident #304's admission Record, revealed the facility admitted the resident on 02/23/2024, with diagnoses that included acute respiratory failure with hypoxia, asthma, and morbid obesity. A review of Resident #304's care plan, initiated on 02/23/2024, revealed the resident was at risk for hypoxemia related to diagnoses of acute respiratory failure with hypoxia and morbid obesity. Interventions directed staff to apply the resident's CPAP device at the prescribed time and setting as indicated by the physician's order. A review of Resident #304's Order Summary Report, revealed an order dated 02/24/2024 for staff apply the resident's CPAP/auto-adjusting positive airway pressure (APAP) device at bedtime and remove in the morning upon awakening. The order did not specify the PEEP setting for the CPAP/APAP. During an interview on 02/29/2024 at 7:18 AM, Licensed Vocational Nurse #7 acknowledged staff did not verify Resident #304's physician order to ensure the order was complete. During an interview on 02/29/2024 at 9:42 AM, the Respiratory Therapist stated the nursing…

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 meet professional standards of quality when one of three residents (Resident 1) complained of persistent and severe pain following a right hip replacement (a surgical procedure in which the diseased parts of the hip joint; ball and socket of the pelvis is replaced with new, artificial parts) and staff did not notify the Attending Physician (medical doctor assigned to care for a patient) according to the facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status. This failure resulted in delaying the identification of the dislocation (when the ball of the new hip implant comes out of the socket) of Resident 1 ' s right hip. Findings: During an interview with Resident 1 ' s son on 10/31/23 at 10:10 a.m., son stated, Resident 1 had a total right hip replacement on 9/19/23 and was admitted to the facility on [DATE] for rehabilitation (services to improve skills and functioning for daily living that have been lost or impaired).…

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

Based on observation, interview, and record review, the facility failed to ensure the food services staff were competent to carry out the functions of food services safely and effective for all residents being provided meals from the kitchen when two of two food service staff were unable to verbalize the cool down process. This failure had the potential for untrained staff to place residents at risk of exposure for foodborne illnesses (food poisoning). Findings: During an interview with [NAME] 1 and Certified Dietary Manager (CDM), on 6/19/19, at 10:25 a.m., [NAME] 1 stated staff started the cool down process when the food was cooked and was cooled by placing it inside the walk in refrigerator. [NAME] 1 was unable to verbalized the temperature of the cooling down process. During an interview with [NAME] 2 and the CDM, on 6/19/19, at 10:31 a.m., regarding cool down food process, [NAME] 2 stated cool down process began by cooling the food down to 71 degrees Fahrenheit (F) within a four hour period and proceeded to further cool down from 71 F to 41 F within a two hour period. The CDM…

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 services provided met professional standards of quality for two of three sampled residents (Resident 136 and Resident 91) when: 1. Licensed Vocational Nurse (LVN) 4 did not follow the facility's policy and procedure on self-medication administration for Resident 136 and left his prepared medications on top of his bedside table unattended; LVN 4 signed the medications as being administered without first verifying Resident 136 took his medications and LVN 2 failed to take the necessary precautions to store Resident 136 medication left at his bed side table by LVN 4. This failure placed Resident 136 at risk for medication error and for unauthorized personnel to access Resident 136's medications. 2a. LVN 1 administered Resident 91's medication without explaining what the medications were being administered for; and 2b. LVN 9 did not notify Resident 91's physician of the resident's non-compliance with the physician's order to shower…

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 care and services to assure residents received the care to attain and maintain their highest practicable physical, mental, and psychosocial well being for two of two sampled residents (Resident 136 and Resident 22) when: Resident 136 and 22 were not assisted to the bathroom in a timely manner. This failure resulted in Resident 136 and Resident 22 feeling upset and frustrated and the potential for the residents to experience an incontinent episode and a fall. Findings: 1. During a concurrent observation and interview with Resident 136, on 6/18/19, at 3:14 p.m. Resident 136 laid in his bed laying across his bed with his legs dangling off the bed. Resident 136 reached for his call light and and turned his call light on. Resident 136 requested assistance to use the restroom and stated, Can you help me go to the bathroom? During an observation on 6/18/19, at 3:15 p.m. in Resident 136's room, Certified Nursing Assistant (CNA) 2…

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

Based on observation, interview, and record review, the facility failed to safely store, prepare and serve food safely when: 1. Multiple open contianers of condiments were stored and available for use without an open date inside the spice rack and walk-in refrigerator. 2. Restorative Nursing Assistant (RNA) 2 her face, hair and mouth while serving plates of food to residents in the dining room. These failures to ensure effective dietetic service operations placed the residents at risk for foodborne illness. Findings: 1. During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 6/18/19, at 1:35 p.m., in the kitchen, the following spices were observed open and without an open date labeled: Ground Nutmeg powder, poultry seasoning, ground turmeric powder, whole bay leaves, light chili powder, and dill weed. The CDM stated, These open spices should all be dated. During a concurrent observation and interview with the CDM, on 6/18/19, at 2:00 p.m., in the walk-in refrigerator, the following items were observed open and without an open date: a small bottle…

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

Based on observation, interview, and record review, the facility failed to ensure the dialysis record used as a communication tool was documented accurately and completely for two of two sampled residents (Resident 111 and Resident 105). This failure resulted in an incomplete and inaccurate documentation of Resident 111's and 105's clinical records and potentially to disrupt the continuity of care between providers. Findings: 1. During a concurrent observation in Resident 111's room and interview with Resident 111, on 6/18/19, at 3:26 p.m., Resident 111 stated he received dialysis (the process of removing waste products and excess fluid from the body to treat both acute (temporary) and chronic (permanent) kidney failure) services. Resident 111 showed the arterio-venous (AV) fistula shunt (a graft inserted to help with dialysis treatment) on his left upper arm. Resident 111 stated he went to the dialysis clinic every Tuesday, Thursday and Saturday at 10 a.m. During a review of the clinical record for Resident 111, the face sheet (a document that contains personal information)…

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 for three of three sampled residents (Resident 44, 62 and 141) when: 1. For Resident 44, Resident 62, Resident 141, the Respiratory Therapist (RT) used his stethoscope (a medical instrument for listening to the action of someone's heart or breathing) and did not sanitized the stethoscope's diaphragm (the flat part at the end of the tubing which contains thin plastic used to listen to high pitch sounds such as lung sounds) in between use of residents. 2. The handwashing sink was located on the same counter as the clean plates and lids next to the steam table holding the food. 3. Six of six non-dietary staff (NDS) (Human Resource -HR 1, Director of Staff Development- DSD 1, DSD 2, Restorative Nursing Assistant- RNA 2, RNA 3, and LVN 14) were observed washing their hands in the kitchen sink and were not wearing hair nets in the food service area in the dining room. These failures placed the residents and staff at high risk for cross contamination 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 interview and record review, the facility failed to send a copy of the resident transfer and discharge notification to a representative of the Office of the State Long-Term Care Ombudsman (an official appointed to represent the elderly and frail residents rights under public authorities) for one of four sampled residents (Resident 98) when Resident 98 was transferred for hospitalization and the local Ombudsman was not notified. This failure had the potential to result in inappropriate resident transfer and discharge practices for Resident 98. Findings: During a review of the clinical record for Resident 98, the admission Record dated 6/21/19, indicated Resident 98 was readmitted to the facility on [DATE]. During a review of the clinical record for Resident 98, the progress note dated 1/24/19 at 8:40 a.m., indicated . Resident appeared to be in respiratory distress [as evidence by] rapid abdominal breathing and diaphoresis (profuse sweating) . Ordered by [medical doctor] to send resident out to [local…

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 grooming needs were met for one of two sampled residents (Resident 116) when Certified Nursing Assistants (CNA's) and Licensed Nurses (LN's) failed to provide Resident 116 with nail care to keep nails short and well trimmed as indicated in her plan of care. This failure resulted in Resident 116's self inflicted scratches to her left arm and leg and placed her at risk for a skin infection. Findings: During a concurrent observation and interview with Resident 116, on 6/18/19, at 4:28 p.m., Resident 116 was sitting up in bed and itching her left thumb. Resident 116 stated she was itchy. Resident 116's nails were long with mauve colored nail polish on both hands. Resident 116 stated she told the nurses she was itchy. During a review of the clinical record for Resident 116, the admission Record dated 6/20/19, indicated Resident 116 was admitted to the facility on [DATE] with diagnoses which included pruritus (itchiness) and diabetes…

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 stored safely inside the medication cart (med cart) when Licensed Vocational Nurse (LVN) 1 left an over the counter (OTC) drug on top of the med cart unattended. This failure had the potential for the medication to be left unattended on top of the med cart which could result to unauthorized access by other residents, staff, and visitors in the facility. Findings: During a medication administration observation with LVN 1, on 6/20/19, at 7:30 a.m., LVN 1 prepared eight scheduled morning medications which included 1 capsule of Vitamin D 5,000 units for Resident 91. The bottle of Vitamin D 5,000 units was placed on top of the med cart. and left unattended while LVN 1 entered and administered the medication to Resident 91. LVN 1 returned to the med cart in front of Resident 91's door, and observed the over the counter bottle of Vitamin D 5,000 units was left on top of the med cart. During an interview with LVN 1, on 6/20/19, at 2:30 p.m., she stated she should have ensured all medications were…

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 timely dental services for one of one sampled residents (Resident 111) when there was no follow up for Resident 111's dentures from the dental office since 2/8/19. This failure delayed Resident 111's acquisition of his full upper and lower dentures that would enable him to eat regular food and enhance his well-being. Findings: During a concurrent observation and interview in Resident 111's room on 6/18/19, at 3:17 p.m., Resident 111 had missing upper and lower teeth. Resident 111 stated he had been served ground food and he wanted to eat regular food. Resident 111 stated he went to a dental office about four months ago for his upper and lower dental impressions. Resident 111 stated he did not get his dentures. Resident 111 stated he asked the facility staff about getting dentures and he was told they were working on it. Resident 111's family who was present during the interview, validated Resident 111 had not yet received his upper and lower dentures. During a concurrent interview and record review…

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.