Rancho Seco Care Center

Based on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 53) was free from unnecessary medications, when Resident 53's lorazepam (an anti-anxiety medication) was prescribed without a stop date.This failure increased Resident 53's potential to receive an unnecessary medication.Findings:A review of Resident 53's admission Record, indicated he was admitted to the facility in October 2025 with a diagnosis of anxiety disorder.A review of Resident 53's Order Summary Report (OSR), dated 12/13/25, indicated an order for lorazepam 0.5 milligrams (mg; a unit of measurement) to be given every eight hours as needed (PRN) for anxiety with agitation with no stop date.A review of Resident 53's Medication Administration Record (MAR), dated 12/25 and 1/26, indicated Resident 53 received lorazepam 13 times in 12/25 and twice in 1/26.During a concurrent interview and record review on 1/8/26 at 9:26 a.m. with the Director of Nursing (DON), Resident 53's OSR and MARs were reviewed. DON confirmed Resident 53's order for PRN lorazepam did not indicate 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 interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) were free from abuse when:1a. Resident 1 and Resident 3 were observed slapping each on the arms on 11/9/25; and 1b. Resident 1 and Resident 2 were observed slapping each other on the arms on 11/11/25.This failure resulted in Resident 1 and Resident 2 sustaining abrasions on their arms. Findings:1a. During a review of Resident 1's clinical record, the clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, cognitive communication deficit, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), and unspecified psychosis (psychotic symptoms such as hallucinations, delusions or disorganized thinking not aligned with a specific psychotic disorder or mental illness). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment, when multiple residents complained of cold temperature and the residents' rooms temperatures were below the requirement. In addition, the facility failed to act in a timely manner when the boiler (a central component of heating system that provides warmth to the building) was not functioning for a census of 98. These failures resulted in residents' discomfort, difficulties with sleeping and had the potential to negatively impact the residents' quality of life.Findings: An investigation of the complaint that alleged the facility was too cold and the heater was not working properly was conducted on 11/22/25, commencing at 7:30 a.m. The temperature outside registered 42 degrees F (Fahrenheit, unit of measurement) at 7:30 a.m. During an observation on 11/22/25 at 7:35 a.m., five residents were observed in the dining room. A female resident sitting next to the table had a warm sweater and pants 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 observations, interviews, and a review of records, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse when Resident 2 slapped Resident 1 on the right cheek and punched him in the stomach.This failure resulted in physical contact that posed a risk of injury and demonstrated the facility's inability to protect Resident 1 from abuse by another resident.Resident 1 was admitted to the facility in Winter of 2024 with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), inguinal hernia (when part of the intestine or soft tissue pushes through a weak spot in the abdominal muscles in the groin area) and depression.A review of Resident 1's Order Summary Report (OSR) indicated, Resident Capable of Understanding Rights, Responsibilities, And Informed Consent.A review of Resident 1's Minimum Data Set (MDS-a standardized assessment tool used in nursing homes), dated 9/11/25, indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to provide supervision and monitoring for one of three sampled residents (Resident 1) when Resident 1, after two attempts, eloped from the facility. This failure had the potential to result in serious injury or death for Resident 1.Findings:Resident 1 was admitted to the facility in 2025 with diagnoses that included stroke, aphasia (a language disorder that affects a person's ability to communicate), and Dementia (problems with reasoning, planning, judgement, and memory).Resident 1's admission MDS (Minimum Data Set-an assessment tool), dated 4/10/25, documented Resident 1 as having clear speech, usually able to understand others, usually able to make self-understood and his Brief Interview for Mental Status (BIMS) summary score as an 11 (moderate impairment). The MDS described Resident 1 as having no delirium or behavioral symptoms. The MDS also described Resident 1 as needing little to no assistance with bed mobility, transfers, locomotion…

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 care in a manner that promoted dignity and respect for one of four sampled residents (Resident 1) when Resident 1 was observed spitting in hallways and was reported to open his bowels on the facility patio. This failure had the potential to minimize Resident 1's self esteem and to negatively impact the psychosocial well-being for other residents in the facility. Findings: During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted in early 2023 with multiple diagnoses including Dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 3/21/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 3 out of 15 that indicated Resident 1 had severe cognitive impairment. During an interview on 6/18/25 at 12:36 p.m. with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 1 has been…

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 protect one of 4 sampled residents (Resident 1) from physical abuse when Resident 2 pushed Resident 1 in the face. This failure resulted in Resident 1 sustaining a bloody nose. Findings: During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted in early 2023 with multiple diagnoses including Dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 3/21/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 3 out of 15 that indicated Resident 1 had severe cognitive impairment. During a review of Resident 2's clinical record, the record indicated Resident 2 was admitted in late 2024 with multiple diagnoses including Diabetes Mellitus (a chronic disease where the body doesn't produce enough insulin (a hormone) to regulate sugar levels in the body and can cause slow wound healing. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1 and Resident 2) in a census of 95 were free from abuse when Resident 2 hit Resident 1 with a wooden and metal reacher. This failure increased the potential for physical injury and psychosocial distress. Findings: Resident 1 was admitted to the facility in the fall of 2024 with multiple diagnoses which included dementia (a general term for impaired thinking, remembering, or reasoning that can affect a person's ability to function safely), abnormality of gait and mobility, visual loss, depression and anxiety. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/4/25, the MDS indicated Resident 1 had severe memory impairment. During a review of Resident 1's nurses notes (NN), dated 6/16/25, the NN indicated Resident had an altercation with roommate. She lost balance and fell across room mate's bed and room mate [Resident 2] started hitting her in the face with a…

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

Based on interview, and record review, the facility failed to protect one of four sampled residents from abuse (Resident 1), when another resident (Resident 2) hit Resident 1 on the arm repeatedly. This failure caused fear and had the potential to cause physical injury to Resident 1. Findings: During a review of Resident 1's admission record, Resident 1 was admitted in March of 2016 with diagnoses of Flaccid Hemiplegia (a disorder where one side of the body is paralyzed, inability to move affected side due to lack of muscle function), Epilepsy (a seizure disorder) and muscle weakness. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 was cognitively intact. During a review of Resident 2's admission record, Resident 2 was admitted in September of 2024 with a diagnosis of Dysphagia (difficulty swallowing). Resident 2's MDS indicated the resident had severe cognitive impairment. During a review of a facility submitted document titled REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE [SOC 341] dated 11/18 indicated that Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dignity was promoted for two of five sampled residents (Resident 2 and Resident 3), when the residents room smelled with a very strong urine odor. This failure led Resident 2 to feel a sense of an undignified existence and Resident 3 felt uncomfortable and lacking in dignity. Findings: Resident 2 was admitted to the facility late 2024 with diagnoses which included high blood pressure and abnormalities of walking and mobility. During a review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 2/21/25, the MDS indicated Resident 2 had no memory impairment. Resident 3 was admitted to the facility in the middle of 2024 with diagnoses which included depression and anxiety. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 had very mild memory impairment. During an observation on 5/21/25 at 1:43 p.m. in Resident 2 and Resident 3 ' s shared bedroom, upon entering…

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 1 of 4 sampled residents (Resident 2) was free from abuse when Resident 1 ran over Resident 2 ' s foot with his wheelchair two times. This failure had the potential to cause injury, fear, and distress to Resident 2. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility in early 2025 with multiple diagnoses including Depression (a condition with persistent sadness, loss of interest in activities, and difficulty in daily life). A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/12/25, reflected a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 1 was cognitively intact. A review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility in late 2024 with multiple…

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 food storage and preparation, as well as maintain kitchen equipment and the kitchen environment in accordance with professional standards for food service safety when: 1. One bag of grits was found open and left unsealed, and was without open and use-by dates, 2. Kitchen environment was not maintained (e.g. walk-in refrigerator floor sealant was worn off with areas of missing metal and texture coating, kitchen walls and ceiling had areas of missing texture and paint, and showed signs of water damage), 3. Fruit and vegetable sink lacked an air gap (a backflow prevention device that prevents contaminated water from re-entering the sink), 4. Five metal bowls and nine steam table pans were stacked and stored wet, 5. Small wares were not discarded when damaged (e.g. fry pan surface covered in light and dark markings and scratches, discolored white cutting board, discolored water container lids -some with cracked and chipped plastic, and the tip of a can opener had missing metal), and 6. Mixer stand 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 observation, interview, and record review, the facility failed to ensure one out of 24 sampled residents (Resident 70) was assisted with nail care as part of her Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 70 had long fingernails and toenails. This failure had the potential for Resident 70 to sustain skin injury and/or to acquire an infection, and not achieve her highest practicable well-being. Findings: A review of Resident 70's clinical record indicated Resident 70 was admitted January of 2025 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), diabetes (elevated sugar in the blood), abnormalities of gait and mobility, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily lives). A review of Resident 70's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 1/12/25,…

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

Based on interview, and record review, the facility failed to ensure one out of 24 sampled residents (Resident 30) was provided with an ongoing activity program that meet psychosocial needs (a combination of mental health, emotional, spiritual, or behavioral needs that are important to a person) when Resident 30 was not provided with any activity that met her psychosocial needs from 2/17/25 to 3/3/25 and from 3/6/25 to 3/24/25. These failures had the potential for Resident 30 to not achieve her highest mental, emotional, spiritual, and psychosocial well-being. Findings: A review of Resident 30's clinical record indicated Resident 30 was admitted September of 2019 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions causing memory loss and confusion), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).…

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 that the completed and/or discontinued controlled medications (substances that have the potential for abuse and addiction and are therefore regulated by law) were remove from the medication cart and destroyed by two licensed facility staff nurses for two of 24 sampled residents, Resident 8 and Resident 59 when, controlled medications not being used were found in two medication carts. These failures had the potential for diversion (obtain or use of prescription medicines such as controlled medications illegally), medication errors, and/or misuse of controlled medications in the facility. Findings: In a review of Resident 8's admission Record, Resident 8 was admitted to the facility on [DATE] with diagnoses that included Radiculopathy, Lumbar Region (symptoms arise from compression or irritation of a nerve root. This often results in pain, numbness, tingling, and weakness), unspecified convulsions (rapid, involuntary muscle…

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 pureed foods (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding ) by methods that conserve nutritive value, flavor, and appearance for ten out of 91 residents (Resident 25, Resident 26, Resident 28, Resident 30, Resident 48, Resident 49, Resident 54, Resident 64, Resident 81, and Resident 347) when the recipes were not followed, and water was used to thin the pureed foods. Failure to ensure the flavor and nutritional value of food may result in decreased intake, weight loss and decreased nutritional value further compromising the medical status of residents. Findings: During an observation on 4/8/25, at 9:20 a.m., with Dietary [NAME] (DC) 1 in the kitchen, DC 1 was observed preparing pureed food for the lunch menu, which included: pasta, meatballs with gravy, and spinach. No pureed diet recipes were seen at the cook's station. During an observation of the preparation of pureeing the pasta, DC 1 poured an unmeasured amount of pasta into a blender. When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 91 when: 1. Two facility staff did not wear required personal protective equipment (PPE) when they performed resident care for Resident 73 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); 2. A facility staff, Licensed Nurse (LN) 9 did not disinfect a blood pressure cuff after using it on three residents, Resident 47, Resident 68 and Resident 80; and, 3. Excess treatment supplies remaining from Resident 85's wound care treatment were placed back into the treatment cart. These failures had the potential to spread germs and cause infection among residents, staff, and visitors. Findings: 1.A review of…

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

Based on observation, interview and record review, the facility failed to ensure comprehensive care plans for dysphagia (difficulty of swallowing) were developed for two out of 24 sampled residents, Resident 49 and Resident 79. This failure increased Resident 44 and Resident 79's risk of not receiving proper nursing care interventions for dysphagia and had the potential to cause choking and aspiration (inhale into the lungs). Findings: In a review of Resident 49's admission Record, Resident 49 was admitted in the facility on 3/25/25 with diagnosis that included Acute Respiratory Failure with Hypoxia (difficulty of breathing, low oxygen in the body), and Gastro-Esophageal Reflux (backflow of stomach contents into the mouth). In a review of Resident 79's admission Record, Resident 79 was admitted in the facility on 3/3/25 with diagnosis that included Acute Respiratory Failure with Hypoxia, and Pneumonia (lung infection making it difficult to breathe). During a concurrent observation, interview, and record review with Activity Director (AD) in the Dining room on 4/7/25 at 12:15 p.m.,…

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 out of 24 sampled residents (Resident 346) received treatment and care in accordance with professional standards of practice, facility's policy and procedures (P&P), and physician's order when Resident 346's right ankle wound care order was not consistently done. This failure possibly resulted in Resident 346 experiencing right ankle pain, increased bleeding on the right ankle, increased confusion, increased heart rate (beat), and elevated temperature and ultimately getting Resident 346 transferred to an acute hospital and was diagnosed with right ankle infection. Findings: A review of Resident 346's clinical record indicated Resident 346 was initially admitted January of 2023 and had diagnoses that included multiple sclerosis (MS- a chronic, unpredictable disease of the nervous system which causes communication problems between the brain and the body leading to a range of symptoms, including vision problems, balance difficulties, fatigue,…

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

Based on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 364) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and physician's orders when Resident 346's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) care and treatment was not done consistently. This failure had the potential to result in suprapubic catheter site infection, clogging of the catheter, and possible development of suprapubic catheter complications. Findings: A review of Resident 346's clinical record indicated Resident 346 was initially admitted January of 2023 and had diagnoses that included multiple sclerosis (MS- a chronic, unpredictable disease of the nervous system which causes communication problems between the brain and the body leading to a range of symptoms, including vision problems, balance difficulties, fatigue, and cognitive changes), malnutrition (state of poor nutrition that occurs when the body does not receive…

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 change the peripherally inserted central catheter (PICC) line (a thin flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart to deliver medications) dressing for one of 24 sampled residents (Resident 3). This failure had the potential to result in a serious infection and/or further health complications. Findings: A review of Resident 3's admission Record indicated, Resident 3 was admitted in 2025 with diagnoses that included Osteomyelitis (an infection of the bone). A review of Resident 3's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 3/31/25, indicated Resident 3 had a Brief Interview for Mental Status (a tool to assess a person's full understanding) score of 13 out of 15 which indicated Resident 3 was able to understand. During a concurrent observation and interview with Resident 3 on 4/7/25 at 9:17 a.m., Resident 3's PICC line dressing was dated 3/27/25. Resident 3 stated he was unsure 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 follow a physician's order for oxygen therapy for one of 24 sampled residents (Resident 49). This failure had the potential to result in hypoxia (a state where tissues in the body, including the brain, don't receive enough oxygen) and/or shortness of breath. Findings: A review of Resident 49's admission Record indicated, Resident 49 was admitted to the facility in 2022 with diagnoses that included chronic obstructive pulmonary disease and respiratory failure (lung disease that makes it difficult to breathe) with hypoxia. A review of Resident 49's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 3/29/25, indicated Resident 49 had a Brief Interview for Mental Status (a tool to assess a person's full understanding) score of 12 out of 15 which indicated Resident 49 was able to understand. During a concurrent observation and interview with Resident 49 on 4/9/25 at 1:07 p.m., Resident 49's oxygen was set at three liters per minute. Resident 49…

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

Based on observation, interview and record review, the facility failed to follow physician's diet orders regarding fluid consistency for two of 24 sampled residents, Resident 49 and Resident 79. This failure placed Resident 49 and Resident 79 at risk for choking, aspiration (inhale into the lungs) and the possible development of pneumonia (a lung infection making it difficult to breathe). Findings: A review of Resident 49's admission Record, indicated Resident 49 was admitted in the facility on 3/25/25 with the diagnosis that included Acute Respiratory Failure with Hypoxia (difficulty of breathing, low oxygen in the body), and Gastro-Esophageal Reflux (backflow of stomach contents into the mouth). A review of Resident 49's Minimum Date Set (MDS, an assessment tool used to guide care) Cognitive Patterns K- Swallowing/Nutritional Status, dated 3/18/25, indicated, Coughing or choking during meals or when swallowing medications .C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids) . A review of Resident 49's Order Summary…

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 food in accordance with the physician's prescribed diet for one out of 24 sampled residents (Resident 30) when Resident 30's prescribed fortified diet (a diet designed to increase the calorie level of foods commonly consumed by resident) was not followed. This failure had the potential for Resident 30 to continuously lose weight, to negatively affect Resident 30's medical condition, and for Resident 30 to not achieve his highest practicable well-being. Findings: A review of Resident 30's clinical record indicated Resident 30 was admitted September of 2019 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions causing memory loss and confusion), dysphagia (swallowing difficulties), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in…

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

Based on observation, interview, and record review, the facility failed to ensure the call light system was accessible for two out of 24 sampled residents (Resident 85 and Resident 39) when the call light buttons were observed not within reach. This failure had the potential to result in residents' needs not being met and prevent the residents' communication for assistance when needed. Findings: 1a. A review of Resident 85's clinical record indicated Resident 85 was admitted November of 2024 and had diagnoses that included dementia (a progressive state of decline in mental abilities). A review of Resident 85's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/21/25, indicated Resident 85 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 85 had a severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 85's MDS Functional Abilities, dated 2/21/25, indicated Resident 85 was dependent with eating, oral hygiene,…

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 medications were stored locked for a census of 93 residents, when two medication carts were left unlocked and unattended. This failure had the potential for medication misuse and drug diversion. Findings: During an observation on 4/1/25 at 11:03 a.m. in the facility ' s lobby, medication cart B was unlocked and unattended. During an interview on 4/1/25 at 11:06 a.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed medication cart B was unlocked and stated it should have been locked. LN 1 further stated other people might take the medications if the medication cart was unlocked. During a concurrent observation and interview on 4/1/25 at 11:25 a.m. with LN 2, LN 2 confirmed medication cart A was left unlocked and unattended and stated the medication cart should always be locked. During an interview on 4/1/25 at 12:25 p.m. with the Director of Nursing (DON), DON confirmed the medication cart should be locked at all times to prevent drug diversion. A review of the facility ' s policy titled, Medication…

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

Based on observation, interview, and record review, the facility failed to follow infection control practices for one of three sampled residents (Resident 1), when: 1. Licensed Nurse 2 (LN 2) did not maintain hand hygiene before donning gloves; and 2. LN 2, LN 3, and the Wound Doctor (WD) did not use required Personal Protective Equipment (PPE, a gown) while providing wound care assessment for Resident 1 ' s right foot; and This failure had the potential to spread infection among residents. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility in 2025 with a diagnosis of diabetic foot ulcer (an open sore or wound that develops on the foot of a person with diabetes). During a concurrent observation and interview on 4/1/25 at 11:30 a.m. with LN 2, Resident 1 ' s right foot wound was observed inside the room. LN 2 entered an Enhanced Barrier Precaution (EBP, infection control intervention to reduce transmission of resistant organisms) room without wearing a gown. LN 2 donned gloves without providing hand hygiene and opened the wound…

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 protect the resident's right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 punched Resident 1 on the head. This failure resulted in Resident 2 punching Resident 1 and sustaining a fall with an abrasion to the elbow. Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated, Resident 1 was admitted to the facility in September 2022 with diagnoses including pancytopenia (abnormally low amounts of all three types of blood cells). Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/18/25, indicated Resident 1 had moderate memory impairment. During a review of Resident 1's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 3/18/25, indicated,…

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

Based on interview and record review, the facility failed to thoroughly investigate staff to resident allegations of sexual abuse (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) for nine of ten residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) by Certified Nursing Assistant (CNA 1) when additional victims were identified (Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10) after the facility ' s initial investigation. This failure resulted in the facility not identifying all victims of abuse in a timely manner which delayed counseling, monitoring and increased the risk for unmet emotional trauma. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility in early 2022 with diagnoses which included muscle weakness, encephalopathy (a medical condition that affects the brain ' s function), and intracranial injury…

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

Based on interview and record review, the facility failed to ensure the Administrator (ADM) managed the facility effectively to meet the need of all residents when a Certified Nursing Assistant (CNA)1, was hired after the ADM and Director of Staff Development (DSD) had knowledge of CNA1 ' s history of abuse. This failure put all resident at risk of abuse and resulted in sexual abuse of nine residents. Findings: During an interview on 1/30/25 at 1:42 a.m. with the Administrator (ADM) and Director of Nursing (DON), the ADM stated CNA 1 ' s background check was completed, and she believed the DSD (Director of Staff Development) checked references. During a concurrent interview and record review on 1/30/25 at 2:30 p.m. with the ADM of CNA 1 ' s BACKGROUND SCREENING REPORT [BSR], the BSR indicated, County Criminal History in [name of county] .INFORMATION FOUND .Charge KNOWLINGY TOUCH WITH INTENTION TO INJURE/INSULT/PROVOKE PERSON .Crime Type MISDEMEANOR .Disposition PLEA OF GUILTY OR RESPONSIBLE; SENTENCE IMPOSED Filing date 10/23/2019 . The ADM confirmed she was aware of the BSR 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 report immediately to the Department three allegations of sexual abuse for three of ten sampled residents (Resident 1, Resident 2, and Resident 5), when the Department received the facility ' s reports of alleged sexual abuse after two hours of occurrence. This failure decreased the facility ' s potential to protect vulnerable residents and provide a safe environment. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility in early 2022. A review of Resident 1 ' s Minimum Data Set (MDS; federally mandated resident assessment tool), dated 11/23/24, indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of four out of 15 with severe cognitive impairment. A review of the facility ' s document titled, Report of Suspected Dependent Adult/Elder Abuse, indicated the report was faxed to 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 protect one of 3 sampled residents (Resident 1) from physical and verbal abuse when he was hit on the left leg by Resident 2 during an argument in the shared bathroom. Additionally, Resident 2 used profanity towards Resident 1. This failure resulted in Resident 1 sustaining an abrasion on the left shin and he was afraid of leaving the room for fear of coming into contact with Resident 2. Findings: According to Resident 1's admission Record, Resident 1 was originally admitted in mid-2023 with multiple diagnoses that included anxiety and depression. The most recent Brief Interview For Mental Status (BIMS, an assessment tool that tests memory and recall), dated 9/27/24, indicated the resident was cognitively intact. A review of a progress post event note, dated 11/6/24, indicated Resident 1 and Resident 2 had a physical and verbal altercation in their shared bathroom. Resident 1 was in the bathroom when Resident 2 opened the door to the bathroom from his side of the room and started using profanity directed…

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 three sampled residents (Resident 2), who had a known history of constipation, received treatment for bowel management as ordered by the physician and, failed to notify the physician when the resident had no bowel movement for 6 days. This failure resulted in Resident 2 experiencing abdominal pain, discomfort, was upset, frustrated and visibly shaken from inability to open his bowels. Findings: A review of admission Record indicated the facility admitted Resident 2 in the summer of 2024 with multiple diagnoses which included diabetes (a disorder characterized by difficulty in blood sugar control), kidney disease with dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine) and below knee amputation A review of Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/14/24 indicated Resident 2 had intact cognition (ability to think, understand, and remember). The MDS further indicated Resident 2 was occasionally…

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

Based on observation and interview, the facility failed to promote and maintain dignity and respect for one of three sampled residents (Resident 1) when the resident waited for 38 minutes to be assisted with feeding. This failure had the risk potential to minimize Resident 1's self-esteem and self-worth. Findings: A review of the facility ' s undated ' Promoting /Maintaining Resident Dignity During Mealtimes, ' policy, indicated, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident ' s individuality and protecting the rights of each resident .All staff members involved in providing feeding assistance promote and maintain resident dignity during mealtimes. A review of admission Record indicated the facility admitted Resident 1 in 2023 with multiple diagnoses which included dysphagia (difficulty in swallowing) and Huntington ' s disease (a disorder that causes nerve cells in the brain to die leading to problems…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident-centered activities were implemented for one of six sampled residents (Resident 1) when one on one (1:1) visits were not done and documented for Resident 1. This failure decreased the facility's potential in supporting and enhancing the physical, mental, and psychosocial well-being for Resident 1. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted [DATE] with diagnoses which included multiple sclerosis (a condition that affects nerves disrupting communication between the brain and the body) and depression. Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had intact cognition. During a review of Resident 1's Annual MDS Assessment, dated 1/25/24, the assessment indicated it was very important for Resident 1 to have books, newspapers, and magazines to read while in the facility. The assessment further indicated it was very important for…

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

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1) accurately reflected Resident 1's wound when his MDS Section M Skin Conditions was not accurately documented. This failure had the potential to result in Resident 1 not receiving interventions to improve skin condition. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in July 2024 with diagnoses which included right ankle and foot acute osteomyelitis (bone infection that occurs suddenly), cellulitis (bacterial skin infection) of right lower limb, and Type 2 Diabetes Mellitus (high levels of sugar in the blood). Resident 1's MDS indicated Resident 1 had intact cognition. During a review of Resident 1's Discharge Summaries Notes, dated 7/31/24, the notes indicated, [Resident 1] has a deep wound just medial [middle] to the right great toe which extends between the digits [toes] on the plantar (sole of the foot) side .The ulceration (break on the skin) is…

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 care and services in accordance with acceptable professional standards of quality for one of three sampled residents (Resident 1) when referral to a podiatrist (a doctor who treats the foot, ankle, and related structures of the leg) was not ordered and carried out upon admission. This failure resulted in the delay in receiving necessary care and services for Resident 1. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in July 2024 with diagnoses which included right ankle and foot acute osteomyelitis (bone infection that occurs suddenly), cellulitis (bacterial skin infection) of right lower limb, and Type 2 Diabetes Mellitus (high levels of sugar in the blood). Resident 1's MDS indicated Resident 1 had intact cognition. During a review of Resident 1's Discharge Summaries Notes, dated 7/31/24, the notes indicated, Summary of Hospital Course .[Resident 1] has a deep wound just medial [middle] to the right great toe which extends between 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, for one of three sampled residents (Resident 1) the facility failed to protect the resident's right to be free from physical abuse by another resident when Resident 2 slapped Resident 1. This failure resulted in Resident 1 developing left eye swelling and experiencing pain. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heartbeat), diabetes mellitus (high blood sugars) and mild cognitive impairment. Resident 1's Quarterly Minimum Data Set (MDS-an assessment tool), dated 8/26/24 described him as having clear speech, able to make himself understood and as able to understand others. Resident 1's Brief Interview for Mental Status (BIMS- a brief screening that aids in detecting cognitive impairment) score was 11 which indicated he was moderately impaired. The MDS described Resident 1 as having no delirium but as having verbal behavioral symptoms directed toward others (e.g., threatening others, screaming 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 protect the Resident's rights to be free from abuse for 1 of 3 sampled residents (Resident 1) when Resident 1's daughter witnessed Resident 2 throwing urine and feces at Resident 1. This failure resulted in Resident 1 abused by Resident 2 with the potential for Resident 1 to develop infection and emotional distress. Findings: A review of Resident 1 ' s admission record indicated he was admitted to the facility winter of 2024 with multiple diagnoses that included Chronic Osteomyelitis (infection in the bone), left ankle and foot. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool), dated 5/27/24, indicated, he was cognitively intact. A review of Resident 1 ' s care plan, initiated, 8/19/24 indicated, The resident was the victim in a resident-to-resident altercation without injury on 8/19/2024 . A review of Resident 1 ' s SBAR [Situation, Background, Assessment, Recommendation] Communication form dated, 8/18/24, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse for one resident (Resident 2) of three sampled residents when staff witnessed Resident 1 hit Resident 2. This failure decreased the facility's potential to ensure Resident 2's right to be free from abuse. Findings: A review of an admission RECORD indicated Resident 1 was admitted to the facility middle of 2023 with multiple diagnoses which included dementia (memory problems), cognitive communication deficit (trouble reasoning and making decisions while communicating), and major depression. Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool) dated 6/26/24, indicated mild cognitive decline. A review of Resident 1's undated Care Plan (CP) indicated, .[Resident 1] was the abuser in a resident to resident physical abuse with [Resident 2] on 7/3/24 . A review of an admission RECORD indicated Resident 2 was admitted to the facility middle of 2023 with multiple diagnoses which…

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 treatment was consistent with professional standards of practice, for an existing pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for one of four sampled residents (Resident 1), when Resident 1 did not receive wound care as ordered and the facility did not notify the physician when Resident 1 repeatedly refused wound care. This failure resulted in an infection of Resident 1's pressure ulcers and hospitalization. Findings: Resident 1 was admitted to the facility in February 2024 with multiple diagnoses that included osteomyelitis (inflammation or swelling that occurs in the bone), depression, pressure ulcer of right buttocks, and pressure ulcer of left buttocks. A review of the Minimum Data Set (MDS, an assessment tool), dated 7/8/24, indicated that Resident 1 did not have a cognitive assessment done and needed maximum assistance with mobility. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to privacy for one of four sampled residents (Resident 1) by allowing an individual to enter their room without permission. This failure had the potential to negatively impact the resident's emotional well-being and sense of security. Findings: Resident 1 was admitted on [DATE], with diagnoses of hemiplegia (muscle weakness or inability to move on one side of the body) and epilepsy (brain condition that causes recurring seizures). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/27/24, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating she had no cognitive impairment. Resident 5 was admitted on [DATE] with diagnoses of cerebrovascular disease (disease that affects blood flow in the brain) and cognitive communication deficit (trouble participating in conversations). His admission notes, dated 6/18/24, indicated he was alert and oriented. 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.

Based on interview and record review, the facility failed to ensure resident's right to privacy for one of four sampled residents (Resident 1) by allowing an individual to enter their room without permission. This deficiency had the potential to negatively impact the resident's emotional well-being and sense of security. Findings: Resident 1 was admitted in early 2016 with diagnoses of hemiplegia (muscle weakness or inability to move on one side of the body) and epilepsy (brain condition that causes recurring seizures). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/27/24, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating she had no cognitive impairment. Resident 5 was admitted in mid 2024 with diagnoses of cerebrovascular disease (disease that affects blood flow in the brain) and cognitive communication deficit (trouble participating in conversations). His admission notes, dated 6/18/24, indicated he was alert and oriented. During an interview on 6/26/2024, at 12:06 p.m., with the Licensed…

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

Based on observation, interview, and record review, the facility failed to ensure accurate reconciliation and accountability of controlled medications (medications with high potential for abuse or addiction) and medication administration for a census of 92 when: 1. Random controlled medication use audits for Resident 83 and Resident 3 did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet in the narcotic book that keeps record of the usage of controlled medications) but was not documented on the Medication Administration Record (MAR, a legal document used to record medications given to the residents) on multiple occasions to indicate it was given to Resident 83 and Resident 3; 2. Resident 3's controlled pain medication was not administered in accordance with the physician's order; and, 3. Resident 14's medications were left unattended and unsupervised on her bedside table. These failures had the potential for diversion and/or misuse of controlled medications in the facility, possible under or over medicating Resident 3 and 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 interview and record review, the facility failed to ensure two out of 19 sampled residents (Resident 3 and Resident 59) did not receive unnecessary narcotic (a controlled substance used to treat pain) pain medication when Resident 3 and resident 59 received narcotic pain medications on multiple occasions which were not in accordance with the physician's order. This failure has the potential for Resident 3 and Resident 59 to overdose (an excessive and dangerous dose of a drug), experience oversedation (excessive state of calmness, relaxation, or sleepiness caused by certain drugs), and/or other side effects of narcotic medication. Findings: 1a. A review of Resident 3's clinical record indicated Resident 3 was admitted February of 2024 and had diagnoses that included fibromyalgia (a chronic disorder that causes pain and tenderness throughout the body), fracture (a break in the continuity of a bone) of left leg, and need for assistance with personal care. A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 2/24/24,…

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 observation, interview, and record review, the facility failed to ensure medications and supplies were properly labeled and properly stored in accordance with the facility's policies and procedures, and accepted professional principles for a census of 92 when: 1. A total of 22 loose pills were found in medication cart A and medication cart B; and, 2. An opened Tuberculin purified protein derivative (PPD) (used in a skin test to help diagnose a contagious lung infection called tuberculosis infection) vial (a glass container used for holding liquid medicines) was found stored in the medication refrigerator without an opened date label. These failures had the potential for diversion of the loose medications, and for residents to receive medication that was expired or with unsafe or reduced potency. Findings: 1. During a concurrent observation and interview on [DATE] at 8:56 a.m. with Licensed Nurse (LN) 2, of medication cart B, five loose pills were found inside the second-right drawer of medication cart…

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

Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for residents who received facility prepared foods for a total census of 92 when: 1.Food items were unlabeled and undated; 2.Expired items were found in dry storage room; 3.Dry storage areas temperatures were not monitored; 4.There was no thermometer in the open-door fridge and freezer; 5. The walk-in freezer was found with; a. food items that were unlabeled, undated and appeared freezer burned, b. temperature was not maintained at the required level, ice buildup on door rim and the gasket (a seal stripping around the edge of freezer door that provides an airtight seal, prevents warm air from entering the cold interior) was misshapen. 6. Certified Nursing Assistant (CNA 3) touched Resident 4's butter knife blade with his bare hands; and 7. Director of Staff Development (DSD) touched the inner part of the salad bowl's rim for Resident 30, Resident 49, Resident 4, Resident 32 and Resident 38. These failures had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 92 residents when: 1. Resident 14's nebulizer (device used to deliver medicine to lungs) facemasks and tubing was not changed within seven days; 2. A shared blood pressure monitor was not cleaned and sanitized in between resident's use; 3. Non-pharmaceutical items were found stored in medication cart D and front station IV (intravenous- administration through a vein) cart with pharmaceutical products; and, 4. Uncovered linen cart contained clean personal clothes of the residents. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of Resident 14 to germs, and may cause infection among residents, staff, and visitors. Findings: 1. A review of Resident 14's clinical record indicated Resident 14 was initially admitted December 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 maintain the walk-in freezer in safe operating condition when ice buildup was noted on the door rim and the gasket (a seal stripping around the edge of freezer door that provides an airtight seal, prevents warm air from entering the cold interior) was found to be misshapen. This had the potential to affect the safety and quality of the food served for the residents eating facility prepared meals. Findings: During a concurrent observation and interview on 4/16/24 at 1:06 p.m. with the Dietary Manager (DM) by the walk-in freezer, the DM confirmed there was ice buildup on the walk-in freezer door rim and the gasket was misshapen on both the upper left and right edges [corners] of the freezer door. The DM stated, maintenance is working on it .they know gasket is broken and [are] ordering parts. During an interview on 4/17/24 at 12:40 p.m. with Maintenance Director (MD), the MD confirmed the walk-in freezer gasket was broken and ice buildup on the door rim. MD stated, .gasket is broken on freezer, we are working on…

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

Based on observation, interview, and record review the facility failed to ensure residents' rights to personal privacy and confidentiality of his or her personal medical information, when meal tray tickets were found thrown into the general trash. This had the potential to compromise resident privacy and confidentiality for the 92 residents residing in the facility. Findings: During a concurrent observation and interview on 4/18/24, at 8:25 a.m. with the Dietary Aide (DA) 3 in the kitchen, the DA 3 confirmed tray tickets with resident name and medical record number were in a regular garbage can. The DA 3 stated, this is how we do it. During a concurrent observation and interview on 4/17/24 at 8:27 a.m. with the Dietary Manager (DM), the DM confirmed there were tray tickets with resident protected health information (PHI) in the garbage. The DM stated, [she was] unaware of current practice. The DM confirmed resident name and medical record number are PHI and should not be in regular trash. The DM instructed DA 3 to remove tray tickets in the garbage and place in a shred bin. 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 ensure two out of 19 sampled residents (Resident 85 and Resident 77) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 85 and Resident 77 had long fingernails with blackish substance underneath the fingernails and had long toenails. These failures had the potential for Resident 85 and Resident 77 to sustain injury and/or for the residents to acquire an infection. Findings: 1a. A review of Resident 85's clinical record indicated Resident 85 was admitted October of 2023 and had diagnoses that included the need for assistance with personal care, muscle weakness, and adult failure to thrive. A review of Resident 85's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 4/7/24, indicated Resident 85's short-term memory was okay and Resident 85 could independently make decisions regarding tasks of daily life. A review of Resident 85's MDS Functional Abilities and Goals, dated 4/7/24,…

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

Based on observation, interview, and record review, the facility failed to ensure one out of 19 sampled residents (Resident 72) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 72's physician's orders for tube feeding and gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) site care were not followed. These failures had the potential for Resident 72 to experience complications of enteral feeding such as regurgitation (happens when digestive fluids and undigested contents in the stomach rise into the mouth), accidental aspiration of feeding formula into the lungs, increased blood sugar, skin breakdown problems, and/or infection. Findings: A review of Resident 72's clinical record indicated Resident 72 was admitted September of 2023 and had diagnoses that included cerebral infarction…

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

Based on observation, interview, and record review, the facility failed to maintain a comfortable environment for three of six sampled residents (Resident 4, Resident 5, and Resident 6) when the heating system in their rooms were not working. This failure caused the residents to be cold and uncomfortable. Findings: Resident 4 was admitted to the facility late 2023 with diagnoses which included multiple sclerosis (a progressive disease involving nerve cells). Resident 5 was admitted to the facility mid 2023 with diagnoses which included diabetes (elevated levels of blood sugars) Resident 6 was admitted to the facility early 2024 with diagnoses which included pain and infection. During a concurrent observation and interview on 4/4/24 at 10:37 a.m. with Resident 4 in her room, a small black portable space heater was plugged into the wall across from the bed. The heater was running and hot to the touch. Resident 4 stated her heater had been broken all winter and since she was cold the facility brought in a heater. During an interview on 4/4/24 at 10:52 a.m. with the Environmental…

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 environment was free from accident hazards for a census of 91 when: 1. Bedframe without a mattress was stored in the hallway; 2. Plastic trim edging was not attached to the beds footboard; 3. Portable space heater was used in a resident room; 4. Windowsills were missing and broken; and 5. Ceiling was damanged. There failures increased the risk for injury to residents in the facility. Findings: 1. During an observation on 4/4/24 at 10:10 a.m. in the hallway in front of the dining room across from the patio, there was a metal bedframe without a mattress stored against the wall. Several residents and staff passed by the bedframe. During a concurrent observation and interview on 4/4/24 at 10:13 a.m. in the hallway with the Business Office Manager (BOM), the BOM was asked if the hall was an appropriate place for the bedframe. The BOM stated, No, it ' s not an appropriate storage area for the bed, it ' s not safe for the residents. 2. During an observation on 4/4/24 at 10:26 a.m. in a resident room, 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 ensure residents' respect and quality of care were maintained for one of three sampled residents (Resident 2) when Resident 2 was not able to reach the call light. This failure had the potential to increase Resident 2's fear of not being able to call for help when needing assistance. Findings: According to the admission Record, Resident 2 was admitted to the facility in 2023 with a medical history including falls and back pain. During a concurrent observation and interview on 3/19/24 at 12:46 p.m. inside Resident 2's room, Resident 2 was laying flat in bed and having a difficult time breathing. Resident 2 was trying to reach for the call light for assistant but was unable to because it was hanging off the bed, and the clip was not secured to anything. Later, Certified Nursing Assistant 1 (CNA 1) came into the room, picked up the call light, and placed it on Resident 2's bed. CNA 1 confirmed the call light should have been placed closer to the resident. During an interview on 3/19/24 at 1:52 p.m. with 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 develop a person-centered care plan for one of three sampled residents (Resident 1) who was admitted to the facility with a sacral (bony region of the lower spine) pressure ulcer stage 3 (full thickness loss of skin extending to the tissues). This failure had the risk potential for the pressure ulcer to deteriorate due to lack of appropriate interventions. Findings: According to Resident 1 ' s admission Record, the facility admitted him on 1/20/24 with multiple diagnoses including sacral ulcer stage 3 and diabetes. Resident 1 ' s admission assessment dated [DATE] indicated he had one unhealed stage 3 pressure ulcer that was present on admission. Resident 1 ' s ' At risk for skin breakdown ' care plan dated 1/22/24 indicated the resident was at risk for skin breakdown due to impaired mobility, incontinent of bowel and bladder and required assistance with toileting. The goal indicated the resident would maintain intact skin. The care plan…

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 meet professional standards of quality when physician ' s laboratory orders were not done in a timely manner for one of 3 sampled residents (Resident 1) when Resident 1 displayed increased signs of confusion. This failure had the risk potential to delay diagnoses of her increased confusion and delay disease management. Findings: According to Resident 1 ' s ' admission Record ' the facility admitted her recently with multiple diagnoses which included a cerebral ischemia (occurs when there is insufficient blood flow to the brain) and dementia. Resident 1 ' s admission Minimum Data Set (MDS, a tool used for assessment) indicated the resident had moderate cognitive impairment. A report received by the Department indicated Resident 1 was found on the floor on 1/29/24 and on x-ray to left hand indicated she sustained acute fractures (broken bone) to the 4th and 5thfingers. A buddy splint was ordered to stabilize the broken bones. During an observation and interview with Resident 1 on 2/5/24 at 11:07 a.m., 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 secure medications were stored locked for a census of 96, when a medication cart and treatment cart in station A were open in the hallway unattended. These failures had the potential for medications misuse and drug diversion. Findings: During a concurrent observation and interview on 11/28/23 at 1:03 p.m. at nursing station A, the medication cart and the treatment cart were unlocked and unattended in the hallway. There were other residents and staffs in the hallway and nursing station. Licensed Nurse 1 (LN 1) confirmed the medication cart and the treatment cart should have been locked when unattended. During an interview on 11/28/23 at 1:27 p.m. with the Director of Nursing (DON), the DON confirmed the medication cart and treatment cart should have been locked when unattended. Review of the facility's policy titled, Medication Storage, dated 2023, indicated, All drugs and biologicals will be stored in locked compartments .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with adequate supervision when Resident 1 fell out of his bed during care. This failure resulted in Resident 1 sustaining a laceration of the plantar surface (sole of foot) of 2nd toe that required 5 sutures, a laceration of base of 3rd toe that required 3 sutures and a fracture of the right great toe. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included dorsalgia (back pain) and abnormal posture. Review of Resident 1's admission MDS (Minimum Data Set-an assessment tool), dated 6/19/23, described Resident 1 as able to make himself understood and able to understand others. Resident 1's BIMS (a brief screening that aids in detecting cognitive impairment) score was 15 which indicated he was cognitively intact. The MDS described Resident 1 as needing extensive assistance with bed mobility, dressing, toilet use and personal hygiene. During a review of…

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