Chestnut Ridge Post Acute LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of two sampled residents (Resident 1) diagnosed of respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult) and recurrent pneumonia (an infection/inflammation in the lungs) by failing to: 1. Administer respiratory medications consistently as ordered for Resident 1 for COPD, chest congestion…

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 four out of five facility staff members, Registered Nurses (RNs) 1 and 2, and Certified Nursing Assistants (CNAs) 1 and 2, demonstrated competencies and skill sets necessary to provide emergency response and perform cardiopulmonary resuscitation (CPR-CPR is an emergency, life saving procedure performed when the heart stops beating and involves chest compressions at a rate of 100-120 beats per minute (bpm) and rescue breaths to maintain blood flow and oxygenation) as indicated in the facilities policy and procedure (PP) for Emergency Procedure - Cardiopulmonary Resuscitation and the American Red Cross CPR guidance as evidence by: 1. CNA 1 stated it took two (2) minutes to check for an unresponsive resident's pulse and breathing prior to performing CPR. 2.CNA 2 stated it took thirty (30) seconds to check for an unresponsive resident's pulse and breathing prior to performing CPR. 3.CNA 1 and CNA 2 failed to indicate the correct chest…

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 were free from significant medication errors for one of two sampled residents (Resident 1). Licensed nurses did not administer prescribed respiratory medications to Resident 1, who had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing breathing difficulty) and was oxygen-dependent. Missed doses included: Acetylcysteine Inhalation Solution 20% (used to thin mucus in the lungs): 25 scheduled doses between September and November 2025 Budesonide Inhalation Suspension (reduces airway inflammation): 31 scheduled doses between September and November 2025 Ipratropium-Albuterol Inhalation Solution (relaxes and opens airways): 60 scheduled doses between September and November 2025 This failure placed Resident 1 at risk for respiratory compromise and deterioration related to COPD exacerbation, potentially resulting in further complications and hospitalization. Cross referenced to F678 Findings: During 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 interview and record review, the facility failed to verify received or follow up with the attending physician (Medical Doctor [MD] 1) and/or the Nurse Practitioner (NP) 1 of the abnormal laboratory and diagnostic results for one of two sampled residents (Resident 1) with abnormal laboratory and diagnostic results. Resident 1 had an elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count of 16.85 x10*3/ul (thousands of cells per microliter- a unit of measurement [Normal range 4.0-11.0 x10*3/ul]) and abnormal chest x-ray (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. This failure resulted in Resident 1 not to receive necessary medical intervention such as prescribing antibiotics (medication used to treat infection) which placed Resident 1 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 Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult), respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), and recurrent pneumonia (an infection/inflammation in the lungs). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/6/2025, the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's care plan (CP) initiated on 4/11/2025…

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 provide medically related social services for one of three sampled residents (Resident 3) by not ensuring the resident attained or maintained his/her highest practicable physical, mental, or psychosocial well-being. Specifically, facility staff did not identify or address factors negatively affecting Resident 3's psychosocial functioning after the resident witnessed and was exposed to a violent incident (physical abuse) involving another resident (Residents 1 and 2). No nursing or facility staff checked or followed up on Resident 3 following the incident. This deficient practice had the potential to result in long-term psychosocial harm as resident 3 verbalized experiencing fear, anxiety, and emotional distress after witnessing and being threatened during a violent incident. These deficiencies may further lead to depression and/or post-traumatic stress disorder (PTSD) symptoms, thereby reducing Resident 3's sense of security and quality of 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 observations, interview, and record reviews, the facility failed to ensure timely implementation of physician-ordered Passive Range of Motion (PROM) services and splint application for 1 of 2 sampled resident (Resident 88) reviewed for Restorative Nursing Assistant (RNA) services. This deficient practice resulted in a 22-day delay in PROM exercises and splint use, which placed Resident 88 at risk for increased joint stiffness, reduced mobility, and progression of contractures (the permanent shortening of a muscle or a joint, leading to a deformity and restricted range of motion). During a review of Resident 88's admission Record [AR], the AR indicated Resident 88 was originally admitted to the facility on [DATE], with diagnoses that included contracture right elbow and contracture right hand. During a review of Resident 88's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the patient's health status) signed by the attending physician on 8/29/2025, 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 observations, interviews, and record reviews, the facility failed to provide a safe and hazard free environment to ensure electrical and extension cord devices were safely used for one of 1 of 8 sampled residents (Resident 75). This deficient practice has the potential to result in fire at the facility, electrical shock, and burns that could lead to residents' hospitalization and deaths. During a review of Resident 75's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses including intervertebral disc degeneration( the cushions between the discs in your spine wear out and become thinner causing pain and irritation to nearby nerves) , urinary tract infection and dependence on supplemental oxygen (extra oxygen given to person when their body isn't getting enough on its own helping them breath better and keeps their oxygen levels in a safe range). During a review of Resident 75's Minimum Set Data (MDS- a resident assessment tool) dated 07/8/2025, the MDS 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 observations, interviews, and record review, the facility failed to implement the facility's policies and procedures, titled storage of Food and Supplies, Procedures for Refrigerated Storage, and Preventing Foodborne illness- Employee Hygiene and Sanitary Practices, professional standards of practice on food storage, food service safety, sanitation and handling practices to prevent the outbreak of foodborne illness (food poisoning) by failing to ensure: 1.Discard one jar of turmeric powder, two (2) jars of curry powder, one jar of ground cumin, two (2) jars of ground Italian seasoning, one jar of ground paprika, one jar of steak sauce, one jar of dry basil leaves, one jar of chili powder, two bags of dried shredded coconut, one bag of pancake mix, one bag of brown rice; a bag of cornflakes, one bag of pepperoni slices when expired. 2. Label and store food that indicate the use-by-date or expiration date, including: a bag of scalloped potatoes, a 64-fluid-ounce bottle of pineapple juice, instant lemon pudding out of original box, individually-wrapped graham pie crust in 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 complete an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of two sampled resident (Resident 101) who was prescribed Ativan (a psychotropic medication used for anxiety). This deficient practice had the potential for Resident 101's rights to be violated by not being providing a complete and accurate explanation of care and treatment provided to Resident 101, in which Resident 101 fully understood the risk, benefits, and expected outcomes. During a review of Resident 101's admission Record [AR], the AR indicated Resident 101 was originally admitted to the facility on [DATE], with diagnoses that included degenerative disease of the nervous system (a progressive brain and spinal cord disease that cause cell death and lose…

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 interviews and record reviews, the facility failed to ensure one of four sampled resident (Resident 65) and her representative was assisted to formulate an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission and to complete an Advance Directive Acknowledgement (ADA a document where a person confirms they have received information about their right to create an advance directive and understand their options for future medical decisions) form timely. This deficient practice had the potential to cause conflict with Resident 65's wishes regarding health care treatment especially in an event of emergency. During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted Resident 65 on 9/10/2025 with diagnoses that included Parkinson's disease (a progressive brain disorder that affects movement and can lead to symptoms like tremors, balance problems, and stiffness) and hypertension (high blood…

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

Based on observation, interview, and record review, the facility failed to develop a base line comprehensive person-centered care plan for one of three residents (Resident 61), who was identified as having dental problems and required change in texture of to be able to chew food effectively. This deficient practice had the potential to delay care and services to Resident 61 and could negatively impact Resident 61's health and lead to nutritional problems. Cross reference to F791 Findings: During a review of Resident 61's admission record (AR), the AR indicated that the facility originally admitted Resident 61 on 9/21/2021 and recently readmitted her on 8/23/2025, with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), anemia (a condition where the body does not have enough healthy red blood cells), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing.) During a review of Resident 61's Minimum Data Sheet (MDS- a Federally mandated 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 provide medically-related social service in accordance with the facility's policy and procedure titled Social Services for one of three sampled residents (Resident 61), who had missing teeth and had requested new dentures (removable oral appliances that replace missing teeth). The Social Service Designee (SSD) failed to follow up with the dentist's recommendation to have a dental hygiene prior to obtaining new dentures for Resident 61. As a result of this deficient practice, Resident 61 did not receive new dentures and leaving Resident 61 to remain with difficulty chewing with the remaining teeth. Cross reference to F791 Findings: During a review of Resident 61's admission record (AR), the AR indicated that the facility originally admitted Resident 61 on 9/21/2021 and recently readmitted her on 8/23/2025, with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over 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 provide necessary dental care services to one of one sampled resident (Resident 61) who was not assisted to receive dental care as recommended by the dentist due to missing teeth and dental cavities and difficulty chewing food. As a result of these deficient practices Resident 61 had the potential for nutrition deficit, weight loss, choking due to difficulty chewing and pain due to untreated dental cavities. Findings: During a review of Resident 61's admission record (AR), the AR indicated that the facility originally admitted Resident 61 on 9/21/2021 and recently readmitted her on 8/23/2025, with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), anemia (a condition where the body does not have enough healthy red blood cells), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing.) During a review of Resident 61's Minimum Data Sheet (MDS- a Federally mandated 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 observations, interviews and record reviews, the facility failed to implement infection control measures for two of eight sampled residents (Resident 75 and Resident 83) by failing to: 1.Ensure Resident 75's respiratory equipment was properly labeled and stored in a plastic bag with the resident's name and the date the tubing was changed. 2. Ensure Resident 83's Peripherally inserted Central Catheter ICC a long, thin tube inserted into a vein in the upper arm that extends to a large vein near the heart.)) site was labeled with the date of the last dressing (typically a transparent, secure, and often antimicrobial dressing that protects the insertion site from infection) change. These deficient practices had the potential to place Resident 75 and Resident 83 at risk for infection. During a review of Resident's 75's admission Record (AR), the AR indicated Resident 75 was admitted to facility on 01/26/2024, with a diagnosis of intervertebral disc degeneration ( a condition where the discs between your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain a safe and sanitary environment for one of three sampled residents (Resident 74); by failing to ensure Resident 74's room was clean and free from stains and dust. 1. Resident 74's room was observed with more than one brown stains on the wall in 2. Resident 74's exhaust vent (a mechanical device designed to pull stale or polluted indoor air out of a room and expel it outdoors) was observed covered in dust. These deficient practices had the potential to result in Residents' discomfort. During a review of Resident 74's admission Record (AR), the AR indicated the facility originally admitted Resident 74 on 9/1/2023 and readmitted on [DATE] with diagnoses that included dementia (an overall term for a decline in mental ability that affects memory, thinking, and daily activities, not a specific disease itself) and type II diabetes mellites (a condition that happens when your blood sugar is too high). During a review of Resident 74's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who displayed behaviors of refusing medications received treatment and services to correct the assessed problem, was provided behavioral health services for one of three sampled residents ( Resident 1) whose primary diagnosis was schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function) by failing to: 1.Notify the physician when Resident 1 refused Haloperidol (a medicine used to treat and manage various mental health and behavioral condition, including schizophrenia and bipolar disorder) 10 milligram (MG, a unit of measurement) one tablet by mouth two times a day for a total of 35 doses. 2. Notify the physician when Resident 1 refused Valproic Acid (a medicine used to treat bipolar disorder) 250 MG three capsules by mouth as two times a day for a total of 14 doses and partial…

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 that a comprehensive, person-centered care plan was developed for one of two sampled resident (Resident 1) who was assessed to be at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) and wandering. This deficient practice had the potential for Resident 1 to not receive care that would prevent the resident from wandering into other resident ' s rooms, which could be a violation of other resident ' s privacy and rights, and/or elope from the facility. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities), and cognitive communication disease. During a review of Resident 1 ' s History and Physical (H&P), dated 4/25/2025, the H&Pindicated the resident does…

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 facility have sufficient and competent nursing staff to address, and provide necessary services (behavior monitoring and management) and implement person centered care plans for the behavioral healthcare needs of one of three sampled residents (Resident 1) diagnosed with schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [a serious mental health condition that affects how people think, feel and behave] with those of bipolar disorder (a mood disorder characterized by extreme mood swings)], and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), in accordance with the facility ' s policy and procedures on Behavioral Assessment, Intervention and Monitoring and Care Planning – Interdisciplinary Team. The facility failed to: 1. Ensure Resident 1 ' s aggressive behavior was addressed, monitored and managed after an incident of choking Certified Nurse…

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 report immediately and/or no later than two hours if the alleged allegation involves abuse, the verbal and physical altercation that happened with two of two sampled residents (Resident 1 and Resident 6) on 5/3/2025. Resident 6 reported that on 5/3/2025 around 9AM, Resident 1 stopped him in the hallway in his wheelchair, and yelled profanity (offensive or vulgar language, often considered impolite, rude, or disrespectful) at him and while in his wheelchair, he was pushed fast, spun around and grabbed his shirt prior to the staff separating them. As a result, Resident 6 verbalized feeling upset, sad and discouraged, which negatively affected his quality of life. Also, it had the potential for a recurrence resulting in harm to other residents and staff in the facility. On the same day, 5/3/2025, approximately four hours after the altercation with Resident 6, the facility failed to report an incident of Resident 1 choking Certified Nurse…

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 provide sufficient nursing staff who have the knowledge, training, and skills sets to address behavioral healthcare needs for one of four sampled residents (Resident 1), who was diagnosed with dementia and assessed at high risk for elopement, in accordance with the resident ' s care plan, the facility ' s policy and procedure on Behavioral Health Services, Dementia Care, and the Facility Assessment. The facility staff failed to intervene when Resident 1, who was visibly agitated and refused to come back inside the facility upon returning from an out-on-pass with the family [FM 1] on 11/27/2024. Registered Nurse [RN] 1 failed to implement Resident 1 ' s care plan on Behavioral Problem. RN 1 did not address Resident 1 ' s agitated behavior and allowed Resident 1 to wander out of the facility and instructed FM 1 to follow the resident and for FM 1 to call law enforcement. As a result of this deficient practice Resident 1 could not be found for two and…

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

Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to ensure one of two sampled resident (Resident 1), who had severely impaired cognition and memory and was assessed at risk for elopement with diagnoses of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) did not elope from the facility on 11/14/2024. The deficient practice had resulted in Resident 1 eloping from the facility on 11/14/2024. As of 11/15/2024, Resident 1 had not been found by the facility staff. Resident 1 had the potential for fall and injury from being struck by motor vehicles. Resident 1 also had the potential to be exposed to extreme weather and malnutrition (lack of proper nutrition. Findings: During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/23/2024 with diagnoses that included dementia and heart failure (a condition that the heart isn ' t pumping as well as it should). During a review of Resident 1's Minimum Data Set (MDS, a standardized…

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 provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by one of two sampled residents (Resident 1), or in a readable hard copy form or such other form and format as agreed to by the facility and the resident, within 24 hours (excluding weekends and holidays), in accordance with the facility ' s Policy and procedure [P&P] titled Resident Rights and Release of Information. This deficient practice violated the rights of Resident 1 to access personal and medical records pertaining to him or herself. Findings: A review of Resident 1 ' s the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a primary diagnosis of polyneuropathies (disease affecting nerves). A review of Resident 1 ' s History and Physical dated 7/27/2024, indicated Resident 1 had capacity to understand and make decisions. A review of Resident 1 ' s…

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

Based on interview, observation and record review, the facility failed to ensure the facility ' s recent (last survey was on 10/5/2023) survey binder with past survey result (outcome of the survey that were conducted to protect residents and to ensure that all residents receive the quality of care) were accessible and available for all the residents, including Resident 27, 102 and 106 who attended the facility ' s resident council meeting on 10/2/2024. This deficient practice had the potential for the residents and their legal representatives to not fully informed of the facility's deficient practices and how they were corrected. Findings: During a review of Resident 27's admission Record indicated the facility admitted Resident 27 on 5/7/2024 with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients), and lack of coordination. During a review of Resident 27 ' s Minimum Data Set (MDS, a federally mandated resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed within the required time frame for four out of four sampled residents (Residents 2, 30, 60, and 77). This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 2, 30, 60, and 77. Findings: During a review of Resident 2's admission Record, indicated the facility initially admitted Resident 2 on 8/4/2020 and readmitted on [DATE]. During a review of Resident 30's admission Record, indicated the facility admitted Resident 30 on 2/21/2024. During a review of Resident 60's admission Record, indicated the facility admitted Resident 60 on 11/10/2022. During a review of Resident 77's admission Record, indicated the facility initially admitted Resident 77 on 2/13/2023 and readmitted on [DATE]. During an interview on 10/2/2024 at 3:52 PM with the MDS Nurse, the MDS Nurse stated, all residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for four of five sampled residents (Resident 58, 3, 70 and 63) by failing to: 1. Develop a care plan for dementia Resident 58 with dementia (a progressive state of decline in mental abilities) 2. Develop a plan of care for Resident 3 and Resident 70 while receiving psychoactive medications ( medications that affects mood and behavior). 3. Develop a plan of care for Resident 63 who refused to have the nasal canula (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) placed in a bag when not in use. These deficient practices had the potential for the residents not to recieve the necesary care and services to achieve their highest potential and/or in adverse side effects (undesired effect) from the use of psychoactive medications. Findings:…

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 who needs respiratory care were provided such care, consistent with professional standards of practice, care plan goals, and facility's policy and procedure for four of four sampled residents (Resident 258, 63, 26 and 55) by failing to ensure: 1. Resident 258, 63 who uses and was receiving oxygen in the room had an oxygen in use warning sign was posted on the resident's doorway. 2. Resident 258 does not receive oxygen therapy since 9/16/2024 without a physician ' s order. 3. Resident 26 and Resident 55 nebulizers (a small machine that turns liquid medicine into a mist that can be easily inhaled) were stored in a sanitary manner and changed according to facility's policy and procedure. These deficient practices had the potential to cause a fire at the resident(s) in the facility that resulting in injuries and death. In addition, for Resident 258 could receive excessive oxygen that could result in oxygen toxicity (develop…

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 were stored prepared and distributed of food under sanitary conditions to all the residents in the facility by failing to: 1.Ensuring to store food with label and open date. 2.Ensure expired food was not stored in the kitchen. 3.Monitoring and documenting Sanitization Bucket Log. 4.Monitoring and documenting Ice Machine cleaning log. 5.Monitoring and documenting cleaning and maintenance schedule log. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: a. During a concurrent observation and interview on 10/1/2024 at 8:55 a.m., during an initial Kitchen tour in the presence of [NAME] (Cook) 1. There were several open items without label and open date. Those items were a liquid whole egg carton, three squeeze bottles containing apple sauce, cottage cheese container, a sliced watermelon covered with plastic wrap with no use by date, Buttermilk Ranch dressing container with no open…

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 2.During a review of Resident 86's admission Record indicated the facility initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include dementia (a group of thinking and social symptoms that interferes with daily functioning) and dysphagia (difficulty swallowing foods or liquids). During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/2/24, indicated Resident 86 had severely impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 86 required substantial/maximal assistance with eating, and was dependent with oral hygiene, toilet hygiene and personal hygiene. During a review of Resident 86 ' s Order Summary Report (OSR), dated 8/29/24, indicated the physician ordered the resident to receive Jevity 1.5 (a liquid nutritional supplement that can be used for patients who are at risk of malnutrition or have altered taste perception) at 100 milliliter (ML, unit 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 obtain an informed consent for psychotropic (any drug that affects behavior, mood, thoughts, or perception) drug for one of one sampled resident (Resident 99) who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and Zolpidem (medication used for used to treat insomnia (trouble sleeping) . This deficient practice had violated Resident 99's rights to be informed when choosing the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which could negatively affect Resident 99 ' s quality of life. Findings: A review of the admission record indicated Resident 99 was admitted on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), psychotic disorder (affect 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 communication board (a sheet of symbols, pictures, or photos that one can use by point to, to help people who have limited spoken language ability to communicate with others.) to facilitate and help residents express and have their needs met for one of twenty-three sampled residents (Resident 23). This failure had a potential to result in Resident 23's needs not met, feeling upset, potential decline in quality of care provided to her and her overall quality of life. Findings: During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain is disrupted,…

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 facility's written abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) policy and procedure for two of three sampled residents (Resident 106 and Resident 29) by not conducting a thorough investigation when the two residents were involved in a resident-to-resident altercation. Resident 106 allegedly physically abused by Resident 29 during a resident -to-resident altercation on 9/26/24. Resident 29 poured a cup of water on Resident 106, who was sleeping on his bed around 7:30 PM on 9/26/24. Resident 29 walked out the room with Resident 106 following behind him. Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the nursing station #1. Resident 106 asked Resident 29 loudly why did you pour water me? Resident 29 stayed quiet and did not say anything. These deficient practices resulted in 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 report immediately and within two hours an allegation or suspicion of physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to the Administrator (the facility ' s Abuse Coordinator), state agency, responsible party, police department and ombudsman (state personnel that advocates for the residents in the facility) for one of three sampled residents (Resident 106) in accordance with the facility ' s policy Abuse Reporting and Investigation. LVN 4 witnessed the confrontation between Resident 106 and Resident 29 in front of the nursing station #1 after Resident 106 allegedly poured water on Resident 29 while the resident was asleep, and did not report the incident to the Abuse Coordinator or designee within two hours. CNA 3 changed Resident 106's wet bed linens and wet floor in the resident's floor and heard about the altercation, but did not report 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 ensure assistance was provided ADLS (Activities of Daily Living- (routine tasks, activities such as eating, that a person performs daily to care for themselves) during mealtimes for one of twenty-three sampled residents (Resident 23). This failure resulted in Resident 23's feeling upset, not able to eat her chicken during lunch on 10/1/2024, and a potential risk for malnutrition and weight loss. In addition, could result in a decline in the resident ' s ability to perform ADLS. Findings: During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents provide necessary care and services for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent skin breakdown for one of three sampled residents (Resident 4) by failing to ensure Resident 4 who uses a low air loss mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to resident's weight. As a result of this deficient practice placed Resident 4 at additional risk for developing pressure injuries. Findings: During a review of Resident 4's admission Record (Face Sheet), dated 9/12/2023, the face sheet indicated the facility admitted Resident 4 on 9/12/2023, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), muscle weakness and generalized osteoarthritis ( degenerative joint disease, in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate device and appropriate rehabilitation services (assessment and evaluation of the residents to determine exercises or devices needed to improve or maintain mobility) to maintain or improve mobility for one of two sampled residents (Resident 58). with limited mobility and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) on both arms was observed with towel between the arms. This failure practice had a potential to result in Resident 58's worsened elbow contractures that could lead to pain, discomfort and high risk for fractures (broken bones). Findings: During a review of Resident 58's admission Record indicated the facility initially admitted Resident 58 on 4/27/2021 and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 63's admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admitted Resident 63 on 2/18/2022, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and bronchiectasis (a condition where your airways widen or develop pouches). During a review of Resident 63's History and Physical (H&P), dated 3/3/2024, indicated, Resident 63 had the mental capacity to make medical decisions. During a review of Resident 63's Smoker's Risk Assessment, dated 7/21/2024, indicated Resident 63 was an independent smoker (no supervision needed). During a review of Resident 63's Order Summary Report, dated 10/2/2024, the Order Summary Report indicated a physician order on 3/3/2024, ordered Resident 63 to receive oxygen at two (2) liters per minute (L/min) via nasal cannula (device use for delivery of oxygen) to maintain oxygen saturation (amount of oxygen carried in blood) at 92% (normal…

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 verify one of seven sampled residents (Resident 89)'s identity before medication was administered to the resident in accordance with the facility's policy and procedure. The deficient practice had put Resident 89 at risk of receiving the wrong and unnecessary medications that could cause the adverse effects (an undesired effect of a drug or other type of treatment). Findings: During a review of Resident 89's admission Record indicated the facility admitted Resident 89 on 9/29/23 with diagnoses that included diabetes mellitus (a group of diseases that affect how the body uses blood sugar) and hypertension (high blood pressure). During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/10/24, indicated Resident 89 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 89 required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal…

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 two of five sampled residents (Resident 58 and 4) were free of unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility's policy and procedureby [NAME] to ensure: (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure. Resident 58 1. Resident 58 with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) recieved specific indication for Risperidone (medication used to treat symptoms of schizophrenia) and Trazodone (medication used to treat depression), and behavior for the indication of use were monitored and documented from the period of 7/1/2024 to 10/4/2024. These efficient practices had potential to result in placing Resident 58 at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals used in the facility were, stored under proper temperature, are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in accordance with the facility's policy and procedures. The facility failed to: 1. Ensure the medication room [ROOM NUMBER] ' s thermometer readings were monitored and recorded in the Daily Room Temperature Log to assure a safe temperature range for medication storage. 2. Label Resident 257's opened multi-dose medication bottles (a bottle of medication in the forms of liquid, tablet, or capsule, that contains more than one dose of medication) with the name in the Medication Cart #1 for: a. Ascorbic acid (vitamin C, a dietary supplement) 500 milligram (mg, a unit of measurement) b. Vitamin E (a dietary supplement) 400 unit (a unit of measurement) c. Vitamin D3 (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 food prepared in a form designed to meet individual needs for one of twenty-three sampled residents (Resident 23) with dysphagia (difficulty swallowing) and was ordered by the physician to be served Regular diet (diet that does not include any restrictions) with mechanical soft texture (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) since 7/16/2024. This failure resulted in Resident 23 received regular texture instead of mechanical soft texture as ordered from 7/16/2024 to 10/3/2024, which could place her at risk for aspiration (happens when food, liquid, or other material enters a person ' s airway by accident. It can happen as a person swallows) and choking. Findings: During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included…

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 screen for the need of pneumococcal (PNA) vaccine (an administration of vaccine that stimulate the body's own immune system to protect the person against infection or disease) and offer the vaccine to one of five sampled residents (Resident 160) when the resident was initially admitted to the facility as indicated in the facility's policy and procedure titled, Pneumococcal Vaccine The deficient practice had the potential to result in Resident 160 did not receive the PNA vaccine as recommended by the Department of Public Health and Centers of Disease Control and Prevention (CDC), which out the resident at risk for contracting pneumonia (a severe lung infection). Findings: During a review of Resident 160's admission Record indicated the facility admitted Resident 160 on 9/5/24 with diagnoses that include depression (a common mental disorder, involving a depressed mood or loss of pleasure or interest in activities for long periods of time) and low back…

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 safe and sanitary environment for one of three sampled residents (Resident 160) who was observed with stained and soiled both upper bed siderails (one of the long narrow members connecting the headboard and footboard of a bed). This deficient practice had the potential to result in Resident 160's discomfort and the spread of infection. Findings: During a review of Resident 160's admission Record indicated the facility admitted Resident 160 on 9/5/24 with diagnoses that include depression (a common mental disorder, involving a depressed mood or loss of pleasure or interest in activities for long periods of time) and low back pain. During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/9/24, indicated Resident 160 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 160 required supervision or touching assistance with eating, partial/moderate assistance with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 1) by not escalating the process of finding Resident 1 ' s whereabout by not informing the Medical Doctor (MD), Director of Nurses (DON)] or the Social Worker (SW) for guidance when Resident 1 went out on pass (OOP) (temporary permission of a patient to leave the hospital in a specified time) on 5/23/2024 at 8:30 AM, and did not return to the facility the same day at 12:00 PM (which was Resident 1 ' s estimated time of return). This incident delayed the notification of law enforcement and other appropriate agencies, who were notified more than 24 hours from the time of the incident. Resident 1 returned to the facility on 5/25/2024 at 1:30 AM (more than 24 hours from the time resident went OOP), feeling tired, with untidy clothes and dirty hands and feet. Resident 1 also missed 2 days of due medications. This deficient practice had the potential for Resident 1 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to provide adequate supervision for one of five residents (Resident 1) based on the resident ' s individual and assessed needs. This lack of supervision has increased risk for falls and injuries due to resident ' s wandering (Going one location to another aimlessly, usually without a plan or definitive purpose). This deficient practice had the potential for Resident 1 to sustain injuries and increases the risk of altercations with other residents. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE], with diagnosis of, but not limited to, dementia (decline in mental ability server enough to interfere with daily function) and Alzheimer ' s disease (A progressive disease that destroys memory and other important mental functions). A review of Resident 1 ' s History and physical dated 11/2/2023, indicates Resident 1 does not have the capacity to understand and make decisions with chief complaint 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 comprehensively assess the root cause of behavioral symptoms and develop measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of five sampled residents (Resident 1) with diagnosis of dementia with behaviors. This deficient practice had the potential to negatively affect the safety, wellbeing, and the delivery of services. Findings: A Review of admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included but was not limited to Dementia (loss of memory, language, problem – solving and other thinking abilities) with behavioral disturbances, schizoaffective disorder (hallucinations or delusions, and symptoms of a mood disorder, such as depression), anxiety disorder( responds to situations with fear and…

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

Based on observation, interview, and record review the facility failed to provide the resident's call light (device used to alert facility staff assistance as needed by residents) within reaxh as indicated in the care plan, for one out of three sampled residents (Resident 2). This deficient practice had the potential in a delay in meeting the resident ' s needs for assistance and can lead to frustration, unavoidable falls and accidents. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 8/5/2023, with diagnoses including but not limited to cognitive communication deficit (difficulty with understanding information and knowledge), difficulty in walking, muscle weakness. A review of Resident 2 ' s History and Physical dated 12/8/2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS – a comprehensive standardized assessment and screening tool) dated 2/7/2024, indicated moderate assistance is required for all transfers from chair/bed to chair and toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his individuality for one (1) of seven sampled residents (Resident 5). The facility staff was observed removing Resident 5's shirt and exposing Resident 5's upper body in the facility's Activity Room, in the presence of Resident 6, Resident 7, and Resident 6's Family Member (FAM 1). This deficient practice had the potential to affect Resident 5 's self-esteem and self-worth. Findings: A review of Resident 5 ' s admission Record, indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, 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 Resident 1 was free from physical restraints by allowing emergency medical technicians (EMT) to apply physical restraints attached in a gurney to Resident 1 ' s wrists and ankle on 11/15/2023 from 9:30 AM to 10:45 AM (one hour and 15 minutes) while waiting for Resident 1 to be evaluated by the Psychiatric Evaluation Team (PET), without a physician ' s order, on-going assessments and monitoring of the resident while on physical restraints, in accordance with the facility policy and procedure on Physical Restraint Application. This failure resulted in Resident 1 ' s restriction of freedom of movement and had the potential to result in the resident ' s increased anxiety, agitation, and loss of dignity. Findings: A review of Resident 1 ' s Face Sheet (document that gives a patient ' s information such as contact details and brief medical history) indicated the facility admitted Resident 1 on 9/12/2023, with diagnoses that included major 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 4. A review of Resident 46's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and encephalopathy (damage or disease that affects the brain). A review of Resident 46's Minimum Data Set (MDS a standardized assessment and care screening tool), dated 8/30/2023, indicated that Resident 46 had moderate impaired cognition (the ability or mental action or process of acquiring knowledge and understanding). During a concurrent interview and record review of Resident 46's Care Plan, with the Director of Nursing (DON), on 10/4/2023, at 11:35 AM, the DON stated there was no care plan in Resident 46's medical records for elopement. The DON stated Resident 46 had a history of elopement on 3/17/2022 from the facility. The DON stated the care plan for elopement should have been in Resident 46's medical records. The DON stated the elopement care plan was 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 and interview and record review the facility failed to follow its policy and procedure on food storage, preparation, distribution and serving food in accordance with professional standards for food service safety by failing to: 1. Label the cut-up cantaloupe, ham slices and cheese sandwiches with the date of when the food were prepared and when to be consumed by. 2. Remove an egg carton with white liquid from the storage refrigerator. 3. Store two uncracked eggs with other uncracked eggs in the same egg carton. These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food. Findings: 1. During an initial kitchen observation conducted with the Dietary Manager (DM) on 10/2/2023 at 8:38 AM, the walk-in refrigerator had a cut-up cantaloupe was wrapped in a clear plastic wrapper and stored in a clear plastic…

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 implement the facility's policy and procedure for infection control practices by failing to: 1. Implement the facility's policy and procedure titled Departmental (Respiratory Therapy) Prevention of Infection by ensuring the oxygen nasal cannula (NC) tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was labeled when first used for one of 3 sampled residents (Resident 67). 2.Implement the facility's policy and procedure titled Legionella Water Management Program related to prevention, detection and control of water-borne (recreational or drinking water contaminated by disease-causing organisms) contaminants, including Legionella (a bacteria that can cause Legionellosis, a serious type of pneumonia (lung infection) that can lead to severe respiratory failure (failure of the lungs to oxygenate the body), septic shock (a life threatening condition due to severe infection) and multi-organ failure…

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 2. A review of Resident 38's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia following cerebral infarct (difficulty swallowing), polyneuropathy (when multiple peripheral nerves symptoms include problems with sensation, coordination, or other body functions), and depression (constant feeling of sadness). A review of Resident 38's History and Physical (H&P) dated 8/24/23, indicated Resident 38 had fluctuating capacity to understand and make decision. A review of Resident 38's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/12/23, indicated Resident 38 had severe cognitive impairment. On 10/03/23 at 09:10 AM during a review of Resident 38's Physician Orders for Life-Sustaining Treatment Resident (POLST- a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical…

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

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment by not repairing a leaking flushometer of a toilet (a metal water-diverter that uses an inline handle to flush tankless toilets or urinals) for one of four residents (Resident 17). The failure had the potential to result in Resident 17 falling and sustaining an injury from the slipping on the wet restroom floor. Findings: During a review of Resident 17's Face Sheet indicated the facility admitted Resident 17 on 9/23/2022 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and difficulty in walking. During a review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/29/2023, indicated the resident had moderately impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 17 required supervision (oversight, encouragement or cueing) with bed mobility, transfer, walking 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to receive care consistent with professional standards of practice (specialty practice guidelines or protocols of care for specific populations) to prevent worsening of pressure injury/ulcers (a skin injury resulting from prolonged unrelieved pressure or being in one position in the bony areas of the body) and/or does not develop new pressure ulcers that were unavoidable by ensuring one of three sampled residents (Resident 21) received and documented the skin treatment as ordered by the physician for skin redness on both heels on 10/1/23. This deficient practice had the potential for the Resident 21 and other potential residents with pressure ulcer to develop worsened pressure injury/ulcer. Findings: During a review of Resident 21's Face Sheet, an admission record, Resident 21 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hypertension (high blood pressure) and muscle weakness. During a review of Resident 21's…

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

Based on interview, observation, and record review, the facility failed to follow its policy and procedure on Oxygen Administration for one of 3 sampled residents (Resident 67) who had a was receiving oxygen therapy (a supplemental delivery of oxygen) without a physician's order. This deficient practice had the potential for Resident 67 and other residents receiving oxygen therapy to develop complications associated with oxygen therapy such as oxygen toxicity (also called oxygen poisoning is a lung damage due to receiving too much (supplemental) oxygen that can cause coughing, trouble breathing and in severe cases leads to death). Findings: A review of Resident 67's Face sheet (admission Record) indicated the facility initially admitted Resident 67 to the facility on 2/18/22 and readmitted date of 3/30/23 with the diagnoses that included, emphysema (gradual damage of lung tissue or alveoli [tiny air sacs] this damage causes the air sacs to rupture and traps air in the damaged tissue and prevents oxygen from moving through the bloodstream that causes the lungs to overfill with air…

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 monitor and review their hospice communication binder for 2 of 2 sampled residents (Resident 63 and Resident 342) which contains hospice nurse sign-in sheet, weekly calendar visits and hospice nurses notes that include treatment recommendations. This deficient practice had the potential to negatively affect the delivery of care and services related to the resident's change of health (including but not limited to pain, shortness of breath, spiritual and psychosocial needs related to dying) and may put at risk the personal needs that are particular to end of life issues not being met. Finding: A review of Resident 63's admission Record indicated the resident was readmitted to the facility on [DATE] with the diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and human immunodeficiency virus (HIV -virus that attacks the body's immune system). A review of Resident 63's Minimum Data Set (MDS, 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 administer two doses of Norco (a medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) on 8/2/23 for one of three sampled residents (Resident 1). Failure to administer pain medication according to the physician ' s order increased the risk that Resident 1 could have experienced increased pain resulting in a decline in ability to perform activities of daily living (ADLs - everyday activities like brushing teeth or bathing) and quality of life. Findings: A review of Resident 1 ' s Face Sheet, dated 8/3/23, indicated she was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure) and muscle weakness. A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive resident assessment tool) section C (Cognitive Patterns) indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a interview tool used to determine cognitive impairment) score of 12…

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.