Dreier's Nursing Care Center

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 17) received Restorative Nursing Services (RNA, an exercise program to maintain or prevent decline in the resident's joint mobility) as indicated in the care plan and the facility ' s policy and procedure to prevent decrease in range of motion (ROM- how far you can move or stretch a part of your body). This deficient practice had the potential to place Resident 17 at increased risk for ROM decline and development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 17 ' s admission Record (AR), the AR indicated that Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a change in how a person ' s brain dysfunctions due to an underlying condition), generalized muscle weakness,…

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 eight sampled residents (Resident 47) with weight loss received a comprehensive nutritional assessment and provided the resident ' s food preferences. This deficient practice had the potential to result in unmet nutritional need, poor meal acceptance, and increased risk for further weight loss. Findings: During a review of resident 47's admission Record indicated the resident was admitted on [DATE] with a diagnosis of Chronic pulmonary edema (fluid accumulation in the tissue or spaces of the lungs) and acute respiratory failure (a condition where you don ' t have enough oxygen in the tissues in your body). During a review of Resident 47's History and physical (H&P), dated 5/18/2025, indicated the resident has the capacity to understand and make decisions. During a review of Resident 47's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/12/2025, indicated the resident ' s cognition was intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide necessary respiratory care services for two of six sampled residents (Resident 44 and Resident 41) reviewed receiving oxygen therapy by failing to: 1. Ensure Resident 44 received three liters (L, unit of volume used to measure how much oxygen gas was being delivered) of oxygen routinely according to physician ' s orders, and displayed a No Smoking/Oxygen in Use sign for Resident 44. 2. Follow the facility' s P&P for displaying a No Smoking/Oxygen in Use sign for Resident 41. This deficient practice had the potential to cause complications associated with oxygen therapy and result in respiratory distress and place residents at risk of injury due to a fire hazard. Findings: 1. During a review of Resident 44 ' s admission Record (AR), indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia (a sudden and life-threatening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 had sufficient skills sets and competency to accurately aspirate (removal of fluid from the body part) and check the gastric residual volume (GRV, the amount of fluid remaining in the stomach at a specific time) of one out of one sampled resident (Resident 15) who had a gastrostomy tube (G-tube, a feeding tube inserted through the abdominal wall directly into the stomach) when: 1. LVN 3 was observed only aspirating 20 mL (milliliters, unit of measurement) of gastric contents from Resident 15 ' s G-tube. 2. LVN 3 verbally stated he only aspirates up to 20 mL of gastric contents when measuring the resident ' s GRV. This deficient practice had the potential for Resident 15 to be at risk of aspiration pneumonia (food or liquid inhaled into the lungs when the fluid from stomach backs up from the stomach due to vomiting) and abdominal distension (bloating or swelling of the stomach) or discomfort.…

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 Certified Nursing Assistant (CNA) 3 ' s certificate was not expired and not permitted to perform resident care when CNA 3 ' s CNA certification expired on [DATE]. As a result of this deficient practice, the residents were at risk to receive substandard quality of care from CNA 3 with incompetent nursing skills. Findings: During a concurrent interview and record review on [DATE] at 10:34 AM with the Director of Staffing Development (DSD), CNA 3 ' s employee files were reviewed. CNA 3 ' s employee files indicated the CNA ' s certification expiration date was [DATE]. The DSD confirmed that CNA 3 ' s certification was expired and has not been renewed. The DSD stated CNA 3 was currently working and providing resident care. The DSD added that since CNA 3 ' s certification was expired, the CNA must be sent home until the certification has been renewed. During an interview on [DATE] at 10:49 AM with CNA 3, CNA 3 stated she 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 observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or (5%) or less during medication pass in accordance with the professional standard of practice and facility ' s policy and procedure on medication administration for two of four observed residents (Residents 17 and 31) in which three (3) medication errors were identified out of 29 opportunities which yielded a cumulative error rate of 10.3 %. The facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 1 did not flush Resident 17 ' s gastrostomy tube (G-tube, a feeding tube inserted through the abdominal wall directly into the stomach) after administering the medication methimazole (medication to treat hyperthyroidism, a condition where the thyroid gland produces too much thyroid hormone). 2. LVN 3 administered Resident 31's ophthalmic medication including Brimonidine and Brinzolamide (medications specifically formulated to decrease the pressure in the eyes) and did not apply pressure…

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 records reviews, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnoses of shortness of breath (SOB), was administered oxygen (O2) via nasal cannula (device used to deliver supplemental oxygen), as ordered by the physician when Resident 1 initially verbalized feeling unwell and having SOB with wheezing (a high-pitched, whistling sound heard during breathing, often indicating a narrowing or obstruction in the airways heard) on 5/06/25 at approximately 8 AM. This deficient practice resulted in Resident 1 not receiving O2 from 8 AM to 4:30 PM, a total of 8.5 hours, and Resident 1 stating she was panicking and struggling to breath, and leading to Resident 1 being transferred to the general acute care hospital (GACH) for respiratory distress. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted on [DATE] with diagnoses that included, hypertensive heart disease with heart failure (a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) had appropriate measures taken to ensure the privacy and confidentiality of medical records by mistakenly sending Resident 2 ' s medical records to a general acute care hospital (GACH) with Resident 1, in accordance with the facility ' s policy and procedure titled Confidentiality of information. This failure violated Resident 2 ' s rights to personal privacy and confidentiality of personal and medical records. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included, but not limited to, influenza (contagious respiratory illness caused by influenza viruses) and dementia (a group of symptoms that affect memory, thinking, behavior, and the ability to perform everyday activities). During a review of Resident 1 ' s History and Physical (H&P) Progress Note dated 1/27/2025, the H&P 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 interview and record review, the facility failed to ensure that appropriate information and documentation is communicated to the receiving health care institution for one of four sampled residents (Resident 1), who was transferred to the General Acute Care Hospital (GACH) emergency room (ER) due to a change in condition (COC) on 2/16/2025. The facility transferred Resident 1 to the GACH for a COC, with the incorrect resident ' s records meant for another resident (Resident 2), that included another resident ' s Advance Directive (a legal document that provides guidance on a person ' s preferences for medical treatment), history and physical [H&P], medication orders, and laboratory results. This deficient practice had the potential to result in a delay in treatment, inappropriate medical interventions, or the GACH not being able to follow Resident 1 ' s wishes with regard to life sustaining treatments. This failure also had the potential to impede a safe and effective transition of care. Findings: During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was transferred in the General Acute Care Hospital for a change in codition, in a safe and orderly manner on 2/16/2025. The Facility failed to ensure proper transfer procedures and preparation necessary were carried out, such as providing the resident ' s correct medical history and medication to ensure the resident ' s medical status and condition was clearly communicated to the receiving facility (GACH). Furthermore, Resident 1 did not have any form of identification with him such as an identification wrist band for proper identification after being sent out to a GACH on 2/16/2025. This failure had the potential for delays in treatment and or worsening the Resident 1 ' s condition due to the possibility of the receiving facility rendering the wrong treatment or procedures due to the incorrect medical records provided. Findings: During a review of Resident 1 ' s admission Record (AR), the AR 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 observation, interview, and record review, the facility failed to maintain a safe environment in two of two resident ' s rooms (Residents 1 and 2), residents ' shared bathroom, facility kitchen, and resident ' s activity room. This had the potential for residents to be placed at risk for injury. Findings: During an observation on 2/14/2025 at 10:43 AM in facility parking lot, plastic tarp cover was observed in various parts of the roof of the facility. During an interview on 2/14/2025 at 10:49 AM with the director of nursing (DON), the DON stated she does not know if there is a water leak in the facility. During an observation on 2/14/2025 at 10:51 AM in Resident 2 room bed B, the room was observed with paint bubbling around ceiling above bed B with discoloration. During an interview on 2/14/2025 at 10:55 AM with Resident 2, Resident 2 stated on 2/13/2025 around 11 AM, water started leaking at the foot of bed B. Resident 2 stated the leak was a steady constant drip of water. Resident 2stated the staff soaked up the big puddle of water with bed linens and towels. Resident 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to provide a safe environment from rain damage to resident ' s rooms for three of five sampled residents (Resident 1, Resident 2 and Resident 3). This deficient practice had caused Resident 1, 2, and 3 to experience anxiety that resulted in the residents ' psychosocial well-being not to feel safe at the facility. Findings: During a review of Resident 1 ' s admission Record [AR], the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (mental illness can combines disorganized thinking and inappropriate behavior) and anxiety disorder (persistent worry or fear). During a review of Resident 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient ' s health status) dated 11/1/2024 signed by the attending physician indicated Resident 1 has the capacity to make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive standardized assessment 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 develop and implement a comprehensive care plan to address Resident 1's use of the knee immobilizer and/or abduction pillow ordered by the physician on 1/15/2025 s/p right hip reduction (a procedure that involves physically moving a dislocated hip back into place) surgery for one of three sampled residents (Resident 1). This deficient practice had the potential to result in post-surgical complications for Resident 1's recent right hip reduction surgery that included but not limited to increased pain, delayed recovery, and recurrent hip dislocation. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility initially admitted the resident on 12/27/2024 , and readmitted on [DATE] with diagnoses including fracture(a break in a bone that can be partial or complete) of unspecified part oof neck of right femur (the bone of the thigh), dysphagia(difficulty swallowing), and unspecified dementia(a progressive…

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 five sampled residents (Resident 2) was treated with dignity and respect during a routine diaper change by failing to: 1. Ensure Resident 2 was treated with kindness, respect, and dignity as indicated in the Facility Policy titled Dignity dated February 2021. 2. Ensure the facility's staff spoke respectfully, without the use of demeaning practices and standards of care that compromised dignity as indicated in the Facility Policy titled Dignity dated February 2021. These deficient practices had the potential to negatively impact the resident, leading to decreased self-worth, fear, vulnerability and depression. Findings: A review of Resident 2's admission record indicated Resident 2 was admitted on [DATE] with a diagnosis that included cerebral infarction (or stroke, occurs when blood flow to the brain is blocked, damaging brain cells) and hemiplegia (weakness of one side of body) and hemiparesis (inability to move on one side…

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 (Skilled Nursing Facility [SNF] 1) failed to allow one of two sampled residents (Resident 1) to remain in the facility and does not initiate a facility-initiated discharge (a discharge which the resident objects to or did not originate through a resident ' s verbal or written request, and/or is not in alignment with the resident ' s stated goals for care and preferences) to another facility (SNF 2) based on SNF 1 ' s inability to meet the resident ' s need for supervision due to wandering (residents who aimlessly move about within the building or grounds unaware of their personal safety) and risk for elopement (a resident who is incapable of adequately protecting himself, and who departs a health care facility unsupervised and undetected). Furthermore, SNF 1 failed to ensure SNF 1 and Resident 1 ' s physician (Physician 1) documented the information about the basis for Resident 1 ' s discharge to SNF 2, that included the specific resident needs the…

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

Based on interview and record review the facility (SNF 1) failed to follow its Policies and Procedures (P&P) titled, Transfer or Discharge, Facility-Initiated, dated October 2022, to provide the resident (Resident 1), who has a diagnosis of dementia and wandering behavior and Resident 1 ' s responsible party (RP 1) a written notice and send a copy of the notice to the Ombudsman prior to discharging Resident 1 to another Skilled Nursing Facility (SNF 2). This deficient practice had the potential to result in an unsafe discharge and or denying the resident of the right to appeal the discharge. Findings: During a review of Resident 1 ' s admission Record, (AR) the AR indicated Resident 1 was admitted to the facility with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], altered mental status (a change in how well the brain is working, which can cause a variety of behavioral changes), difficulty walking, and abnormalities of gait and mobility. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a personal centered comprehensive care plan (a detailed plan for an individual's healthcare that is entirely focused on their unique needs, preferences, and goals) to address the care of Resident 2 ' s left eye after he was hit by Resident 1. This deficient practice led to Resident 2 ' s left eye not appropriately cared for by facility staff which had the potential for complications. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), altered mental status, and dementia (a progressive state of decline in mental abilities). A review of Resident 1 ' s History and Physical (H&P), dated 1/10/2025, indicated the resident does not have the capacity to understand and make decisions. A review…

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

Based on interview and record review, the facility failed to notify the physician of one of three sampled residents (Resident 1) with the significant change in condition when the resident ' s blood sugar level (the amount of glucose in the blood) was consistently elevated from 12/12/2023 - 12/14/2023. This deficient practice can cause the resident to be in a state of hyperglycemia (a condition where there is too much glucose in the blood) that could result to a serious health problem requiring emergency care, including a diabetic coma (a life-threatening medical emergency that occurs when a person with diabetes has dangerously high or low blood sugar levels) that could lead to death. Findings: A review of Resident 1 ' s admission Record indicated that the facility admitted the resident on 11/29/2023 with diagnoses that included type 2 diabetes mellitus. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/05/2023, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through…

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 implement its policy and procedure for the care of a resident with urinary catheter (a thin, flexible tube that drains urine from the bladder into a collection bag outside the body) for one of three sampled residents (Resident 1) by failing to maintain an accurate record of the resident ' s daily urine output to prevent a urinary catheter-associated urinary tract infection (UTI-infection of the urinary tract, the bladder, ureters, urethra and the kidney). This deficient practice resulted Resident 1 to be hospitalized in an acute care hospital (GACH), transfered via 911 (an emergency service) due to a UTI, sepsis (severe infection in the blood) and a sudden decline in health condition. Findings: A review of Resident 1 ' s admission Record indicated that the facility admitted the resident on 11/29/2023 with diagnoses that included severe sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury) and pneumonia (an infection/inflammation in the lungs). 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 implement its own policy and procedure by failing to provide necessary respiratory care to one of three sampled residents (Resident 1) by failing to: 1. Assess the respiratory status and report to the physician immediately when Resident 1 ' s oxygen saturation decreased to 92% (a measurement of how much oxygen the blood is carrying as a percentage, normal range 90-100%). 2. Obtain a physician ' s order to safely administer oxygen. 3. Reassess the effectiveness of the oxygen intervention. This deficient practice had the potential to expose Resident 1 to oxygen toxicity (a condition when the lungs and the central nervous system are damaged due to an excessive amount of oxygen breathed in) or respiratory depression (a condition when a buildup of carbon dioxide is in the blood due to slow or shallow breathing) due to an inappropriate amount of oxygen delivered and oxygen monitoring. Findings: A review of Resident 1 ' s admission Record indicated that the facility admitted the resident on 11/29/2023 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.

Based on interview and record review, the facility failed to implement its abuse prevention policy for one of five sample residents (Resident 1) by failing to report allegation of abuse to law enforcement according to the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 7/31/2024 with diagnoses including Diabetes Type II (high blood pressure), dysphagia (difficulty swallowing), and cirrhosis of liver (a condition where scar tissue replaces healthy liver tissue , preventing the liver from functioning properly). During a review of Resident 1's History and Physical (H&P - a formal assessment of a patient and their medical condition performed by a healthcare provider, usually during an initial visit) dated 7/31/2024, indicated Resident 1 has the capacity 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.

Based on interview and record review, the facility failed to develop a resident-centered care plan and monitor Resident 1 after the allegation of abuse for one of five sampled Residents (Resident 1). Resident 1 did not have a care plan developed for allegation of abuse. This deficient practice had the potential to negatively affect Resident 1 psychosocial wellbeing. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 7/31/2024 with diagnoses including Diabetes Type II (high blood pressure), dysphagia(difficulty swallowing), and Cirrhosis of liver (a condition where scar tissue replaces healthy liver tissue , preventing the liver from functioning properly) During a review of Resident 1's History and Physical (H&P - a formal assessment of a patient and their medical condition performed by a healthcare provider, usually during an initial visit) dated 7/31/2024, indicated Resident 1 has the capacity to understand and make decisions. 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 observation, interview, and record review, the facility failed to ensure to protect resident rights for privacy and dignity for eight of eight sampled residents (Resident 1,2,3,5,6,7,8, and 9) by failing to: 1) Ensure other male residents does not shower in Resident 1 and 2 ' s shower room (SR12) located in room [ROOM NUMBER] (RM 12). 2) Ensure Resident 3 does not shower in RM12/SR12 without privacy. 3) Ensure other female residents does not shower in shower room (SR2) located inside the residents (Resident ' s 5, 8 and 9) room, room [ROOM NUMBER] (R2) without privacy. 4) Ensure Resident 6 does not shower in RM2/SR2 without privacy. 5) Ensure Resident 7 does not shower in RM2/SR2 without privacy. These deficient practices violated resident rights for privacy and dignity for Resident ' s 1,2,3,5,6,7,8, and 9 that could affet the pdychosocial being of the residents. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a reasonable accommodation of needs for two of three sampled resident (Resident 1 and 3) who preferred to take a shower in a shower room with privacy by failing to: 1) Accommodate Resident 1 ' s preference to not have other residents use his bathroom to shower. 2. Accommodate Resident 3 ' s preference not to shower in Resident 1 ' s bathroom. This deficient practice had negatively affected Resident 1 and 3 rights for privacy and dignity and feeling embarrassed which affects the resident ' s psychosocial well being. Findings: 1. A review of Resident 1 ' s admission record indicated Resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (an interruption in the flow of blood to cells in the brain. ) affecting right dominant side, chronic obstructive pulmonary disease (COPD) (prevents airflow to the lungs, causing breathing problems), cirrhosis of the liver (severe scarring of the liver), 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 observation, interview, and record review, the facility failed to implement the care plan to place a low mattress post fall for one of one sampled resident (Resident 4) who was a high risk for fall and had an actual fall from bed with injury on 8/11/24 during a seizure (a sudden, uncontrolled burst of electrical activity in the brain, it can cause changes in behavior, movements, feelings, and levels of consciousness). This deficient practice had the potential for the resident to sustain a severe injury or death from a fall. Findings: A review of Resident 4 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included epilepsy (abnormal electrical activity in the brain that causes loss of consciousness), chronic obstructive pulmonary disease (COPD) (lung and airway diseases that restrict your breathing), and cirrhosis of the liver (liver damage where healthy cells are replaced by scar tissue). A review of Minimum Data…

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 designate a physician to serve as the medical director responsible for implementation of resident care policies and coordinating medical care, help to implement and evaluate resident care policies or overall goals, directives, and governing statements that direct the delivery of care and services to residents consistent with current professional standards of practice. The facility did not have a designated medical director since June 2023 a total of 6 months to serve the 46 residents of 46 residents in the facility that included Resident 53. The facility failed to: 1. Ensure Resident 53 ' s death was thoroughly evaluated to ensure the resident received healthcare services according to the facility ' s policy and procedure and standard of practice. 2. Ensure the facility ' s residents health care policy and procedures (refers to the facility's overall goals, directives, and governing statements that direct the delivery of care and services…

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 the privacy for one of 12 sampled residents (Resident 35), by ensuring the resident's personal information was disposed in a secure manner in accordance with the facility's policy and procedure titled HIPPA (Health Insurance Portability Act- a law that protects the residents privacy) Privacy- Basic Do's and Dont's to Remember, This deficient practice caused Resident 35's personal information readily observable by others not authorized to view information and could be a risk for identify theft (a form of fraud in which the person's personal information is used without the person's permission) Findings: A review of Resident 35's admission Record indicated a readmission to the facility on 5/31/2024 with diagnoses that included metabolic encephalopathy (disease of the brain that alters brain function or structure), unspecified severe protein-calorie malnutrition (lack of proper nutrition), and hemorrhage (loss of blood from a damage blood vessel) of anus and rectum. A review of Resident 35's latest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for three of three sampled residents (Resident 41, 45 and 26). This deficient practice had the potential to result in confusion regarding the care and services provided to Resident 41,45,26 and other potentially affected residents. In addition, the deficient practice could affect the quality-of-care monitoring system to ensure safe, efficient, resident centered care in a timely manner. Findings: 1.A review of Resident 41's admission Record indicated the facility admitted Resident 41 on 1/05/2024 and readmitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a condition in which the body blood sugar) facility. A review of Resident 41 ' s MDS, dated [DATE], indicated the resident ' s last submitted MDS assessment was a MDS admission Assessment. 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 ensure that two of three sampled residents (Residents 1 and 44) were not receiving any medications without an indication for use, in excessive dose or duration, and with inadequate monitoring by failing to: 1. Ensure that Resident 1 ' s behavior monitoring for auditory hallucinations was specific to the resident ' s behavioral issues for the use of Olanzepine oral tablets (antipsychotic medication). 2. Ensure that Resident 1 ' s behavior monitoring was specific to the resident ' s behavioral issues for the use of Divalproex Sodium Capsule Delayed Release Sprinkle (anticonvulsant medication). 3. Ensure that Resident 44 ' s behavior monitoring was specific to the resident ' s behavioral issues for the use of Risperdal (psychotropic medication). These deficient practices increased the risk of Residents 1 and 44 to receive unnecessary medications and experience adverse effects of psychotropic medication therapy leading to an overall negative…

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 system to systemically identify adverse events (a harmful and negative outcome that happens due to improper medical care), monitor, investigate, analyze root cause, implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies [a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement]) to 46 of 46 sampled residents including Resident 53. Resident 53 ' s change of condition that lead to resident ' s death was not investigated, analyzed of the root cause, to determine if the resident ' s death was a result of the facility ' s staff to call the physician and the registered nurse health care failure to implement interventions when Resident 53 ' s blood pressure initially declined, heart rate increased from baseline and later became unresponsive and stopped breathing.…

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 and observation the facility failed to ensure prompt efforts were made to resolve grievances verbalized by Resident 32 one of two sampled residents and keep Resident 32 apprised of progress towards resolution This deficient practice increased the risk for negative psychosocial impact on Resident 32's quality of life. Findings: A review of Resident 32 ' s admission Record indicated the facility had initially admitted Resident 32 on 3/06/202 and then readmitted on [DATE] with diagnoses that included acute embolism and thrombosis of unspecified deep veins (is a blood clot that forms within the deep veins) of lower extremity bilateral (both sides) ,essential hypertension (is high blood pressure that doesn't have a known secondary cause). A review of Resident 32 ' s History and Physical dated 5/24/2023 indicated Resident 32 had the capacity to understand and make decisions. A review of Resident 32 ' s Minimum Data Set (MDS, an assessment and screening tool) dated 4/28/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive and resident-centered care plans for three of three sampled residents (Residents 1, 44 and 48) by failing to: 1. Ensure to develop a comprehensive resident centered care plan for Resident 48 that included what side effects to monitor for the use of Lexapro (a medication used to treat depression (a constant feeling of sadness and loss interest, which affects your daily normal activities). 2. Ensure to develop a comprehensive resident centered care plan for Resident 48 ' s use of Vistaril (a medication used to treat anxiety) that included what side effects and specific behaviors to monitor. 3. Ensure to develop a comprehensive resident centered care plan for Resident 1 that included specific interventions for the use of Apixaban, Olanzapine and Divalproex. 4. Ensure to develop a comprehensive resident centered care plan for Resident 44 that included the use of Risperdal (medication used to treat certain mental/mood disorders) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote resident safety in administering oxygen in accordance with the facility ' s policy and procedure for one (1) of 1 sampled residents (Resident 44) who was receiving oxygen therapy, by failing to ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) was not touching the floor. This deficient practice had the potential for Resident 44 to contract infection when receiving oxygen therapy which could increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: A review of Resident 44 ' s admission Record indicated a readmission to the facility on 5/11/2024 with diagnoses that included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (an irregular and often very rapid heart rhythm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two (Licensed Vocational Nurse (LVN 1 and LVN 2) had the specific competency and skill sets necessary to assess, monitor, intervene and notify the physician of a change Resident 53 ' s vital signs (measurement of the blood pressure, heart rate, respiration and body temperature). As a result of these deficient practices, Resident 53 was not monitored and assessed for increased heart rate (HR), declining blood pressure (BP), respiratory rate and unresponsiveness to tactile stimuli with diagnosis of transient ischemic attack ([TIA] a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain) and cerebral vascular accident (CVA) and atrial fibrillation (an irregular, often rapid heartbeat that can cause irregular heart rhythm and can lead to blood clots in the heart which increases ones risk of stroke, myocardia infarction (MI or heart attack a disruption of blood flow to the heart ) 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 ensure staffing information was posted and updated on a daily basis. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors. Findings: During an observation on 6/8/2024 at 10:39AM, the staffing information posted by Nursing Station 1, indicated the date of 6/7/2024. During an interview on 6/8/2024 at 10:50AM with Director of Staff Development (DSD) stated the nurse staffing data needs to be posted on a daily basis before the beginning of each shift. The DSD stated the nurse staffing posted for 6/8/2024 was incorrect that he forgot to post the correct one, it had yesterday ' s date of 6/7/2024. During a review of the facility ' s policy and procedure titled, Posted Direct Care Daily Staffing Numbers, revised 8/2006, indicated the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to resident. The policy indicated within two hours of the beginning of each shift 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 ensure one of two sampled residents` (Resident 53) medications were received and transcribed correctly by failing to: Ensure Resident 53 ' s Ativan tablet orders was transcribed correctly to indicate via g-tube instead of by mouth. These deficient practices increased the risk that Residents 1 and 53 and other residents could experience serious medical complications resulting in fall with injury, coma, or death. Findings: A review of Resident 53 's admission Record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included encounter for surgical aftercare following surgery on the digestive system aftercare following surgery on the digestive system, encounter for attention to gastrostomy ([G-tube] a soft tube surgically placed into the stomach for the introduction of nutrition and medication), and dysphagia (difficulty swallowing) following cerebral infarction. A review of Resident 53's History and Physical Examination…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to assess and monitor continued angry outbursts for one of two sampled residents (Resident 1 and Resident 2): 1. The facility did not initiate a care plan for Resident 1 ' s initial aggression and outburst on 11/3/2023. 2. The facility did not conduct an Interdisciplinary Team (IDT) meeting addressing Resident 1 ' s continued behaviors and aggression. 3. The facility did not monitor Resident 1 ' s aggression after continued incidence of angry outburst. These failures resulted in Resident 1 ' s increased aggression, resulting in Resident 1 physically assaulting certified nurse assistant (CNA) 2, and Resident 1 being arrested at the facility on 2/14/2024. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted on [DATE] with type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) and hypertension (abnormally high blood pressure). A review of Resident 1 ' s Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain infection control (methods used to prevent, control, or stop the spread of infections) precautions by having expired alcohol hand sanitizer available and used throughout the facility. This failure had the potential to result in the spread of bacteria, viruses, and pathogens (harmful microorganisms) to residents, visitors and staff while increasing the risk of infections. Findings: During an observation, on [DATE] at 10:51 am at the Nurses Station, two bottles of hand sanitizer found with expiration dates on the label of [DATE]. During an observation on [DATE] at 10:54 am, Licensed Vocational Nurse (LVN) 1 was observed using a bottled hand sanitizer found on Medication Cart B (MC- a movable piece of equipment used to store, transport, and dispense medications) with an expiration date of [DATE], for hand hygiene (a way of cleaning one's hands that substantially reduces potential bacteria, viruses and pathogens on the hand) upon…

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 decrease the risk of preventable falls for two of three sampled by failing to: 1. Complete the post fall monitoring for Residents 1 and 2, every shift for 72 hours per the facility protocol. 2. Ensure facility staff are aware of Resident 1's fall history, fall status, fall prevention interventions and injury from a previous fall during assigned shift. These failures placed Residents 1 and 2 at an increased risk for preventable falls with possible injury. Findings: 1. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of generalized muscle weakness (decreased muscle strength of the muscles), muscle spasm (involuntary contractions of a muscle), fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), epilepsy (a disorder of the nervous system in which abnormal electrical activity in the brain…

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 prevent misappropriation of properties (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money) by failing to complete an inventory form of the resident ' s personal belongings and signing the Resident ' s Clothing and Possession, (form used that list the personal belongings that was brought in by the residents in the facility) by two staffs or the resident ' s representative upon admission and discharge from the facility, in accordance with the facility ' s policy and procedure on Inventory of Personal Belongings for one of four sampled residents (Resident 3). These deficient practices had the potential to result in Resident 3 ' s failure to exercise the resident's rights to be free from theft, loss of property, misuse of personal funds, including the loss of a silver necklace. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 12/14/2022 with diagnoses that included dysphagia (difficulty swallowing foods or…

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

Based on observation, interview, and record review, the facility failed to ensure food had labels with open and expiration dates. This deficient practice placed the store food at risk for growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins). Findings: During an initial kitchen tour on 04/12/2022, at 7:30 AM, there were several open items in the freezer and dry storage area without label and no open/expiration date. Those items were: -Kaklava with date of 2/18/22, date not indicated if open or expired -Delicje Biscuit opened and placed inside ziplocked bag no date. -Tray with small salad dressing container covered with plastic, small fruit container covered with plastic, small salad covered with plastic dated 4/10/22, no indication if open or expired -plastic bag full of green vegetables no date -cookie dough container dated 4/8/22, no indication if open or expired - Snicker Doodle dated 4/10/22, no indication…

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 staff failed to provide one out of 14 sampled residents (Resident 18) a written notice of room change. This deficient practice had the potential to cause confusion and psychosocial harm to the resident. Findings: A review of Resident 18's admission Record indicated the facility admitted the resident on 1/9/2022, with diagnoses including type 2 diabetes (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and gastro-esophageal reflux disease (occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach). A review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 1/25/2022, indicated Resident 18's cognitive skills (learning and understanding, and making sound decisions) for daily decision making were moderately impaired. Resident 18 required extensive assistance from staff with bed…

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 one of three sampled residents (Resident 54) with treatment and care in accordance with resident's choice. The facility staff initiated cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore blood circulation) against resident's wishes. This deficient practice had the potential to place the resident in a situation or quality of life they did not desire. Findings: A review of Resident 54's admission Record indicated the facility admitted Resident 54 on [DATE] with diagnoses including metabolic encephalopathy (chemical imbalance in the blood causing problems in the brain), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and gastro-esophageal reflux disease (occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach). A review of Resident 54'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 observation, interview and record review, the facility failed to ensure staffing information was posted and updated on a daily basis. This deficient practice resulted in the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors. Findings: During an observation on 04/15/2022 at 12:11 PM, the staffing information posted in Nurses' Station, indicated the date of 04/14/2022. The staffing information posted in Nurses' Station, was not updated or changed. During an observation and interview on 04/15/2022 at 12:11 PM, the Director of Staff Development (DSD) stated, the facility staffing information posted in Nurses' Station was still not updated or changed. The DSD stated he was the one updating and posting the staffing information. The DSD stated, he posted the projected staffing information every day in the morning. The DSD stated the staffing information was not the actual staff and hours for 04/15/2022. DSD further stated he overlooked updating the information with the actual staff and hours and will update 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 the appropriate treatment for one of one sampled resident (Resident 12) diagnosis for resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). Resident 12 was prescribed two medications for schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) without having the diagnosis. This deficient practice had the potential to implement the incorrect interventions of the care plan for the active diagnosis of Dementia with behavioral disturbance. Findings: A review of Resident 12's admission Record indicated Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia without behavioral disturbance (psychological symptoms and behavioral abnormalities), and anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety,…

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 implement a consistent process of drug reconciliation for one of two medication carts by ensuring incoming and outgoing licensed nurses were consistently reconciling the controlled medication by signing the Narcotic Medications Sign-Off Sheet. The deficient practice had the potential to delay the identification of medication discrepancy and possible inappropriate use of the controlled medication. Findings: During a concurrent record review and interview with Licensed Vocational Nurse 1 (LVN 1) on 4/15/2022, at 9:03 AM, LVN 1 verified missing signatures on the Narcotic Medications Sign-Off Sheet between charge nurses for controlled medication counts dated 1/1/2022-1/5/2022 between the 3 pm-11 pm shift, 1/8/2022-1/12/2022 between the 3 pm-11 pm shift, 1/9/2022 between the 11 pm-7 am shift, 1/15/2022-1/16/2022 between the 3 pm-11 pm shift, 1/28/2022-1/29/2022 between the 11 pm-7 am shift, 1/29/2022-1/30/2022 between the 3 pm-11 pm, 2/1/2022-2/2/2022 between the 3 pm-11 pm shift, 2/10/2022, 2/12/2022, 2/19/2022, 2/20/2022 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 observations, interview and record reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to improper medication administration for two (2) medications out of thirty-five medication opportunities for errors. This yield a medication administration error rate of 5.17 percent (%), that exceeded the five (5) percent threshold. This deficient practice placed the resident at risk for decrease absorption of the medication. Findings: A review of the admission Record indicated Resident 24 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 24's diagnoses included multiple sclerosis (a potentially disabling disease of the brain and spinal cord causing many different symptoms, including vision loss, pain, fatigue, and impaired coordination), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and anemia (a condition lacking enough healthy red blood cells to carry adequate oxygen 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.

Based on observation, interview, and record review, the facility failed to respect resident's food choices for one of 14 sampled residents (Resident 23) by not offering preferred foods and not allowing any outside food per facility policy. This deficient practice had the potential to result in Resident 23 not eating most of the meals provided by the facility and causing Resident 23 with weight loss as a result. Findings: A review of Resident 23's weights indicated the following: 1. on 10/28/2020 Resident's 23 weight was 132 lbs. 2. on 4/04/2022 Resident's 23 weight was 117.2 lbs. Resident 23 had a weight loss of 14.8 lbs. During an interview with Dietary Supervisor on 4/13/2022 at 1:14 PM, she stated, per Policy and Procedures residents aren't allowed to receive outside food from visitors or family. She stated no new policy in place and still following policy dated 4/04/2020. During an interview with the Director of Nurses (DON) on 04/14/2022, at 2:01 PM, he stated no outside food items are allowed for residents at this time and that the Policy & Procedure regarding Outside Food…

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

Based on observation, interview, and record review, the facility failed to maintain its infection prevention control program for one of six contact isolation precautions room (require medical staff and visitors to wear gowns and gloves when entering the patient's room) when facility staff entered without proper personal protective equipment (PPE). The deficient practice had the potential to result in the spread of diseases and infection. Findings: A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 8/28/2020 and readmitted resident on 2/11/2022 with diagnoses including essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), gastro-esophageal reflux disease (occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach), and chronic kidney disease (involves a gradual loss of kidney function). A review of Resident 42's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 3/4/2022, indicated Resident 42's cognitive skills…

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.