Gladstone Sub-Acute And Rehab Center

Based on observation, interview, and record review, the facility failed to meet professional standards of care for one of three sampled residents (Resident 10) observed during medication administration by:1. Pushing medications through a gastrostomy tube (g-tube: a feeding tube that's surgically placed into the stomach) with a g-tube syringe (a medical device used for feeding and medication delivery via g-tube) instead of administering the medications by gravity.2. Failing to administer Omeprazole per manufacturer's specifications through a g-tube.3. Failing to flush five milliliters (mL- a unit of liquid measurement) of water between medications administered through a g-tube.4. Failing to administer Pro-Stat (a protein supplement) per manufacturer's specifications through a g-tube to dilute the medication with water prior to administration.The failure to administer medications in accordance manufacturer's specifications, and standards of practice placed Resident 10 at risk to experience significant medical complications including g-tube dislodgement (where the g-tube comes out 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 three of three sampled residents (Residents 253, 2, and 90) received treatment and care in accordance with professional standards of practice and the facility's policies and procedures (P&P) by failing to ensure:A. Resident 253's peripheral intravenous (IV - into or within a vein) Heplock (Heparin Lock [H/L] - a medical needle or tube catheter device placed in a vein to administer medication, fluid or nutrients directly into the bloodstream) was discontinued.B. Resident 90 received treatment for a self-inflicted scratch on the nose.C. Resident 2 was evaluated for self-administration of medications. On 6/23/2025, an unprescribed and unlabeled tube of hydrocortisone 1% cream was observed on Resident 2's bedside table.This deficient practice could potentially result in complications from an old H/L access including infiltration (when IV fluid leaks into tissue because of improper catheter placement or dislodgement), phlebitis…

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,A. implement a care-planned intervention to provide a padded landing mat at bedside for one of three sampled residents (Resident 37), who was identified as a high fall risk.B. Remove an oxygen condenser (a medical device that concentrates oxygen from room air for use in oxygen therapy), from one of three sampled resident's (Resident 87) room.This failure had the potential to result in falls and injuries such as fractures or head trauma for Resident 37 and the potential to result in Resident 87 receiving additional oxygen and leading to hyperoxemia (condition characterized by abnormally high levels of oxygen in the blood). Cross Reference F656Findings: A. During a review of Resident 37's admission Record (AR), the AR indicated the facility admitted Resident 37 on 2/1/2025, and re-admitted the resident on 5/22/2025, with diagnoses including acute respiratory failure (when the lungs suddenly cannot get enough oxygen into the blood and/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the oxygen humidifier was labeled for two of two sampled residents (Resident 11 and 85).This failure had the potential to result in infection and complications associated with oxygen therapy to Resident 11 and 85. Findings:During a review of Resident 11's admission Record (AR), the AR indicated, Resident 11 was originally admitted to the facility on [DATE] with multiple diagnoses including Chronic Respiratory Failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [C02, a colorless, odorless gas that is a waste product made by the body) with hypoxia (low levels of 02 in the body) and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause ongoing inflammation and narrowing of airways, making it difficult to breathe).During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated that Resident 11'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 observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%, unit of measurement). The facility had 12 medication errors out of 27 opportunities which resulted in an overall medication error rate of 44.44%, affecting three of three residents (Residents 40, 51, and 10) observed during medication administration (pass). The medication errors noted were as follows:A.For Resident 40, compatibility (the ability to combine two medicines without interfering with the action of either) was not checked before tablets of Escitalopram (Lexapro, a medication used to treat depression [serious illness that negatively affects how one feels, thinks, and acts]), Senna (a laxative), Multivitamins with Minerals (a naturally occurring element, a supplement used to treat vitamin and mineral deficiency), Vitamin D3 (type of vitamin D that is naturally produced in the body when the skin is exposed to sunlight), and Docusate Sodium (stool softener) were crushed…

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 an arbitration agreement that provided for a selection of a neutral arbitrator and a venue with both parties agreed upon for three of three sampled residents (Resident 28, 48, and 54.)This deficient practice had the potential to infringe on residents' rights.Findings:a. During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes (condition in which the body cannot properly store or use sugar, the body's main source of energy) and dementia (a gradual decline in mental ability usually caused by brain disease.)During a review of Resident 28's History and Physical (H&P) dated 5/25/2025, the H&P indicated Resident 28 had the capacity to understand and make decisions.b. During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple…

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

Based on interview and record review, the facility failed to ensure the facility/QAA (Quality Assessment and Assurance) committee measured the success of actions implemented and tracked performance to ensure improvements were realized and sustained.This deficient practice could potentially result in the facility to miss opportunities to identify and address weaknesses in resident care processes, leading to a higher chance of medical errors, resident harm, and negative outcomes and hinder the improvement of resident safety measures, leaving residents vulnerable to preventable risks.Findings:During an interview on 6/27/2025 at 5:15 PM with the Administrator (ADM) in the presence of the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the ADM stated, the facility did not have a tracking system in place. The ADM stated, the facility had binders of data collections but not tracking analysis. The ADM stated, it was important to have a tracking system in place so facility could identify where the facility's strengths and weaknesses were.During a review of the…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained the dignity of one (1) of three (3) residents (Resident 15) when Resident 15 did not have a privacy bag over Resident 15's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bag.This failure violated Resident 15's right to receive care in a manner that maintained dignity and privacy.Findings:During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 5/17/2023, and re-admitted Resident 15 on 5/20/2025, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), emphysema (a long-term lung condition that causes shortness of breath), and obstructive and reflux uropathy (a condition in which the flow of urine is blocked).During a review of Resident 15's Minimum Data Set (MDS-a resident assessment tool), dated 5/22/2025, the MDS indicated Resident 15's cognition (the ability to think and process information) was moderately…

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 call light (a device used by a resident to signal the need for assistance) was within reach for one of one sampled resident (Resident 74), in accordance with Resident 74's multiple care plans (CP).This failure had the potential to result in Resident 74 not having Resident 74's needs met in a timely manner and/or injury to Resident 74 if Resident 74 was unable to alert staff during an emergency.Findings:During a review of Resident 74's admission Record (AR), the AR indicated, Resident 74 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - long standing lung disease causing difficulty in breathing) with (acute [sudden onset]) exacerbation and anxiety disorder (a group of mental disorders characterized by intense, excessive, and persistent worry and fear about everyday situations), unspecified.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 inform the physician of a change of condition in one of one sampled resident (Resident 90) when Resident 90 removed his tracheostomy (self-decannulated (the removal of a tracheostomy tube [a curved plastic tube inserted into a surgically created opening in the neck to help with breathing] from a patient's airway) on 5/14/2025 and 5/28/2025.This deficiency had the potential to result in physical trauma to Resident 90's airway and infection.Findings:During a review of Resident 90's admission Record (AR), the AR indicated Resident 90 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (complete paralysis) and hemiparesis (partial weakness) following a cerebral infarction (stroke) affecting right dominant side and dementia (a gradual decline in mental ability usually caused by a brain disease).During a review of Resident 90's Respiratory Progress Notes (RPN) dated 5/14/2025, the RPN indicated an accidental decannulation…

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 one sampled resident's (Resident 35) overbed light was in working condition in accordance with Resident 35's care plans (CP).This deficient practice could potentially make it difficult for Resident 35 to navigate Resident 35's surroundings, potentially increasing the risk of falls or result in accidents. Additionally, this deficient practice could also hinder the staff's ability to observe and monitor Resident 35 effectively, potentially leading to missed signs of distress or complications. Findings:During a review of Resident 35's admission Record (AR), the AR indicated, Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing lung disease causing difficulty in breathing) with (acute [sudden onset]) exacerbation and anxiety disorder (a group of mental disorders characterized by intense, excessive,…

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 adequately monitor one of one sample resident (Resident 91) psychotropic (drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings and behavior) medications by failing to indicate specific anxious behavior and monitor side effects of lorazepam (medication used to treat anxiety.)This failure had the potential to result in Resident 91 receiving unnecessary medication and experiencing adverse (unwanted) effects from lorazepam.Findings:During a review of Resident 91's admission Record (AR), the AR indicated Resident 91 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (condition where the inability of the lungs to oxygenate the blood leads to dangerously low oxygen levels in the body) and dependence on ventilator (when one cannot breathe on their own and relies on a machine to support their respiratory…

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 that one (1) of two (2) sampled residents (Resident 41) had a completed and accessible Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) ) Level II evaluation available in the medical record, as required for individuals with newly evident or possible serious mental disorder, intellectual disability (ID), developmental disability (DD), or related conditions (RC). This failure resulted in Resident 41's specialized behavioral health and support needs not being clearly identified to staff, potentially impacting care planning and delivery of services. Findings:During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted Resident 41 on 8/17/2024, and re-admitted the resident on 10/9/2024, with diagnoses including chronic respiratory failure (when the airways that carry air to the lungs…

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 and provide appropriate treatment and sufficient services for one of four sampled residents (Resident 38) who had a clinically-justified indwelling catheter (a medical device that drains urine from your bladder into a bag outside your body) by failing to monitor Resident 38's supra-pubic catheter (a type of indwelling catheter) closely for changes in condition, recognizing, reporting and addressing such changes.This deficient practice could potentially result in Resident 38 to develop a recurrence of a urinary tract infection (UTI - an infection in the bladder/urinary tract) leading to more serious complications.Findings:During a review of Resident 38's admission Record (AR), the AR indicated, Resident 38 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including UTI, site not specified and neuromuscular dysfunction of bladder (loss of bladder control), unspecified.During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label and date a tube feed water flush bag for one of one sampled resident (Resident 83) who was receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine). This failure could potentially lead to infections (the invasion and growth of germs in the body) and other complications in Resident 83's digestive system (a group of organs that work together to digest and absorb nutrients from the food you eat).Findings:During a review of Resident 83's admission Record (AR), the AR indicated, Resident 83 was originally admitted to the facility 8/27/2024 and readmitted on [DATE] with multiple diagnoses including encephalopathy (a disturbance of brain function), unspecified and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions for all the residents in the facility by failing to:A. Ensure opened food containers in one (1) of two (2) refrigerators were labeled with a 'best by' or 'use by' date. B. Ensure 1 of four (4) chemical sanitizing buckets maintained the regulated concentration range for 24 of 25 days in June 2025. These deficient practices placed all the residents in the facility at risk for foodborne illnesses (caused by the ingestion of contaminated food or beverages). Findings:A. During an observation on 6/23/2025 at 8:23 AM in the kitchen, three (3) opened containers that were not labeled with a best by or use by date was found inside Refrigerator 1. One (1) of the containers contained tapioca pudding, one contained vanilla pudding, and one contained apple sauce. cDuring an interview on 6/23/2025 at 8:23 AM with the Director of Dietary Services (DDS), the DDS stated that opened containers must be labeled with a best by or use by date to ensure…

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 document one of one sampled residents (Resident 91) diagnosis of anxiety in Resident 91's admission Record (AR).This failure had the potential to result in Resident 91 not receiving medication and services related to anxiety.Findings:During a review of Resident 91's admission Record (AR), the AR indicated Resident 91 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (condition where the inability of the lungs to oxygenate the blood leads to dangerously low oxygen levels in the body) and dependence on ventilator (when one cannot breathe on their own and relies on a machine to support their respiratory function).During a review of Resident 91's Medical Professional Progress Note (MPPN) dated 2/27/2025, the MPPN indicated a plan from Resident 91's psychiatrist to begin lorazepam for anxiety manifested by restlessness for 14 days.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 observation, interview and record review, the facility failed to maintain and implement its Infection (the invasion and growth of germs in the body) Control Program by failing to ensure:a. A personal toiletry was labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) for two of four sampled residents (Resident 47 and Resident 51.)b. Enhanced barrier precautions ((EBP, an approach to use Personal Protective Equipment [PPE, protective clothing or equipment, designed to protect the wearer from injury or the spread of infection or illness] to reduce transmission of multidrug-resistant organism) were in place by failing to post a sign in front of one of four sampled resident's (Resident 5) rooms who was on EBP due to having a suprapubic catheter (tube inserted through a small incision in the abdomen to drain urine directly from the bladder.)These deficient practices had the potential to result 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 observation, interview and record review, the facility failed to follow the public health nurse (PHN) guidance intended to reduce the transmission of Covid-19 (infectious disease caused by the SARS-CoV-2 virus) in the facility during a Covid-19 outbreak by failing to: a. Ensure the proper signage was displayed in front of the rooms with residents presumed to be infected with Covid-19 for 4 of 4 sampled residents (Resident's 8,7,5 and 4). b. Test newly admitted and re-admitted residents to the facility for Covid-19 on day 0, 3, and 5 per the PHN guidance for 4 of 4 sampled residents (Residents 8, 7, 9, 5 and 4) c. Ensure one of eleven facility staff (LVN 2) ensured their Covid-19 rapid antigen test (RAT -quick test done to find out if one has Covid-19) was negative prior to entering patient care areas at the beginning of the 3-11PM shift on 6/3/2025. This deficiency had the potential to spread Covid-19 to patients and other staff throughout the facility. Findings: a. During a review of Resident 8'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 adequately monitor one of two sampled residents (Resident 1) psychotropic (drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication by failing to monitor Resident 1's anxious behavior and side effects of Ativan (brand name psychotropic drug used for anxiety) from 5/9/2025 to 5/23/2025. This deficient practice had the potential for Resident 1 to experience adverse (unwanted) effects from Ativan. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure (lungs can't get enough oxygen into the blood) and quadriplegia (a condition where a person experiences paralysis in both arms and legs.) During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/20/2025, the MDS indicated Resident 1 had 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 interview and record review, the facility failed to document one of one sampled resident's (Resident 1) diagnosis of mood disorder in Resident 1's admission Record (AR). This failure had the potential to result in Resident 1 to not receive medication and services related to a mood disorder. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure (lungs can't get enough oxygen into the blood) and quadriplegia (a condition where a person experiences paralysis in both arms and legs). The AR did not indicate a diagnosis of mood disorder. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/20/2025, the MDS indicated Resident 1 had intact cognition (ability to understand and process information) and was dependent (helper does all the work) on staff for bathing and toileting. During a review of Resident 1's Order…

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 Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) interventions for two of 12 sampled residents (Residents 1 and 5), in accordance with the facility's policy and procedure (P&P) titled, Care Planning, by failing to: 1. Obtain an order for Resident 1's left heel splint (medical device used to support and protect an injured part of the body) and failing to assess pedal pulses every shift as indicated in the CP. 2. Ensure the Restorative Nursing Aides (RNA) provided restorative nursing services (RNS- specialized nursing interventions provided by a RNA focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) to Resident 5 for the month of 4/2025. This deficient practice had the potential to inflict further injury to Resident 1. As a result of these failures, Resident…

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

Based on observation, interview and record review, the facility failed to provide care and services for one of 12 sampled residents (Resident 12), to prevent the develop of new pressure injury (PI- localized injury to the skin and/or underlying tissue usually over bone prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against others]) by failing to: 1. Ensure licensed nurses (LN) and certified nursing assistants (CNA) changed Resident 12's position in bed every two hours as indicated in the facility's policy and procedure (P&P) titled, Positioning and Body Alignment. 2. Ensure Resident 12 was not double briefed (the layering of two briefs [disposable, tab-style under garments designed to provide protection against urinary and fecal incontinence [lack of control over urination or defecation]) when changing Resident 12. These failures had the potential to place Resident 12 at risk for skin breakdown and moisture associated skin damage (MASD- inflammation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing aide [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) on the Restorative Nursing Record (RNR) for four out of 12 sampled residents (Residents 5, 7, 8, and 10), in accordance with to the facility's policy and procedure (P&P) titled, Documentation- Nursing Manual- Restorative Nursing Program, by failing to: 1. Ensure Restorative Nursing Assistant 3 (RNA- a specialized Certified Nursing Assistant [CNA] 3 with additional training in rehabilitation techniques) did not willfully falsify in Resident 5's RNR that RNA 3 had provided ambulation (the act of walking) RNS as ordered by the physician for the month of 4/2025. 2. Ensure RNA 3 did sign/initial Residents 7 and 10's RNR on 4/4/2025, indicating RNA 3 had performed 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 accurately document restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing aide [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) on the Restorative Nursing Record (RNR) for four out of 12 sampled residents (Residents 5, 7, 8, and 10), in accordance with the facility's policy and procedure (P&P) titled, Documentation- Nursing Manual- Restorative Nursing Program, by failing to: 1. Ensure Restorative Nursing Assistant 3 (RNA- a specialized Certified Nursing Assistant [CNA] 3 with additional training in rehabilitation techniques) did not willfully falsify in Resident 5's RNR that RNA 3 had provided ambulation (the act of walking) RNS as ordered by the physician for the month of 4/2025. 2. Ensure RNA 3 did not sign and initial Residents 7 and 10's RNR on 4/4/2025, indicating RNA 3 had performed…

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 ensure all staff had updated N95 respirator (N95 mask- filtering face mask designed to protect the wearer from breathing in airborne [transmitted by air] particles such as viruses) fit test (verifies that a respirator creates a tight seal with the wearer's face, ensuring proper protection from airborne particles), according to the Centers for Disease Control (CDC) and the National Institute of Occupational Safety and Health (NIOSH). As a result of this failure, 101 staff had expired fit tests, 37 of which were working at the facility on [DATE] between 7 am and 3 pm. This failure had the potential to result in staff spreading infectious agents throughout the facility. Findings: During a review of the facility's titled Fit Test Log (FTL), the FTL indicated 101 staff had expired N95 fit tests. During a concurrent interview and record review on [DATE] at 11:20 am, with the Director of Nursing (DON), the facility's FTL was reviewed. the DON…

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 certified nursing assistant (CNA) 3 worked within their scope of practice (the legal and ethical boundaries within which a health care professional is permitted to practice) by not handing one of 12 sampled residents (Resident 12) gastrostomy tube (G-tube- tube inserted through the belly that brings nutrition directly to the stomach) (medical device used to deliver liquid nutrition, medications, or special formulas to residents who cannot eat by mouth). This failure had the potential to place Resident 12 at risk for G-tube dislodgement (accidental removal, a serious issue that can lead to several complications) and pump malfunction. Findings: During a review of Resident 12's admission Record (AR), the AR indicated the facility admitted Resident 12 on 3/14/2025 with diagnoses that included quadriplegia (form of paralysis that affects all four limbs and torso), and encounter for attention to G-tube. During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool) dated 3/20/2025, 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.

Based on interview and record review, the facility failed to designate an individual as the infection preventionist nurse (IPN- oversees the facility Infection Prevention and Control program) on 5/21/2025 and while the facility was having a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak (at least three COVID-19 positive cases in the facility within a seven-day period among residents and/or staff). This failure had the potential for the facility ' s Infection Prevention and Control program to not be implemented which could result in residents (in general), staff, and visitors contracting and spreading COVID-19. Findings: During a review of the IPN ' s Time Card Report (TCR) for 5/2025, the TCR indicated the last date the (former) IPN worked was 5/20/2025. During an interview on 5/22/2025 at 9:58 AM with the Director of Nursing (DON), the DON stated on 5/21/2025, the DON was covering as the IPN in the facility because, There was no one here. The DON stated the DON did not have IPN certification. The DON stated the last date the (former) IPN worked was…

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

Based on observation, interview, and record, review facility failed to follow its policy and procedure (P&P) titled, Physician Orders, and Care Planning (CP), for one of five sampled residents (Resident 5) by failing to: 1. Ensure licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs] followed Resident 5's physician order, dated 11/14/2024 for Resident 5 to wear Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings that help prevent blood clots and swelling in the legs). 2. Ensure licensed nurses implemented Resident 5's untitled CP, dated 6/12/2024. 3.Ensure Licensed Nurses were monitoring and documenting Resident 5 wearing the TED hose. As a result of these failures, facility staff were not applying TED hose to Resident 5's left and right legs. Facility staff did not know when Resident 5 last wore the TED hose. Resident 5 experienced 6 out of 10 pain score (pain score indicating level of pain with zero being no pain and 10 being the worst pain) to Resident 5's toes. These failures put Resident 5…

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 facility failed to follow its policy and procedure (P&P) titled, Care Planning, by failing to: Ensure licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs]) implemented Resident 5's untitled care plan (CP) for the potential for fluid volume overload (occurs when there is an excessive accumulation of fluid in the body) related to left and right lower extremities (limb) pitting edema, plus four [+ 4, severity of edema, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade +4: 8-millimeter (mm) of depression, rebounding in 2-3 minutes], and left upper extremity pitting edema plus one [+1, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade 1: Immediate rebound with 2 mm pit]. As a result of this failure, facility staff were not applying Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings…

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 documentation of resident status and care given by nursing staff for one of five sampled residents (Resident 5), according to the facility's policy and procedure (P&P) titled, Documentation- Nursing, by failing to: Ensure the licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs]) documented when Resident 5 wearing the Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings that help prevent blood clots and swelling in the legs) when Resident 5 had a physician order, dated 11/14/2024 for Resident 5 to wear TED hose to bilateral (both) lower extremities for leg swelling/edema. As a result of this failure, facility staff were not applying TED hose to Resident 5's left and right legs. Facility staff did not know when Resident 5 last wore the TED hose. LNs were not documenting Resident 5's TED hose application. These failures put Resident 5 risk for increased edema to the lower legs and complications such as decreased…

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 physician's orders were timed and carried out or noted timely for three of nine sampled residents (Resident 6, Resident 8, and Resident 9) when: 1. An Optometrist (eye care specialist who diagnose and treat injuries and health conditions that affect the eyes and vision) ordered to administer antibiotic (medication used to prevent and treat infections) eye ointment to Resident 6 on 3/31/25, the order was carried out on 4/3/25, but the antibiotic eye ointment was not administered to Resident 6 until 4/4/25. This failure resulted in delay in providing medication to Resident 6 and had the potential to delay Resident 6's relief from eye discomfort due to blepharitis (inflammation of the eyelids). 2. A physician's order to administer ropinirole (medication used to treat restless leg syndrome which is a condition characterized by an irresistible urge to move the legs due to uncomfortable sensations) to Resident 8, dated 3/28/25 and untimed, was carried…

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 prevent the spread of infections for 4 of 6 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) when failing to ensure hand hygiene was performed appropriately. This failure had the potential to increase the risk of healthcare-associated infections, including the transmission of multidrug-resistant organisms for Resident 1, Resident 2, Resident 3, and Resident 4. Findings: 1. During observation on 04/16/2025 at 12:08 PM in the dining room, Certified Nursing Assistant (CNA) 1 prepared Resident 1's lunch tray and Resident 2's liquid drinks and lunch tray without handwashing or hand hygiene using alcohol-based hand rub (ABHR). CNA 1 assisted in feeding Resident 1 without handwashing or hand hygiene. During an interview on 04/16/2025 at 12:36 PM with CNA 1, CNA 1 stated that staff must use ABHR before and after patient care. CNA 1 stated it is important to sanitize hands before and after contact with a resident to prevent the spread of infection. 2. During observation on 04/16/2025 at 12:14 PM,…

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 Sub-Acute unit medication room refrigerator was free from unauthorized and unlabeled items preventing a safe and sanitary environment. This deficient practice had the potential to cause cross-contamination that could lead to the spread of infections to residents of the facility. Findings: During an observation and record review on 4/4/2025 at 2:00 PM, the Sub-Acute unit and facility Census was reviewed. The Sub-Acute unit had ten isolation (specialized rooms designed to separate patients with contagious illnesses or those with compromised immune systems from others) rooms. During an observation on 4/4/2025 at 7:30 PM, with Registered Nurse (RN) 2, the Sub-Acute medication room, designated for residents was observed of having one Coca-Cola can with no name or date, one-pint sized Oatmeal Extra Thick with no name or date, and one eight ounce Ensure with no name or date. Concurrently, while in the medication room, Licensed Vocational Nurse (LVN) 1 walked into the medication room and grabbed a bag of…

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

Based on interview and record review, the facility failed to notify the physician of one of five sampled residents (Resident 1) regarding Resident 1's missed hemodialysis (HD, a process of filtering the blood of a person whose kidneys are not working normally) on 1/15/2025 and 1/16/2025. This failure had the potential for Resident 1 to not receive HD treatment and to experience a decline in Resident 1's health and well-being. Cross Reference F684 and F776 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident on 1/7/2025 (no diagnoses documented in AR). The AR indicated Resident 1's responsible party (RP) was RP 1. During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 had diagnoses including congestive heart failure (CHF, the heart doesn't pump blood as well as it should), end stage renal disease (ESRD, a condition in which a person's kidneys cease functioning), and required hemodialysis. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/24/2025,…

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.

Based on interview and record review, the facility failed to monitor one of five sampled resident's (Resident 1) condition following an acute change of condition (ACOC- a sudden, clinically important deviation from a resident's baseline in physical, cognitive [relating to or involving the processes of thinking and reasoning], behavioral, or functional domains) on 1/16/2025. This failure had the potential for Resident 1 to not receive the necessary care and treatment which could result in a decline of Resident 1's health. Cross Reference F580 and F776 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident on 1/7/2025 (no diagnoses documented in AR). The AR indicated Resident 1's responsible party (RP) was RP 1. During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 had diagnoses including congestive heart failure (CHF, the heart doesn't pump blood as well as it should), end stage renal disease (ESRD, a condition in which a person's kidneys cease functioning), and required hemodialysis ( 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 ensure a chest X-ray (an imaging test that uses X-rays to create detailed pictures of the organs) was completed for one of five sampled Residents (Resident 1) as ordered by Resident 1's physician on 1/16/2025. This failure had the potential for Resident 1 to not receive the necessary services to meet the medical needs of Resident 1. Cross Reference F580 and F684 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident on 1/7/2025 (no diagnoses documented in AR). The AR indicated Resident 1's responsible party (RP) was RP 1. During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 had diagnoses including congestive heart failure (CHF, the heart doesn't pump blood as well as it should), end stage renal disease (ESRD, a condition in which a person's kidneys cease functioning), and required hemodialysis ( a process of filtering the blood of a person whose kidneys are not working normally). During a review of Resident 1's Minimum Data Set…

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, the facility failed to accurately assess one of three sampled residents (Resident 3) health status according to the facility's policy and procedure (P&P) titled, Resident Assessment Instrument [RAI] Process, by failing to ensure Resident 3's Minimum Data Sets (MDS- a resident assessment tool) dated 2/28/2022, 7/7/2023, and 10/7/2024, did not include a diagnosis of seizure (sudden, controlled electrical disturbance in the brain that can cause temporary changes in behavior, movement, consciousness, or sensation) disorder or epilepsy (disorder in which nerves in the brain are disrupted, causing seizures). This deficient practice placed Resident 3 at risk for receiving unnecessary medication and services from an incorrect diagnosis. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included epilepsy, chronic respiratory failure (serious 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 develop a resident-centered comprehensive care plan (CP-a document that describes a resident's needs and how the nursing home will meet them) for one of three Residents (Resident 1) as indicated in the facility's policy and procedure titled, Care Planning. This failure resulted in Resident 1 was not provided with a timely care plan for the administration Trazodone (antidepressant medication). Findings: During a review of admission Record (AR), , the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including infection of internal right knee prosthesis (a bacterial infection that occurs around or within the artificial components of a knee replacement joint, causing pain, swelling, redness, warmth, and limited range of motion in knee, type 2 Diabetes Mellitus (a health condition that affects how your body turns food into energy), Diabetic Chronic Kidney Disease ( a condition that occurs when diabetes damages the kidneys'…

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 complete and accurate documentation for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to not get the appropriate care and treatment. Findings: During a review of admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including infection of internal right knee prosthesis (a bacterial infection that occurs around or within the artificial components of a knee replacement joint, causing pain, swelling, redness, warmth, and limited range of motion in knee, type 2 Diabetes Mellitus (a health condition that affects how your body turns food into energy), Diabetic Chronic Kidney Disease ( a condition that occurs when diabetes damages the kidneys' ability to filter waste), and Chronic Kidney Disease, Stage 3 (a condition in which the kidneys are damaged and cannot filter waste and fluid out of blood). During a review of History & Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable temperature level in the room of one of nine sampled residents (Resident 1). The room temperature was 87 degrees Fahrenheit (F-Unit of temperature measurement). This failure resulted in Resident 1 feeling uncomfortable and hot and had the potential to result in hyperthermia (dangerously overheated body, usually in response to prolonged, hot, humid weather). Findings: During a concurrent observation and interview on 11/15/2024 at 11 a.m. with Maintenance Supervisor (MS) in the sub-acute unit, the MS stated the normal Resident room temperature should be 71 to 75 degrees F. The MS took the temperature inside of room [ROOM NUMBER] and 223. The MS stated the temperature of the room was 87 degrees F. TheMS continued to the next room [ROOM NUMBER] and 227 and stated the temperature of the room was 84 degrees F. The MS stated we placed fans in the rooms to help with the heat because he knew the air conditioner was not working…

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 sanitary (clean) environment to prevent the spread of infections for six of eight sampled residents (Residents 2, 3, 5, 6, 7, and 8) by failing to: 1. Ensure Hospitality Aide 1 (HA 1 - staff who accompanies residents to appointments and assists in answering call lights and monitoring residents) performed hand hygiene (cleaning hands by either washing hands with soap and water, or by using an alcohol-based hand sanitizer) according to the facility's policy and procedure (P&P) titled, Hand Hygiene, when HA 1 went inside Resident 3's, Resident 7's, and Resident 8's room. 2. Ensure Certified Nursing Assistant 5 (CNA 5) removed CNA 5's soiled gloves and performed hand hygiene in between residents and before touching clean linens. 3. Ensure flies and mosquitoes did not enter Resident 2's, Resident 5's, and Resident 6's rooms. These failures had the potential to spread infection to all residents, staff, and visitors in the facility.…

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 and implement a care plan (CP) that addressed individual assessed needs for one of two sampled resident (Resident 1) by failing to include Physical Therapy 1's (PT 1) assessments and recommendation and Resident 1's behavior of getting up (from wheelchair or from Resident 1's bed) without calling for assistance from staff as indicated in the facility's Policy and Procedure (P&P) titled Care Planning. This deficient practice had the potential to result in unmet individualized needs, inconsistent provision of treatment and services for Resident 1, and the potential to affect Resident 1's physical and psychosocial well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/19/24, with diagnoses that included hemiplegia (weakness and paralysis of one side of the body) affecting the right dominant side, gout [a type of arthritis (joint inflammation) that causes pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the rights of four of four sampled residents (Residents 18, 29, 36, and 49) or inform the resident's representatives (RPs), of their right to formulate an advanced directive (AD) when: a. For Resident 18, The Social Service Director (SSD) failed to provide information regarding AD to Resident 18's RP. b. For Resident 29, the SSD failed to document in Resident 29's medical record that the SSD discussed with Resident 29's RP about the right to formulate an AD for Resident 29. c. For Resident 36, the SSD failed to provide information regarding the right to formulate an AD to Resident 36's RP. d. Resident 49's AD was not kept in Resident 49's Medical Chart (medical record). These failures had the potential to result in lack of knowledge regarding decision making for care and treatment for Resident's 18, 29, 36, and 49 and for the resident's wishes regarding medical treatment to not be followed. Findings: a. During a review of Resident 18'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 the physician was notified of a change in condition for two of two sampled residents (Resident 19 and 40) when: a. Resident 19 was noted to have mild work of breathing (working harder to breathe, the amount of energy required to overcome the elastic and resistive elements of the respiratory system and move gas into and out of the lungs during spontaneous breathing) on 2/24/2024 and Resident 19 was hospitalized the next day on 2/25/2024 for shortness of breath. b. For Resident 40, the facility failed to inform Resident 40's physician regarding Resident 40's significant weight loss of 12.06% within six months. These failures had the potential to result in physical declines for Residents 19 and Resident 40. Cross Reference F656 and F803 Findings: a.During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic respiratory failure with…

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 review, the facility failed to ensure four of five sampled residents (Residents 90, 49, 84, & 69) did not receive unnecessary psychotropic medications (drugs used to treat mental health disorders that alter neurotransmitters [transmit messages from neurons to muscles] in the brain) by failing to: a. Limit Resident 90's as needed (PRN) Alprazolam (a psychotropic medication used for the treatment of anxiety [a feeling of fear, dread, and uneasiness]) order to 14 days as indicated the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management. b. Ensure Resident 49's physician documented a rationale to indicate the reason why a Gradual Dose Reduction (GDR, the stepwise tapering [to reduce dose over time] of a dose to determine if symptoms, conditions, or risks can be managed by use of a lower dose or determination of whether the dose or medication can be discontinued) was not attempted for Resident 49's Trazodone (a psychotropic medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food preferences, such as nuts and foods that did not contain oil, were served and followed for one of one sampled resident (Resident 40) as indicated in the facility's policy and procedures (P&P). This failure resulted in further weight loss to Resident 40 and had the potential to result in a physical decline to Resident 40. Cross Reference F656 and F580 Findings: During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (an adult-onset long-term condition in which the body has trouble controlling blood sugar) with diabetic neuropathy (a type of nerve damage that can occur when you have diabetes), unspecified, heart failure, unspecified and gastro-esophageal reflux disease (GERD, a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus…

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 remove one unopened expired milk carton and 22 apples, received 4/18/2024, from one of one walk-in refrigerator (Refrigerator 1). This failure had the potential to result in food poisoning (illness caused by food contaminated with bacteria [living organism that can cause an infection]) from serving spoiled foods to the residents who were able to consume the food items. Findings: During a concurrent observation and interview on 6/10/2024 at 9:45 AM with the Dietary Services Supervisor (DSS) in the facility's Refrigerator 1, there was a clear plastic bin that contained 22 red apples labeled received on 4/18/2024 and opened on 4/18/2024. The DSS stated the label was correct and the fruit was received on 4/18/2024. During a concurrent interview and record review on 6/10/2024 at 9:49 AM with the DSS, the facility's Suggested Refrigerated Storage Guideline, dated 2018, was reviewed. The Suggested Refrigerated Storage Guideline, indicated to store apples for one month. The DSS stated the DSS would throw out 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 the right to a dignified existence for one of one sampled resident (Resident 95) by failing to accommodate Resident 95's needs. On 6/10/2024, Resident 95 requested incontinence (having no voluntary control over urination or defecation [discharge of feces from the body]) care and Certified Nursing Assistant (CNA) 1 did not attend to Resident 95's needs timely due to Resident 95's roommate having a meal. This deficient practice resulted with Resident 95 feeling confused and uninformed and had the potential to result in Resident 95 feeling unsupported with Resident 95's care and had the potential to affect Resident 95's psychosocial well-being. Findings: During a review of Resident 95's admission Record (AR), the AR, indicated Resident 95 was admitted to the facility on [DATE] with multiple diagnoses including heart failure (condition that develops when the heart doesn't pump enough blood for the body's needs), morbid obesity (body…

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 one sampled resident (Resident 40) had a resident-centered comprehensive care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective and an evaluation plan]) developed to address Resident 40's progressive weight loss in accordance with the facility's policy and procedure (P&P), titled, Care Planning. This deficient practice had the potential to result in Resident 40 not to receive the necessary care and services in accordance with Resident 40's specific needs and the potential for continued weight loss and a physical decline to Resident 40. Cross Reference F580 and F803 Findings: During a review of Resident 40's AR, the AR indicated Resident 40 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (an adult-onset…

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 one sampled resident (Residents 17) was provided proper interventions for edema (swelling caused by too much fluid trapped in the body's tissues) when the facility failed to elevate Resident 17's upper extremities (shoulders, elbows, wrists, or hands) to decrease edema as indicated in Resident 17's care plan (CP), titled, [Resident 17] is at Risk for Impaired Skin Integrity as evidenced by edema . This failure had the potential to result in worsening or unresolved edema for Resident 17 and placed Resident 17 at an increased risk of developing blood clots and/or skin injuries, additionally, the failure had the potential to result in a physical decline to Resident 17. Findings: During a review of Resident 17's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (when the lungs can't get enough oxygen into 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 licensed nursing staff failed to offer the pneumococcal vaccine (vaccination against pneumonia [inflammation of the lungs]) to five of ten sampled residents (Residents 5, 6, 7, 8, and 9). This failure placed Residents 5, 6, 7, 8, and 9 at high risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to facility on 05/17/2017 with diagnoses included but not limited to chronic respiratory failure (results in the inability to effectively exchange carbon dioxide and oxygen in lungs) and diabetes (chronic long lasting health condition that affects how your body turns food into energy). During a review of History and Physical (H&P) Examination, dated 11/27/2023, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized 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 one of six sampled residents (Resident 3) remained free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident ' s body, cannot be easily removed by a resident, and restricts the resident ' s freedom of movement or access to their body) for use of convenience (the result of any action that has the effect of altering a resident ' s behavior and requires a lesser amount of care or effort, and is not in a resident ' s best interest) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not restrain Resident 3 during patient care (prevention, treatment, and management if illness and preservation of physical and mental well-being through services offered by health professionals) witnessed by CNA 3 (unable to recall specific date). 2. Ensure CNA 1 did not restrain Resident 3 during patient care, witnessed by Licensed Vocational Nurse (LVN) 2 (unable 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 interview and record review the facility failed to implement the facility's policy and procedures (PP) titled, Abuse Prevention and Prohibition Program, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 reported Resident 3 restrained with a bed sheet by CNA 1 when providing patient care (prevention, treatment, and management of illness and preservation of physical and mental well-being through services offered by a health professionals), to the administrator (ADM/abuse coordinator, designated staff within a skilled nursing facility [SNF] responsible for coordinating efforts to prevent resident abuse) (unable to recall specific date). 2. Ensure CNA 4 reported Resident 3 restrained with a bed sheet by CNA 1 to the ADM (unable to recall specific date). As a result of these failures, Resident 3 was restrained by CNA 1 during patient care over a period of 6 months. These failures had the potential for Resident 3 to suffer psychosocial (mental, emotional, social, and spiritual effects) harm, physical…

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

Based on interview and record review the facility failed to ensure one of two residents sampled residents (resident 1) had a person-centered comprehensive care plan developed and implemented to address the resident ' s medical, physical, mental and psychosocial needs. This failure had the potential to negatively impact Resident 1 ' s quality of life as well as the quality of care and services received. Cross Reference: F742 Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 08/16/2023 with diagnoses which included depression (a common and serious medical illnesses that negatively affects how you feel, the way you think and how you act) and aftercare following joint replacement surgery (physical therapy to strengthen new joint after surgery). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 08/23/2023, indicated Resident 1 ' s cognitive (ability to think and reason) skills for decision making was intact and Resident 1 verbalized Resident 1 ' s needs.…

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

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) received a psychological evaluation (psych eval - a method to assess an individual's behavior, personality, cognitive abilities, and several other domains by a mental health professional, including a psychologist, psychiatrists, or family doctor) service per Resident 1 ' s physician order. This failure had the potential to negatively affect Resident 1 ' s psychosocial well-being. Cross Reference: F656 Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated facility admitted Resident 1 on 08/16/2023 with diagnoses which included depression (a common and serious medical illnesses that negatively affects how you feel, the way you think and how you act), and aftercare following joint replacement surgery (physical therapy to strengthen new joint after surgery). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 08/23/2023, indicated Resident 1 ' s cognitive (ability to think and reason) skills 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 interview and record review, the facility failed to expediate the readmission of Resident 1 by failing to readmit Resident 1 on [DATE] when the facility had a room available for Resident 1. This failure had the potential for Resident 1 to suffer psychosocial (mental, emotional, social, and spiritual effects) harm and deny Resident 1's rights. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and again [DATE], with diagnoses that included type II diabetes mellitus (DM 2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), autism (developmental disability caused by differences in the brain), and osteomyelitis (serious infection of the bone that be either be acute or chronic). During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool) dated [DATE], indicated Resident 1 had moderately impaired cognition (ability to think,…

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 1 and Resident 2) were free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) by failing to: a. Protect Resident 1 from Certified Nursing Assistant 1 (CNA 1) when CNA 1 handled Resident 1 roughly and hit Resident 1's shoulder. b. Protect Resident 2 from CNA 1 when CNA 1 tossed Resident 2's legs and pinned Resident 2 on the bed to prevent Resident 2 from moving. These deficient practices resulted in Residents 1 and 2 to experience physical abuse, and Resident 1 feeling afraid. Findings: a. During a review of Resident 1's admission Record indicated, Resident 1 was admitted to facility on 4/9/2010, and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six of 26 sampled residents (Residents 71, 13, 31, 46, 31, and 21) by failing to: a. For Resident 71, the facility failed to develop a care plan to reflect the resident's vegetarian (a person who does not eat meat) preferences. b. For Resident 13, the facility failed to implement a care plan to address edema (swelling caused by excess fluid). c. For Resident 31, the facility failed to implement a comprehensive person-center care plan when the resident was not wearing the tab alarm (a pull-string that attaches magnetically to the alarm with garment clip to the resident). d. For Resident 46, the facility failed to have a care plan pertaining to self-administering medications. e. For Resident 21, the facility did not create a care plan to address range of motion exercises (activity aimed at improving movement of a specific joint) timely. These deficient practices had 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 treatment and services to maintain or improve the ability to perform activities of daily living for two of 42 sampled residents (Residents 70 and 288). a. For Resident 70, the facility did not perform sit-to-stand exercises per physician's order and did not report Resident 70's improvement in the ability to perform sit-to-stand exercises to the therapy department. This deficient practice prevented Resident 70 from receiving intervention in preparation for walking with a prosthetic (device designed to replace a missing part of the body) leg. b. For Resident 288, the facility did not assist the resident out-of-bed daily and did not dress Resident 288 in appropriate clothing. Resident 288, who was used to sitting up in a wheelchair daily, yelled multiple times per day in the bedroom without redirection. Resident 288 also unintentionally removed a hospital gown, exposing Resident 288's body to anyone walking down the hallway. This…

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 three of three sampled residents (Residents 57, 136 and 13) receive quality of care. a. For Resident 57, the facility could not provide documented evidence that various medications were restarted upon the resident's readmission on [DATE]. b. For Resident 136, there was no documented evidence that the lidoderm (medication for pain) patch was removed at 11 pm and reapplied at 9 am, the next day. c. For Resident 13, the facility failed to identify the presence of edema on bilateral lower extremities. These deficient practices had the potential to result in Residents 57, 136 and 13 not receiving the care necessary to thrive at their highest practical level. Findings: a. A review of the admission Record indicated Resident 57 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage kidney disease, type 2 diabetes (high blood sugar), dependence on kidney dialysis (process 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 correct weights were programmed on mattress settings for three of four sampled residents (Residentz 137, 136, and 53). These deficient practices had the potential to result in reoccurrence of pressure sores for Resident 137 and delayed wound healing and worsening of pressure sores for Residents 136 and 53. Findings: a. A review of the admission Record indicates Resident 137 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia (a condition that causes pain all over the body), hyperlipidemia (high levels of fat particles in the blood), muscle weakness, and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) of the left buttock and sacral (bottom of the spine) region. A review of the Norton Pressure Ulcer Scale, dated 11/25/21, indicated Resident 137 is at high risk for pressure sores (injuries to the skin and underlying tissue, primarily caused by…

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 residential environment remained free of accident hazards for three of three sampled residents (Residents 31, 72, and 288). a. For Resident 31, the facility failed to ensure the environment remained free of accident hazards when the resident was not wearing the tab alarm as ordered. b. For Resident 72, the facility failed to ensure the right floor mat was in place and that a chair was not positioned next to the resident's bed instead of the floor mat. This could result in injuries to the resident if he fell out of bed. c. For Resident 288, the facility performed an unsafe transfer from the bed to the wheelchair. These deficient practices had the potential to result in injury and harm to Residents 31, 72, and 288 in the event of a fall. Findings: a. During a review of Resident 31's face sheet (admission record), the face sheet indicted Resident 31 was readmitted to the facility on [DATE] with diagnoses that included Dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate pain management for two of three sampled residents (Resident 32 and Resident 48). As a result, Resident 32 and Resident 48 experienced severe pain, placing them at risk for decreased mobility, isolation, and possible depression. Findings: a. During an observation of Resident 32 and concurrent interview on 12/8/2021 at 11:51 am, the resident was in bed, laying on her back. During the interview, Resident 32 stated that she had back pain of 8/10. Resident 32 stated that she gets pain medications as needed but hoped that she had pain medications administered around the clock to prevent the pain A review of Resident 32's Face sheet (admission Record) indicated the facility admitted Resident 32 on 9/16/2021. Resident 32's medical diagnoses included pressure ulcer of sacral region (part of the body that lies between the end of the lumbar spine and the tailbone), stage 4 (open wound that is very deep, reaching into muscle 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 ensure it was free of medication error rate of five percent or greater, as evidence by the identification of two medication errors out of 30 opportunities, to yield a facility error rate of ten percent. 1. For Resident 50, Lisinopril (a blood pressure medication) was administered to the resident prior to checking her blood pressure. Resident 50's physician's order indicated to hold if her systolic blood pressure was below 110. 2. For Resident 17, two of two medications were observed crushed and administered together. These deficient practices increased the risk for Resident 50 and Resident 17 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to their medication therapy. Findings: 1. A review of an admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnosis that included hypertensive heart disease (heart problems that occur because of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide safe and secure storage of medication for four of 26 sampled residents (Residents 46, 136, 57 and 286). a. Resident 46 had four plastic tubes of Ipratropium-Albuterol Solution (used to prevent and treat wheezing and shortness of breath), and two plastic tubes of DuoNeb Solution (an inhaled steroid used to can treat asthma) were observed unlabeled and unattended on the resident's bedside table. b. Resident 136 had an unlabeled medication patch on the left lower back. c. Resident 57 had one unlabeled sore throat Lozenges in her room. d. Resident 286's unlabeled medication (albuterol inhaler) was observed at the resident's bedside. These deficient practices had the potential for the residents to receive medications not intended for them. Findings: a. A review of an admission record indicated Resident 46 was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure (airways that carry air to your lungs become narrow…

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 compare meal trays in three carts (carts 1, 2, and 3) with the physician's orders prior to serving meals to the residents. This deficient practice had the potential for the residents to receive meals inconsistent with physician's orders for therapeutic diets (meal plan that controls the intake of certain foods or nutrients). Findings: During a lunch observation on 12/7/2021, at 12:28 pm, Treatment Nurse 1 (TN 1) checked the diet card on each tray from cart 1 and visually inspected the meals prior to serving the meals to the residents. During a lunch observation on 12/7/2021, at 12:33 pm, a facility staff (unidentified) served the meal trays from cart 2 to the residents prior to having a licensed nurse check each meal tray. During an observation and interview on 12/7/2021, at 12:35 pm, Dietary Staff (DS 2) rolled cart 3 with meal trays and stated the cart came directly from the kitchen. Hospitality Aide 1 took a meal tray from the cart to a resident (unidentified). On 12/7/21, at 12:38 PM, TN 1 checked the…

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

Based on observation, interview, and record review, the facility failed to provide adequate snacks for residents at night after the kitchen was closed. This deficient practice had the potential for residents to feel hungry at nighttime. Findings: During a group interview on 12/8/2021, at 11:02 am, with alert and oriented residents, four of the 10 residents stated the kitchen was closed at 7 pm, and were unable to get any snacks once the kitchen was closed. The residents stated they needed to take a snack when offered, just in case they get hungry later, because they were unable to get anything else once all the snacks were gone. During an interview on 12/10/2021, at 3:01 pm, Dietary Staff 3 (DS 3) stated snacks were offered at 10 am, 2 pm, and 8 pm to residents with specific snack requests and extra snacks, a minimum of 10, were provided for any resident who wanted a snack. DS 3 stated the charge nurse usually had a spare key to the kitchen because the kitchen staff leaves at 8 pm. During an interview on 12/10/2021, at 3:13 pm, Certified Nursing Assistant 2 (CNA 2), who worked the…

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

Based on observation and interview, the facility failed to ensure no expired foods were stored in one of two refrigerators (Refrigerator 1) and in the walking freezer. This deficient practice could place the residents at risk for ingesting contaminated food and could result in illness to the residents. Findings: During an interview and initial tour observation on 12/7/2021 at 8:15 am with the dietary supervisor (DS 1), during inspection of the Refrigerator 1, there was one glass containing orange juice with no expiration date. During a concurrent interview, DS 1 stated all prepared food items should have an expiration date. During the inspection of the walking freezer, on 12/7/2021 at 8:30 am, with DS 1, there was a five pounds bag with diced turkey with expiration date 11/15/2021 and a bag containing egg rolls with an expiration date 11/28/2021. During a concurrent interview, DS 1 stated that no expired food should be kept in the freezer.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accuracy of medical records Residents 75 and 136, and failed to have accurate documentation for Restorative Nursing (RNA, nursing aide program that helps residents to maintain their function and joint mobility), on the flowsheets (record of RNA sessions). 1. The RNA flowsheets for 44 residents were blank from 12/1/2021 to 12/6/2021. 2. The RNA flowsheet for Resident 21's documentation did not match the RNA performing the range of motion or RNA sessions were performed on a different day. These deficient practices resulted in incomplete and inaccurate documentation of RNA sessions and had the potential to result in wrong level of oxygen administration for Resident 75 and uncontrolled pain for Resident 136. Findings: a. A review of the admission Record indicates Resident 75 was admitted to the facility on [DATE] with diagnoses that include: chronic (long standing) respiratory failure, tracheostomy (a hole made through the front of the neck to allow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices as indicated in the facility's policy and procedure for five of 26 sampled residents (Residents 63, 30, 75, 53, and 136) out of 26 by failing to: a. Ensure to label Resident 63's intravenous help-lock (IV, a catheter inserted into a vein to administer fluids or medications) to indicate the date of insertion or dressing change. b. Ensure to change Resident 30's peripheral intravenous central catheter (PICC, a flexible tube inserted to a vein to administer fluids or medications) and the resident's suction machine (used to remove liquids) filter. c. Ensure to label Resident 75's tracheostomy (is a surgically created hole in the windpipe that provides an alternative airway for breathing) tubing. d. Ensure to label Resident 53's intravenous fluid tubbing and intravenous site dressing. e. Ensure to label Resident 136's oxygen tubbing and intravenous access site dressing, and ensure Resident 136's oxygen tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a dignified environment for one of two sampled residents (Resident 57) as indicated on the facility policy. Resident 57 was not able to sleep at night due to loud noises at the facility. This deficient practice resulted with Resident 57 feeling horrible. Findings: A review of the admission Record indicated Resident 57 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage kidney disease (), type 2 diabetes (high blood sugar), dependence on kidney dialysis (process of purifying the blood of a person whose kidneys are not working normally), schizophrenia (mental disorder characterized by loss of contact with the environment), and Parkinson's disease (disorder that affects movement). During an observation and interview on 12/7/2021 at 10:40 am, Resident 57 was observed lying in bed awake, alert, eating a sandwich, and watching television. Resident 57 stated last night 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 one of 26 sampled residents (Resident 46), was assessed and had an order to self-administer medications. Resident 46 was observed with four plastic tubes of Ipratropium-Albuterol Solution (used to prevent and treat wheezing and shortness of breath) and two plastic tubes of DuoNeb Solution (an inhaled steroid used to can treat asthma) at the bedside. This deficient practice had the potential for Resident 46 not to have the right to self-administer medications. Findings: A review of an admission Record indicated Resident 46 was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure (airways that carry air to your lungs become narrow and damaged) with hypoxia (not enough oxygen reaching tissues). A review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 10/11/21, indicated Resident 46 was cognitively intact, had clear speech and had to ability to understand others…

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 right to formulate advanced directives was exercised for four of 26 sampled residents (Residents 136, 10, 66, and 49). This deficient practice had the potential to result with inability to make medical decisions for residents. Findings: a. A review of the admission Record indicated Resident 136 was admitted to the facility on [DATE] with diagnoses that included: pneumonia (infection in the lungs), long term respiratory failure, heart failure, difficulty walking, dysphagia (difficulty swallowing), epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). A review of the Acknowledgement of Signatures, dated 12/3/21, indicated the form was to acknowledge the residents were informed of resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the status of two of 26 sampled residents (Residents 41 and 71). a. For Resident 71, the facility dietary staff failed to accurately assess the resident's food preferences and indicate the resident was a vegetarian (a person who does not eat meat). b. For Resident 41, the Minimum Data Set Nurse failed to accurately assess the resident as being incontinent of urine (urinary incontinence, leaks urine by accident). These deficient practices resulted in Resident 71's dietary assessment not being tailored to reflect the resident's dietary restrictions to make sure the resident received the adequate amount of calories needed to avoid weight loss and resulted in Resident 41 not receiving appropriate treatment and services to prevent urinary tract infections (UTI, an infection in any part of your urinary system, which includes your kidneys, ureters, bladder, and urethra) and to restore continence (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 create an admission baseline care plans for one of one sampled resident (Resident 87). This deficient practice had the potential to result with a delay of individualized care for Resident 87. Findings: A review of the admission Record indicated Resident 87 was admitted to the facility 11/12/21 with diagnoses that included atrial fibrillation (two upper chambers of the heart beat chaotic and irregular), aftercare following surgery, and hyperlipidemia (abnormally high concentration of fat in the blood). A review of the Baseline Care Plan sheet, dated 11/15/21, indicates Resident 87 was a new admission and had the following: uncontrolled high blood pressure, bradycardia (a slower than normal heart rate), medication for (a disease that thins and weakens the bones), atrial fibrillation, hyperlipidemia, bowel movement concern, took supplements, had eye inflammation, on soft texture/low fat/sodium diet, uses grab bars to both sides of bed, had a pacemaker…

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 revise the care plan for one of 26 sampled residents (Resident 48), as indicated on the facility's policy. Resident 48's care plan for pain was not revised to include pain in his left great toe (big toe). This deficient practice had the potential for Resident 48 to not receive specific interventions to address his pain, which could result in harm and injury and could lead to a decline in functional well-being. Findings: During a review of Resident 48's face sheet (F/S, admission record), the face sheet indicted Resident 48 was admitted to the facility on [DATE] with diagnoses that included Dementia (loss of memory, language, problem-solving and other thinking abilities), Urinary tract infection (UTI, an infection in any part of your urinary system, which includes your kidneys, ureters, bladder, and urethra), and Polyneuropathy (a disease of, or damage to nerves). During a review of Resident 48's History and Physical (H&P), dated…

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 ongoing sensory stimulating activities program designed to meet the interest for one of one sampled resident (Resident 236). Resident 236 who preferred to stay in his room, listen to music or watch television. This deficient practice had the potential to decreased Resident 236's quality of life; cause boredom, loneliness, and frustrations resulting in distress and agitation. Findings: A review of an admission record indicated Resident 236 was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure (airways that carry air to your lungs become narrow and damaged), and diabetes (elevated blood sugar). A review of Resident 236's minimum data set (MDS, a resident assessment and care screening tool) dated 11/30/21, indicated Resident 236 was cognitively intact meaning Resident 236 had the ability to understand and be understood by others. A review of a care plan indicated Resident 236 was at risk 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 provide one of 42 sampled residents (Resident 21) with appropriate services for active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment) to both arms and legs. This deficient practice had the potential for Resident 21 to experience a decline in ROM in both legs and mobility. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body), presence of cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm), osteoarthritis (bone disease that progresses over time, resulting in joint pain and stiffness), and history of falling. A review of Resident 21's Minimum Data Set (MDS, a comprehensive assessment used…

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 26 sampled residents (Resident 41), who is incontinent of bladder (urinary incontinence, leaks urine by accident), received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in any part of your urinary system, which includes your kidneys, ureters, bladder and urethra) and to restore continence (the ability to control movements of the bladder) to the extent possible when they failed to trial her on a toileting program (scheduled regular bathroom trips to facilitate bladder training and to avoid bladder accidents). This deficient practice had the potential to negatively impact Resident 41's psychosocial well-being and increase the potential for the resident to develop a UTI or to experience skin breakdown. Findings: During a review of Resident 41's face sheet (F/S, admission record), the face sheet indicted Resident 41 was admitted to the facility 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 observation, interview, and record review, the facility failed to ensure that nutritional care and services were provided for one of two sampled residents (Resident 21). Resident 21 was observed with gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding running. The G-tube formula label did not have the resident's name, date, time hung, and G-tube feeding rate, as indicated on the facility policy. This deficient practice had the potential for G-tube administration error. Findings: During a review of Resident 21's face sheet (F/S, admission record), the face sheet indicted Resident 21 was readmitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar as a fuel), Chronic Respiratory Failure (a syndrome in which not enough oxygen travels from the lungs into the blood), and Atrial Fibrillation (an irregular and often very rapid heart rhythm). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist medication regimen review recommendations for one of five residents (Resident 70) with recommendation for a blood test to assess for magnesium levels in the blood. This deficient practice had the potential for Resident 70 to have low blood magnesium levels that do not increase even with the use of magnesium supplements. Findings: A review of Resident 70's admission Record indicated the resident was admitted on [DATE] with diagnoses that included diabetes (imbalance blood sugar levels in the blood) with chronic kidney disease (gradual loss of kidneys function to meet the body's needs) and chronic systolic heart failure (the left ventricle of the heart, which pumps most of the blood, has become weak which could lead to heart failure). A review of Resident 70's Minimum Data Set (MDS- an assessment and care planning tool) dated 9/10/2021, indicated the resident was able to express ideas and wants and was able to understand…

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 three of four dryers were cleaned for lint in the laundry room. This deficient practice had the potential to place residents, staff, and outpatients, at risk for fires. Findings: During an observation on 12/7/2021, at 10:12 am, the facility's laundry area was located directly next to the outpatient rehabilitation area. A review of the laundry's Lint Removal Log dated from 12/5/2021 to 12/11/2021, there were check marks and initials on the log for 12/7/2021 at 6 am, 8 am, and 10 am. During an observation and interview on 12/7/2021, at 10:29 am, the Laundry Aide 2 (LA 2) stated Laundry Aide 1 (LA 1) cleaned the dryer lint every two hours. LA 2 reviewed the log and stated the lint traps were last cleaned on 12/7/2021 at 10 am. LA 2 opened the lint traps for dryers #2, #3, and #4 which were all full of lint. During an interview on 12/8/2021, at 12:47pm, in the laundry area, the Laundry Supervisor stated it was important to clean the lint traps every two hours to prevent fire hazards. A review of 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.