Casitas Care Center

Based on observation, interview, and record review, the facility failed to ensure the double door exit in the middle station (MSDDE) was fully sealed when closed and did not have gaps, which created an opening from top to bottom measuring 72 inches in length and 1/3 of an inch in width for one of three doors in the facility. This deficient practice created an entry point and access for insects to get inside the building which could potentially transmit insect borne illnesses to the 94 out of 94 residents in the facility. Findings: During a concurrent observation and interview on 3/25/2026 at 12:54 p.m., with the Maintenance Director (M-Dir.) while inspecting the MSDDE, the M-Dir stated that the exit doors must always be closed and sealed to prevent insect infestation in the facility. The M-Dir confirmed that the MSDDE had a wide opening, allowing visibility of cars passing through from the gaps in the double door. The M-Dir measured the opening which measured 72 inches in length and 1/3 of an inch in width. The Medical Director (M-Dir) stated that he would immediately go to Home…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 measure the pressure ulcer/injuries (PU/ls - injury to skin and underlying tissue resulting from prolonged pressure on the skin) wound measurements for two of three sampled residents' (Resident 1 and Resident 2). This deficient practice had the potential to delay necessary treatments and services and to increase the residents' risk of further skin breakdown.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/27/2025 with diagnoses including unstageable pressure ulcer unspecified site, osteomyelitis (infection of the bone that causes inflammation and pain), spina bifida (a birth defect where the spine doesn't close completely during early pregnancy, leaving the spinal cord and nerves exposed), and abnormal posture. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2025, the MDS indicated Resident 1's cognitive (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 ensure that a 72-hour neurological check (neuro check- an assessment conducted to assess a person's brain and nervous system function by checking level of consciousness, behavior, pupils, movement, and vital signs to identify any changes in condition) was completed for one of three sampled residents (Resident 1) after Resident 1's unwitnessed fall on 12/18/2025. This deficient practice had the potential to result in delayed identification of changes in Resident 1's condition, which could affect the timely delivery of appropriate care and treatment.Findings: During review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 12/3/2025 with diagnosis including type 2 diabetes (a condition that affects the way the body processes blood sugar), work together to provide structure, support, stability, and enable movement), abnormal posture, unspecified fall, and vascular dementia (a decline in thinking, memory, and reasoning caused by brain damage from impaired blood flow,, leading…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 admission Coordinator (AC) was aware that residents and their representative can rescind the facility's arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) within 30 days after obtaining the signature for two of three sampled residents (Residents 2, and 5 ).These failures could potentially result in the residents and residents' representatives not knowing or understanding what an arbitration agreement is and potentially causing feelings of doubt and confusion.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/12/2025, with diagnoses including metabolic encephalopathy (your brain is having trouble processing information due to a chemical imbalance in your blood), diabetes mellitus (DM-a disorder characterized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Notify one of four sampled residents (Resident 1) physician and Resident 1 regarding the missed dose of Levothyroxine Sodium (levothyroxine - a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy]) scheduled to be given on 1/15/2025 at 6:30 a.m. 2. Notify one of four sampled residents (Resident 1) physician of Resident 1's refusal to allow body weight monitoring for a duration of 58 days (2/6/2025 to 4/4/2025). These deficient practices may result in worsening symptoms, increased risk of hospitalization or complications and health decline. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for one of four sampled residents (Resident 1) to address Resident 1's refusal to allow body weight monitoring. These deficient practices had the potential to negatively affect the delivery of care and services and placed Resident 1 at risk for impaired nutrition and decline in well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body needs), diabetes mellitus (DM - a condition that happens when your blood sugar is too high), hypertension…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct a nutritional assessment upon admission for one of four sampled residents (Resident 1), as per the facility's policy and procedure (P&P) titled, Nutritional Assessment. This deficient practice had the potential to place Resident 1 at risk for undetected nutritional status and at risk for medical complications related to impaired nutrition. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body needs), diabetes mellitus (DM - a condition that happens when your blood sugar is too high), hypertension (abnormally high blood pressure), and morbid (severe) obesity (a medical condition where someone has excessive fat accumulation that presents a risk to health). 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 review, the facility failed to: 1. Ensure that the on-coming nurse (Licensed Vocational Nurse 1 [LVN 1]) signed the Narcotic (a controlled medication or substance with a high potential for abuse that in moderate doses dulls the senses, affects mood or behavior, relieves pain and induces sleep) Count Sheet (NCS- a form used to account all controlled medications, and to transfer accountability from the out-going nurse to the on-coming nurse) on 4/24/2025 for 7 a.m. to 3 p.m. shift after counting the controlled medications with the out-going nurse (Licensed Vocational Nurse 2 [LVN 2]). 2. Ensure that the on-coming nurse (Licensed Vocational Nurse 3 [LVN 3]) signed the NCS on 4/9/2025, 11 p.m. to 7:00 a.m. shift in one of two inspected medication carts (MC 3) at the Nursing Station (NS). 3. Administer Levothyroxine Sodium (levothyroxine - a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure,…

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

Based on interview and record review, the facility failed to implement its policy and procedure titled Wandering (to walk around without any clear purpose or direction) and Elopement (leaving the facility without notice or permission) and failed to ensure one of three sampled residents (Resident 1), who was observed with periods of confusion, agitation (a condition in which a person is unable to relax and be still) and was observed wandering and entering other resident rooms on 4/7/2025 was kept free from accidents and hazards by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) followed the facility's policy and procedure titled Wandering and Elopement to attempt to prevent Resident 1, who was at risk for unsafe wandering, from leaving the facility premises. These deficient practices resulted in Resident 1 leaving the facility on 4/7/2025 at 11:10 p.m., without being stopped by CNA 1, who observed Resident 1 leave the facility. These deficient practices placed Resident 1's health and well-being at risk and could result to Resident 1 sustaining severe injury requiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt attempts were made to resolve the grievance of one of three sampled residents (Resident 1). This deficient practice violated the residents' right to have his grievance addressed. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/27/2025 and readmitted on [DATE] with diagnoses that included pneumonitis (general inflammation of lung tissue) due to inhalation of food and vomit, urinary tract infection (UTI-an infection in the bladder/urinary tract), and gastrostomy status (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 Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/6/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS also indicated Resident 1 was dependent on staff with oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility ' s intravenous (IV -fluids given directly into the blood stream) administration policy was implemented to prevent complications from intravenous therapy by failing to monitor a resident receiving intravenous hydration for Intake & Output (I&O- the careful tracking and recording of fluids a patient consumes [intake] and eliminates [output] to monitor fluid balance and overall hydration status) and failed to assess a resident prior to the administration of IV fluids for one of three sampled residents (Resident 1) This deficient practice had the potential to place Resident 1 at risk for developing complications such as inflammation of the vein, fluid overload (a medical condition characterized by having too much fluid volume in the body, potentially leading to health complications like swelling, high blood pressure, and heart problems), electrolyte (minerals in your blood and other body fluids that carry an electric charge) imbalances…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy on quality of life by failing to ensure three of four sampled residents (Resident 2, Resident 3 and Resident 4) were assisted by staff to participate in activities. This deficient practice had the potential to affect the resident's sense of well-being, self-esteem and self-worth. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/23/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and encounter for palliative care (specialized medical care focused on relieving suffering and improving the quality of life for residents with serious illnesses). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 2 had severely impaired cognition (the process of acquiring knowledge and understanding…

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

Based on interview and record review, the facility failed to implement its policy and procedure titled Activity Programs by failing to incorporate at least one activity a month held away from the facility and offer at least one evening activity per week to 93 residents residing in the facility for two of three sampled months (January 2025 and February 2025). This deficient practice had the potential to result in psychosocial decline and a decreased quality of life. Findings: During a concurrent interview and record review on 3/27/2025 at 11:52 a.m., with the Activities Director (AD), the activity calendar for the month of January 2025 and February 2025 were reviewed. The AD stated that she (AD) is responsible in scheduling activities for the residents one month prior. The AD stated that there should be one scheduled activity held outside the facility such as outings for each month to provide a different environment to the residents. The AD stated that the facility should also schedule evening activities once a month. The AD stated that there were no outside activities such as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory services (refers to the collection, testing. and analysis of a resident's specimen [such as blood, urine or stool] for health-care professionals to make decisions on the diagnosis and treatment of their residents) were provided to one of three sampled residents (Resident 1) timely per physician's order. This deficient practice resulted in the delay of necessary care and services for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 4/4/2024 and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where the lungs struggle to deliver enough oxygen to the blood, leading to low levels of oxygen in your body tissues), urinary tract infection (UTI - when bacteria gets into your urine and travels up to your bladder [a hollow, muscular organ in the lower abdomen that stores urine]) 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 call lights were within residents' reach while in bed for three of three sampled residents. (Resident 5, Resident 44, and Resident 45) This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility readmitted the resident on 7/5/2023 with diagnoses including acute respiratory failure (results from acute or chronic impairment of gas exchange between the lungs and the blood) with hypoxia (a condition in which the body's tissues do not receive enough oxygen), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often caused by damage to the brain) following unspecified cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and spinal cord) affecting left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for four of four sampled residents (Resident 287, Resident 36, Resident 37, and Resident 20) by failing to: 1. Develop and implement a comprehensive person-centered care plan addressing Resident 287`s intravenous catheter (IV- a thin flexible tube inserted into a vein to allow for administration of fluids or medications). This deficient practice had the potential to result in Resident 287`s inadequate care of IV site. 2. Develop and implement a comprehensive person-centered care plan addressing Resident 36's Ceftriaxone Sodium (antibiotic used to treat bacterial infections) use. This deficient practice had the potential to result in complications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe environment for three out of six residents (Resident 70 and Resident 37) investigated under the care area of accidents when: 1. The facility failed to place a landing mat to Resident 70's right side of the bed while Resident 70 was in bed as indicated in the care plan and physician's order. This deficient practice placed the resident at risk for avoidable pain and/or injury in an event of Resident 70 experiencing an actual fall. 2. The facility allowed Resident 37 to keep an electric tea kettle in his room. This deficient practice had the potential to result in injuries to Resident 37. Findings: 1. During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), encounter for palliative care (person and family-centered treatment, care and support 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.

b. During a review of Resident 287's admission Record, the admission Record indicated that the facility initially aditted Resident 287 on 4/27/2024 and readmitted the resident on 3/3/2025 with diagnoses including pneumonitis (lungs tissue inflammation, swelling, and irritation), urinary tract infection (an infection in any part of the urinary system), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). During a review of Resident 287's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/12/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 287 was dependent on the assistance of two or more helpers for activities of daily living (ADL-activities related to personal care). During a review of Resident 287's History and Physical (H&P), dated 3/4/2025, the H&P indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure licensed nurses did not leave medications at residents' bedside unattended by a licensed nursed for one of three sampled resident (Resident 57) This deficient practice increases the risks of harm to the resident from omitting the dose, double dosing, and mixing the medications that could cause adverse (unfavorable) or even fatal effects on the resident 2. Ensure a resident was given the first dose of antibiotic timely for one of three sampled residents (Resident 60) This deficient practice resulted in the delay of medication administration of an antibiotic which has a potential to cause bacteria to reproduce. Findings: a. During a review of Resident 57's admission Record, the admission Record indicated the facility readmitted the resident on 2/15/2025 with diagnoses including chronic hematogenous osteomyelitis (a bone infection that occurs when bacteria spread through the bloodstream to the bone) right ankle and foot, type 2…

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

Based on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by residents' family and visitors were labeled with a resident identifier and use-by-date in one of one resident refrigerator (Refrigerator 1). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents. Findings: During a concurrent observation and interview on 3/7/2025 at 6:33 p.m., with Registered Nurse 3 (RN 3), observed the residents' refrigerator in the nurse's station. Observed in the refrigerator, two plastic bags of undetermined leftover food with one bag with a room number with no name and date and the other plastic bag containing undetermined food items with no resident's name and no date. RN 3 stated that this refrigerator is used to store resident's food and had to be labeled with an identifier and date. RN 3 stated that any leftover food that is more than three days old had to be discarded. RN 3 stated that leftover food that is more than three days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had arranged provisions of hospice services by failing to: 1. Ensure the contracted hospice agency provided training programs to facility staff as per contractual agreement. 2. Ensure there is a designated staff to coordinate care and services provided by hospice and the facility. 3. Ensure documented evidence was provided to validate hospice staff was physically in the facility to provide hospice related services to one of three sampled residents (Resident 70) These deficient practices has the potential to negatively affect the resident's physical comfort, psychosocial well-being, and has the potential to delay or have a lack of necessary care and services. Findings: During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), encounter for palliative care (person and family-centered treatment, care and…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 137). 2. Ensure a resident's nasal cannula was labeled with the date when it was last changed for one of three sampled residents (Resident 287). These deficient practices had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. Findings: 1. During a review of Resident 137's admission Record, the admission Record indicated the facility admitted the resident on 2/28/2025 with diagnoses including morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems) and heart failure (a chronic condition that occurs when the heart can't pump enough blood and oxygen to the body). During a review of Resident 137's History and Physical (H&P- a formal assessment by a healthcare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity to a resident by failing to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder [organ that stores urine] and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of one sampled resident (Resident 238). This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 238's admission Record, the admission Record indicated that the facility admitted the resident on 3/7/2025 with diagnoses including infection and inflammatory reaction (the body's response to injury or infection) due to urinary catheter, and malignant neoplasm of bladder (an uncontrolled growth of abnormal cells that form a tumor in the bladder, the organ that stores urine). 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 develop a baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) within 48 hours of admission and/or readmission for three of four sampled residents (Resident 21, 59, and 62) by failing to: 1. Develop a baseline care plan that addressed Resident 21 and 59's antibiotic (medication used to treat bacterial infections) use. 2. Develop a baseline care plan that addressed Resident 62's insulin (a hormone that works by lowering levels of glucose [sugar] in the blood) use. These deficient practices had the potential to result in failure to deliver the necessary care and services. Findings: 1.a. During a review of Resident 21's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/20/2017 and readmitted the resident on 2/20/2025 with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe) and…

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

Based on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's physician discontinued administration of Januvia (a medication that helps control blood sugar levels) on 10/25/2024, for one of two sampled residents (Resident 20). This deficient practice had the potential to result in confusion regarding the care and services Resident 20 received at the facility. Findings: During a review of Resident 20's admission Record, the admission Record indicated that the facility originally admitted the resident on 10/25/2024 and readmitted the resident on 11/19/2024 with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type two diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and cerebral infarction…

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

Based on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 20) whose primary and preferred language was not English. This deficient practice has the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed. Findings: During a review of Resident 20's admission Record, the admission Record indicated that the facility originally admitted the resident on 10/25/2024 and readmitted the resident on 11/19/2024 with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type two diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide religious services to one of one sampled resident (Resident 10) investigated under Activities. This deficient practice violated the resident's right to have access and receive religious services which had the potential to affect the resident's sense of self-esteem and self-worth. Findings: During a review of Resident 10's admission Record, the admission Record indicated that the facility admitted the resident on 6/20/2023 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and anemia (blood has a lower than normal number of red blood cells). During a review of Resident 10's Annual Minimum Data Set (MDS - a resident assessment tool) dated 6/21/2024, the MDS indicated in Section F that participating in religious services or practice is somewhat important to Resident 10. During a review of Resident 10's Quarterly MDS dated [DATE], the MDS indicated the resident's…

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

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 62) with an indwelling catheter (a hollow tube inserted into the bladder [organ that stores urine] to drain or collect urine) received proper care and services by failing to monitor the resident for signs and symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract) and pain associated with the catheter as indicated in the resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment). This deficient practice had the potential to result in Resident 62 receiving inadequate care and monitoring at the facility. Findings: During a review of Resident 62's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including benign prostatic hypertension (BPH, enlarged prostrate [a gland] that makes it difficult to urinate), obstructive uropathy (a blockage in the urinary tract that prevents urine from draining normally), and reflux uropathy (when urine flows backward…

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

Based on observation, interview and record review, the facility failed to follow the pharmacy's medication recommendation label of discarding two opened eye drop bottles after 28 days of opening from one in five medications carts (Medication Cart 1 3-11 shift) This deficient practice had the potential to compromise the therapeutic effectiveness of the medication and increase the risk of contamination, which could result in a negative impact to the health, and well-being of the residents. Findings: During a concurrent observation and interview on 3/7/2025 at 6:05 p.m. with Registered Nurse 2 (RN 2), observed Medication Cart 1 3-11 shift. Observed two opened eye drops: One opened eye drop container of Alpheagan (prescription eye drop that helps lower pressure in the eye and treats glaucoma [A group of eye conditions that can cause blindness]), labeled date open 1/20/2025 discard after 28 days and one opened eye drop container of Latanoprost ( medication that treats glaucoma), labeled date opened 1/24/2025 discard after 28 days. RN 2 stated that both eye drops should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for three of nine sampled residents (Resident 24, 53 and 67). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 24, 53 and 67. Findings: a. A review of Resident 53's admission Record indicated the facility originally admitted the resident on 10/16/2021 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), sepsis (a life-threatening condition that arises…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Ensure blood glucose (the amount of sugar in the blood) monitoring (measure and display the amount of sugar in your blood) was done as per the physician orders for one of two sampled residents (Resident 46). 2. Ensure that one of three sampled residents (Resident 64) was provided with bilateral (both sides) upper bed side rails as ordered by the physician. These deficient practice resulted to inappropriate management of Resident 46`s type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) which could potentially result to hypoglycemia (blood sugar level goes below the standard range) and hyperglycemia (high blood sugar) episodes which could lead to complications such as a condition called diabetic ketoacidosis (diabetic coma) and even death; and resulted in the failure to deliver the necessary care and services for Resident 64. Findings: 1. A review of Resident 46`s admission…

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

Based on observation, interview, and record review the facility failed to provide a comfortable home-like environment by not providing an adequate and comfortable lighting per the facility's policy for one of six sampled residents (Resident 293). This deficient practice had the potential to negatively impact the quality of life and increased risk for discomfort for Resident 239. Findings: A review of Resident 293's admission Record indicated the facility admitted the resident to the facility on 2/5/2024 with diagnoses including malignant neoplasm of palate and mouth (a cancer of mouth and roof of the mouth), acute respiratory failure (condition in which your blood does not get enough oxygen), and atrial fibrillation (an irregular and very rapid heart rhythm). A review of Resident 293's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 2/8/2024, indicated Resident 293's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were mildly impaired. The MDS indicated Resident 293 required moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policy and procedure for the use of restraints (a device that restricts movements) by: a. Failing to ensure a consent (the legal approval that a resident gives to a physician regarding health care decisions) was first obtained prior to utilizing bilateral (both sides) bed side rails for one of three sampled residents (Resident 77). b. Failing to ensure licensed nurses obtained a physician's order for the use of bilateral bed siderails for one of three sampled residents (Resident 77). This deficient practice placed Resident 77 at increased risk for complications of restraint use such as decline in functioning, injury, and entrapment (event in which a resident is caught, trapped, or entangled in a space where they are being restrained). Findings: a. A review of Resident 77's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for one of three sampled residents (Resident 77) by failing to develop a comprehensive care plan for use of Resident 77's bilateral bed siderails. This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A review of Resident 77's admission Record indicated the facility admitted the resident on 9/29/2023 with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), chronic diastolic (measures the pressure in your arteries when your heart rests between beats) congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). 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.

Based on interview and record review, the facility failed to renew and revise a resident's comprehensive care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for high risk for fall for one of two residents sampled residents (Resident 40) investigated under Care Planning. This deficient practice resulted in Resident 40 not being evaluated if the desired outcome or care plan goals have been met or if the plan of care needs to be updated with new interventions to prevent a fall incident. Findings: A review of Resident 40's admission Record indicated the facility admitted the resident on 1/30/2020 with diagnoses that included respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/6/2024, indicated that the resident's cognitive (thought…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free from accidents and hazards by failing to: A. Ensure the electrical extension cord that was connected to an electrical outlet was secured to the wall for one of 21 sampled residents (Resident 9). B. Ensure the electrical power strip (a length of electrical sockets attached to the end of a flexible cable that plugs into an electrical receptacle) was not wrapped around the bed siderail while attached to another power strip for one of 21 sampled residents (Resident 48). These deficient practices had the potential to place Resident 9 and Resident 48 at increased risk of electrical accidents which could then result in injury. Findings: A. A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), cognitive communication deficit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post in a visible and prominent place the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for two of three sampled days (2/23/2024 and 2/24/2024). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing. Findings: During an observation on 2/23/2024 at 10:31 a.m., a projected, not an actual Direct Care Services Hours Per Patient Day (DHPPD) was observed posted at the receptionist area and on the counter of one of one nurse's station (Nursing Station 1). During an observation on 2/24/2024 at 8:18 a.m., a projected, not an actual DHPPD was observed posted at the receptionist area and on the counter of Nursing Station 1. During an interview with Director of Staff Development (DSD) on 2/24/2024 at 4:28 p.m., the DSD stated that the facility posting of the DHPPD include only projection hours and not the actual hours. DSD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Medication Regimen Review (MRR) was acted upon for one of six sampled residents (Resident 21) investigated under the care area of unnecessary medications by failing to act upon the facility's consultant pharmacist's recommendation for Resident 21's Ambien (medication used to treat insomnia [sleep disorder that can make it hard to fall asleep or stay asleep] as needed order. This deficient practice had the potential to cause adverse side effects from the continued use of these medications. Findings: A review of Resident 21's admission Record indicated the facility admitted the resident on 12/20/2023 with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood glucose [sugar]), neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet), and insomnia. A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 12/26/2023, indicated Resident 21's cognitive (mental action or 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.

Based on interview and record review, the facility failed to ensure a resident was monitored for complications that included signs and symptoms of bleeding and side effects related to anticoagulant (medications that help prevent blood clots) use for one of two sampled residents (Resident 190) investigated under Unnecessary Medications. This deficient practice placed the resident at risk for undetected bleeding which could lead to blood loss and hemorrhage (loss of blood from a damaged blood vessel). Findings: A review of Resident 190's admission Record indicated that the facility admitted the resident on 2/22/2024 with diagnoses that included acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood) and pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). A review of Resident 190's History and Physical (a term used to describe a physician's examination of a patient) dated 2/18/2024, indicated that the resident is deaf and non-verbal. A review of Resident 190's physician's orders dated 2/23/2024, included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 48) reviewed for unnecessary medications, was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 48 was adequately monitored for the amount of hours of sleep for the use of Trazodone (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest]). These deficient practices had the potential to place residents at risk of receiving unnecessary medications and/or overuse of medication and adverse consequences while using the medications. Findings: A review of Resident 48's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted on [DATE] with diagnosis including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), major depressive disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete and accurate medical records in accordance with accepted professional standards and practices for two of nine sampled residents (Resident 24, and 58) by failing to ensure the resident's Coronavirus Disease 2019 (COVID-19)- a deadly respiratory disease transmitted from person to person) and influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccination (A preparation that is used to stimulate the body's immune response against diseases) consents (the legal approval that a resident gives to a physician regarding health care decisions) contained the residents name. This deficient practice had the potential to result in confusion regarding Resident 24 and Resident 58's condition and what care and services were provided to the residents. Findings: 1. A review of Resident 24's admission Record indicated Resident 24 was originally admitted to the facility on [DATE] and was readmitted on [DATE] 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 observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to ensure there was a personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials) cart outside of a resident's room and ensure staff wear full personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials) before entering and providing care to one of nine sampled residents (Resident 64) who had an order for enhanced standard precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that have become resistant to certain antibiotics] in nursing homes). This deficient practice had the potential to result in the spread of disease and infection to residents, staffs, and visitors. Findings: A review of Resident 64's admission Record indicated the facility originally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident ' s call light (a device used by a resident to signal his or her need for assistance from healthcare workers) was within reach for two of six sampled residents (Resident 2 and 3). This deficient practice had a potential for the residents not able to call for assistance needed. Findings: A review of the Resident 2 ' s admission Record indicated the facility admitted the resident on 3/16/2022, with diagnoses including sepsis (body ' s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure and death), diabetes mellitus (a disease that occurs when the body is unable to regulate the amount of glucose [sugar] in the blood) and hypertension (high blood pressure). During a review of Resident 2 ' s Minimum Data Set et (MDS- a standardized assessment and screening tool) dated 9/20/2023, indicated the resident ' s cognition (ability to think, understand and reason) was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 1) by: 1.failing to develop a comprehensive care plan for Resident 1's incontinence (inability to control both bowel and bladder). 2. failing to ensure Resident 1's care plan for pain medication therapy included the reason the resident was on pain medication therapy. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 1 ' s admission record indicated the facility admitted the resident on 9/7/2023 with diagnoses including Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection), fall and spinal stenosis (a narrowing of the spinal canal in the lower part of your back). A…

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

Based on interview and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one used commode (a type of chair with an opening to a large pot used by residents as a toilet) containing soaked toilet papers with yellow substances were not left in the courtyard of the facility that is used by residents during smoking breaks and leisure time. 2. Ensure 13 empty trash bins and liners (plastic bags) used for disposal of Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) waste were not scattered in the vacant spaces between resident ' s room windows and the facility ' s fence. These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: 1. During a concurrent observation and interview on 9/25/2023 at 11:45 a.m., with Maintenance Supervisor (MS), the facility ' s courtyard was observed. MS stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a homelike environment was provided by: 1. Failing to ensure that the window screen was not torn and had no cobwebs (a web spun by spiders) accumulating on the screen for one out three residents (Resident 2) investigated for clean and homelike environment. 2. Failing to ensure that room [ROOM NUMBER] and room [ROOM NUMBER] of the facility did not have torn window screens. 3. Failing to ensure that Rooms 1,2,3,4 and 5 did not have missing vertical window blind louvers (slats- a type of window covering). These deficient practices violated the residents ' rights to a safe, clean, comfortable, sanitary, and homelike environment. Findings: 1. A review of Resident 2 ' s admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] with diagnoses that included difficulty in walking and hypertension (high blood pressure). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening…

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

Based on interview and record review, the facility failed to develop and implement a baseline person-centered care plan for one of three sampled residents (Resident 6) that was identified to have been assessed with discolorations and edema (swelling caused by too much fluid trapped in the body's tissues) upon admission. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: A review of Resident 6's admission Record indicated the facility admitted the resident on 7/25/2023, with diagnoses that included sepsis (a life-threatening complication of an infection), unspecified organism, pneumonia (an infection that affects one or both lungs), and unspecified fall. A review of Resident 6's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/27/2023 indicated Resident 6's cognition (relating to the process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated Resident 6 was totally dependent on staff with bed mobility, transfer, and toilet use. 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.