Magnolia Gardens Convalescent Hospital

Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety by failing to:1. Ensure food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident receives their prescribed diet) were at the proper temperatures when [NAME] 2 failed to take the temperature of the Asian salad.2. Follow safe food handling procedures by leaving the resident's breakfast at the beside until she woke up four hours later for one of one resident (Resident 20) during an initial pool observation. These failures had the potential to result in the possibility of harmful bacterial growth and cross contamination leading to foodborne illness.Findings: a. During a kitchen tray line observation on 4/08/2026 at approximately 12:15 p.m., [NAME] 1was observed checking the temperatures of the food. [NAME] 1 and the kitchen aides were about to start to serve the food and place it on the residents' plates. The Asian salad had already placed on the residents' trays. When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and implement a clear policy for controlled drug administration (refers to the process of safely managing medications that are regulated by the government due to their potential for misuse or dependency - often called controlled substances) when its policy did not indicate the required timeframes for documenting controlled substances, including when to sign the Controlled Drug Record (CDR - document used in healthcare settings to track and account for medications that are regulated due to their potential for misuse) and when to sign/complete the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). Three of three licensed nurses (Licensed Vocational Nurse 1 [LVN 1], Licensed Vocational Nurse 3 [LVN 3], Licensed Vocational Nurse 5 [LVN 5]) were unable to identify the proper chronological steps for removing and administering…

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

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life by failing to ensure a staff member was at eye level while providing feeding assistance for one of three residents (Resident 75) investigated under the dignity care area. This deficient practice had the potential to result in a decrease in the residents' psychosocial well-being and loss of dignity.Findings: During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 2/25/2021 and readmitted the resident on 10/24/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 75's History and Physical (H&P) dated 2/23/2026, the H&P indicated Resident 75 did not have the capacity to understand and make decisions. During a review of Resident 75's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote the resident's right to be informed of and participate in their treatment for two of four (Resident 7 and Resident 63) sampled residents by failing to inform the resident and provide the name of medications and their indications (reason for the use of the medication) prior to administration of the medications. This deficient practice violated Resident 7 and Resident 63`s rights to make decisions regarding their medication regimen and afford the residents the opportunity to refuse any or all the medications due for administration. Findings: a. During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted the resident on 12/06/2018 and readmitted on [DATE] with diagnosis including muscle weakness and anxiety disorder (a mental health condition involving excessive, uncontrollable fear or worry that interferes with daily life, lasting for months rather than being temporary). During a…

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

Based on observation, interview, and record review, the facility failed to ensure that discharge documentation included all the required elements, including the reason for transfer/discharge, effective date, and receiving location for one of three residents reviewed for closed records (Resident 102). This deficient practice resulted in incomplete documentation of discharge information, which could impair coordination of care and continuity of services for Resident 102. Findings: During a review of Resident 102's Face Sheet, the Face Sheet indicated the facility admitted Resident 8 on 12/06/2025 with diagnoses including hypertension (HTN, high blood pressure), asthma (condition where the airways in the lungs become swollen and narrow, making it hard to breathe), dislocation of left hip, hypotension (low blood pressure), and hypothyroidism (condition where the thyroid gland [a small gland in the neck] does not make enough hormones and causes the body to slow down). The Face Sheet indicated Resident 102 was discharged from the facility on 2/3/2026. During a review of Resident 102'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 accurately (in a correct or exact manner) complete a smoking and safety assessment (a tool used to measure and interpret information) for one of two sampled residents (Resident 7) reviewed under the Smoking care area. This failure resulted in missing information on the assessment used to determine whether Resident 7 could safely smoke independently or required assistance and supervision. Findings:During a review of Resident 7's Face Sheet, the Face Sheet indicated the facility admitted Resident 7 to the facility on [DATE] with diagnoses (illness or problem) including schizophrenia (a mental illness that is characterized by disturbances in thought), major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, and difficulty walking. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognition (the process of acquiring knowledge and understanding through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of 19 residents investigated under Care Planning. Specifically, the facility failed to include and address the following in the care plan: a. Vascular Dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, often following a stroke or chronic vessel damage) diagnosis, which requires individualized interventions to address safety, cognition, and supervision needs.b. Eliquis (Apixaban- a prescription oral anticoagulant (blood thinner) that lowers the risk of stroke in people) carrying a Black Box Warning (the highest safety-related warnings that medications can have assigned by the Food and Drug Administration) which require monitoring, safety precautions, 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:1. Update and revise a resident`s care plan (CP- a document outlining a detailed, individualized approach to care tailored to a resident's specific needs) to reflect that breakfast should not be left at the bedside until the resident awakens, for one of four sampled residents (Resident 20) reviewed under the Nutrition care area.This deficient practice had the potential to place Resident 20 at risk, as the resident consistently wakes approximately four hours after breakfast is served. Leaving food at the bedside for this duration could promote harmful bacterial growth, increasing the risk of foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals).2. Update and revise a resident's CP to reflect interventions (actions taken to improve a situation or medical condition) for safe smoking practices for one of four sampled residents (Resident 7) reviewed under the Accidents care area.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 a resident with visual impairment was provided with assistive devices to help one of one sampled resident communicate his needs to the care team (Resident 93) investigated under the care area Vision and Hearing. This deficient practice had the potential to result in frustration and unmet needs if the resident is unable to express his care needs.Findings:During a review of Resident 93's admission Record, the admission Record indicated the facility originally admitted the resident on 1/9/2015 and readmitted on [DATE] with diagnosis including dementia ( a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and blepharitis ( a common, chronic inflammation of the eyelids, often caused by bacterial overgrowth, clogged oil glands, or skin conditions like rosacea, leading to red, itchy, flaky, and crusty eyelids). During a review of Resident 93's…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per physician`s order for one (Resident 54) of two sampled residents investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure).This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.Findings:During a review of Resident 54's admission Record, the admission Record indicated the facility admitted the resident on 3/24/2026 with diagnoses including depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy) and sepsis (a life-threatening complication of an infection).During a review of Resident 54's History and Physical (H&P) dated 3/25/2026, the H&P indicated that the resident is alert and oriented x 2 (indicates a patient is awake and aware of their identity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate continence care and interventions for one of five sampled patients (Resident 98). This deficient practice had the potential to result in a decline from continence to incontinence, increased skin breakdown and pressure injuries, compromised dignity and quality of life and an increase in urinary tract infections.Findings:During a review of Resident 98's Face Sheet, the Face Sheet indicated the facility admitted Resident 98 on 12/20/2022 with diagnoses including multiple sclerosis (MS, a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord), type 2 diabetes mellitus (DM II, body does not use insulin properly, causing sugar to build up in the blood instead of being used for energy), polyneuropathy (many nerves in the body are damaged, causing numbness, tingling, or weakness, usually in the hands and feet), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hyperlipidemia (condition where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral feeding (a feeding tube that provides liquid nutrition directly into the stomach) was properly labeled for medication and solution and failed to administer timely prescribed enteral feeding for one of five sample residents (Resident 8).This deficient practice had the potential to result in administering the wrong formula or contaminated fluid, placing patients at risk for gastrointestinal infection (inflammation or irritation of the digestive tract), fluid imbalance (body has either too much or too little fluid for proper function) or aspiration (accidental inhalation of food, liquids, or saliva into the lungs) for Resident 8.Findings:During a review of Resident 8's Face Sheet, the Face Sheet indicated the facility admitted Resident 8 on 3/11/2025 with diagnoses including cerebral palsy (condition that affects how a person moves, balances, and controls their muscles), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled resident (Resident 31), who required hemodialysis (HD or dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment, received care in accordance with standards of practice by failing to: Update a resident's care plan for hemodialysis to address a resident's repeatedly elevated blood creatinine (a waste product from muscle metabolism, filtered from the blood by the kidneys, normal reference range is 0.73 to 1.30 milligrams per deciliter [mg/dL, a unit of measure for kidney function]) blood laboratory (labs) level. Ensure there was information exchanged between the facility and the hemodialysis center when the Resident 31's creatinine was elevated. This deficient practice had the potential for Resident 31 to have unidentified complications after dialysis treatment such as fatigue, swelling (edema) in legs/feet, and confusion. Findings: During a…

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

Based on interview and record review the facility failed to ensure residents were free from significant medication errors by failing to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a medication that helps regulate blood sugar levels) injections sites on multiple occasions between 2/4/2026 and 4/5/2026 for one of five sampled residents (Residents 85) investigated under the care area of unnecessary medications.This failure had the potential to result in bruising, pain, and/or lipodystrophy (a buildup or abnormal distribution of fatty tissue under skin) for Resident 85. Findings:During a review of Resident 85's Face Sheet, the Face Sheet indicated the facility admitted Resident 85 on 1/26/2026 with diagnoses that included but not limited to type 2 diabetes mellitus (DM - a chronic medical condition where the body cannot use insulin properly and eventually fails to produce enough insulin, leading to high blood sugar levels) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys [bean-shaped organs, typically two in number, located in the back of the abdomen] stop working properly) residents received care in accordance with standards of practice for two of three sampled residents (Resident 1 and Resident 2) by failing to ensure that Post Dialysis Assessments (refers to evaluations conducted after a dialysis treatment to monitor a resident's condition and effectiveness of the dialysis process) were accurately and completely documented. This deficient practice had the potential to result in an increased risk of harm due to potential undetected post-dialysis complications. a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 2/5/2024 and readmitted Resident 1 on 3/26/2025 with diagnosis including end stage renal disease (ESRD- a severe, permanent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prescribed renal diet (a specialized diet designed for residents with kidney [bean-shaped organs, typically two in number, located in the back of the abdomen] disease) for two of three sampled residents (Resident 2 and Resident 3) as outlined in the facility's printed menu by serving broccoli instead of green beans, rice instead of wheat pasta, and omitting the parsley garnish on the resident's plate. This deficient practice had the potential to result in residents receiving foods high in potassium (a vital mineral [electrolytes] that the body needs for various functions, including nerve and muscle function, maintaining a regular heartbeat, and transporting nutrients in and out of cells, also crucial for regulating blood pressure), phosphorus (a mineral that needs careful management due to its impact on kidney health) which can contribute to serious complications such as electrolyte imbalances (occur when the levels of essential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of three sampled residents (Resident 3) food preferences were honored when rice, a documented disliked food item, was served during lunch on 7/29/2025. This deficient practice resulted in Resident 3 being served rice, which had the potential to lead to decreased food intake and subsequent weight loss. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 5/29/2025 with diagnosis including end stage renal disease (ESRD- a severe, permanent condition where the kidneys can no longer adequately filter waste and excess fluid from the blood, requiring either dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys {bean-shaped organs, typically two in number, located in the back of the abdomen} stop working properly] or a kidney transplant for survival) and dependence on renal (kidney) dialysis. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 6/4/2025, 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 observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure dietary staff did not have their personal cell phone in the preparation area for one of three sampled staff. This deficient practice had the potential to result in foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages) and had the potential of spreading infection for 95 out of 95 in-house residents living in the facility.During an observation on 7/29/2025 at 12:30 p.m., in the kitchen, observed DA's personal cell phone in the food preparation area. During a concurrent observation and interview on 7/29/2025 at 12:31 p.m., in the kitchen, observed DA reaching for her (DA) personal cellphone, which was located on the food preparation area. The DA stated that the cellphone belonged to her (DA) and stated that cellphone should not have been in the food preparation area. DA stated, I'm sorry. During an interview on 7/29/2025 at 2:18 p.m., with the Registered Dietician (RD), the RD stated that personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate and complete medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by: 1. Failing to document the correct time on Resident 1's Resident Transfer Record. 2. Failing to ensure Resident 1's Resident Transfer Record was complete. These deficient practices had the potential to result in confusion regarding Resident 1's health status at the time of transfer and placed Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), anxiety disorder (mental health condition characterized by persistent and excessive worry, fear, and nervousness 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 interview and record review, the facility failed to: 1. Ensure the Discharge Summary (a concise, written document that summarizes a patient's hospital stay, outlining the care received and the patient's condition upon discharge) included a recapitulation of the resident's stay for one of four sampled residents (Resident 1). 2. Ensure the Post Discharge Plan of Care was completed for one of four sampled residents (Resident 1). 3. Ensure discharge planning was part of the comprehensive care plan for one of four sampled residents (Resident 1). These deficient practices had the potential to cause confusion regarding the care and services rendered to Resident 1 and could cause a delay in the continuity of care after Resident 1's discharge. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included rhabdomyolysis (a condition that causes your muscles to break down and release its contents into the blood, causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) assessment was conducted for one of four sampled residents (Resident 1). This deficient practice had the potential to result in delayed identification of underlying trauma-related issues, which could compromise resident care, delay appropriate referrals, and negatively impact resident outcomes. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included rhabdomyolysis (a condition that causes your muscles to break down and release its contents into the blood, causing kidney damage), dementia (a progressive state of decline in mental abilities) and history of malignant neoplasm (known as cancer, a type of tumor characterized by uncontrolled, abnormal growth of cells that can invade surrounding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. 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 two of four sampled residents (Resident 2 and 4) to address the residents' low air loss mattress (LALM - a specialized mattress designed to prevent and treat pressure ulcers [a localized injury to the skin and underlying tissue caused by pressure, friction, or shear]) setting levels and modes. 2. To implement the fall care plan interventions specifically the continued use of a landing mat (also known as floor mat - a safety device placed on the floor beside a bed to help prevent or reduce injury if a resident falls out of bed) for one of three sampled residents (Resident 3). These deficient practices had the potential to negatively affect the delivery of care and services. Findings: 1.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 notify one of five sampled residents (Resident 1) physician, when on 1/1/2025, Resident 1 had a critically low blood sugar reading (normal blood sugar level is between 70 and 99 milligrams per deciliter [mg/dl - unit of measurement used to express the concentration of a blood sugar]) of 45 mg/dl. This deficient practice placed Resident 1 at risk for untreated hypoglycemia (low blood sugar level) which can lead to adverse effects such as dizziness, falls or further hypoglycemic episodes. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 8/29/2024 and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder in which the body does not produce enough insulin [a hormone produced by the pancreas that helps regulate blood sugar levels] causing blood sugar levels to be abnormally high), morbid obesity (a chronic condition characterized 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 a resident ' s low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) was set to the correct setting for two of three sampled residents (Resident 2 and Resident 4). This deficient practice had the potential to place the residents at risk for discomfort and development of pressure ulcers/injuries. Findings: a. During a review of Resident 2 ' s admission Record, the admission Record indicated that the facility originally admitted the resident on 7/17/2023 and readmitted the resident on 5/8/2025 with diagnoses that included diabetes mellitus (DM -(a chronic condition that affects the way the body processes blood glucose [sugar]) and acquired absence of left leg above knee and right leg above knee. During a review of Resident 2 ' s Minimum Data Set (MDS - a…

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

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of four sampled residents (Resident 4). This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 7/10/2016 with diagnoses including seizures (a sudden, temporary disruption in brain electrical activity that can cause involuntary changes in body movement, behavior, sensation, or awareness), hypothyroidism (a condition where the thyroid gland [butterfly shape in front the neck which regulates growth and development] does not produce enough thyroid hormones [body's chemical messengers that coordinate different functions in your body] to support the body's normal function), and osteoporosis (a disease in which your bones become weak and are likely to fracture [break]). During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect by failing to ensure a staff member knocked on a resident's door prior to entering a resident's room for four of four sample residents (Resident 77, Resident 70, Resident 2, and Resident 49). This deficient practice had the potential to affect Resident 77, Resident 70, Resident 2, and Resident 49's self-esteem and self-worth. a. During a review of Resident 77's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2024 with diagnoses that included unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic (a mental disorder characterized by a disconnection from reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 77'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 develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for two of two sampled residents (Resident 25 and Resident 15), who were observed with a bed pad alarm (a device that uses a pressure-sensitive pad placed underneath the resident to alert caregivers when a person attempts to get up without assistance This deficient practice had the potential to negatively affect the delivery of care and services to Resident 25 and Resident 15. Findings: a. During a review of Resident 25's admission Record, the admission Record indicated the facility readmitted Resident 25 on 8/20/2017 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 25's Minimum Data Set (MDS- an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Provide an environment free from accidents and hazards for one of seven residents (Resident 7) reviewed under the accidents care area by failing to ensure Resident 7 did not store medications at bedside readily accessible to other residents. This deficient practice had the potential to result in residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents. 2. Implement the facility's policy on personal alarms as evidence by the facility not presenting documented evidence of checking the residents' bed pad alarm (a device that uses a pressure-sensitive pad placed underneath the resident to alert caregivers when a person attempts to get up without assistance) daily for functionality for two of seven residents (Resident 15 and Resident 25) reviewed under the accidents care area. This deficient practice has the potential to place Resident 15 and Resident 25 at risk for injuries 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: 1. Drugs and biologicals were stored in accordance with accepted professional principals when an expired first aid kit (a portable collection of supplies and equipment designed to provide immediate medical assistance for minor injuries and emergencies) was not removed and disposed of from the only Medication Storage Room inspected during the investigation of medication storage and labeling. This deficient practice had the potential for the use of less effective medications or supplies which may not produce the expected results. 2. Medication cart was locked while the medication cart was left unattended for one of two sampled medication carts (Covid Unit Cart) This deficient practice had the potential for unsafe nursing practices and unauthorized entry to the medication cart, which could result in a negative impact to the health, and well-being of residents and increases the risk of contamination. Findings: 1. During a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure Treatment Nurse 1 (TN 1) removed their isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) prior to leaving a resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of 13 sampled residents (Resident 86). 2. Ensure a trashcan was provided to doff (take off) PPE inside a resident's room who was under droplet isolation (used to prevent the spread of pathogens that are passed through 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for two out of two sampled residents (Resident 13 and Resident 6) investigated under the environment care area. This deficient practice had the potential to result in the residents being unable to ask health care workers for assistance with care and services as needed. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 12/19/2014 and readmitted on [DATE] with diagnoses including end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), heart failure (heart muscle cannot pump enough blood to meet the body's needs), and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete baseline care plan within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) care interventions for one of one sampled resident (Resident 85) reviewed under the indwelling catheter care area. This deficient practice had the potential for Resident 85 not to receive appropriate care and treatment in the facility. Findings: During a review of Resident 85's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 1/23/2025 and readmitted on [DATE] with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), obstructive uropathy (a blockage in the urinary tract that prevents urine from draining normally), and reflux uropathy (when urine flows backward into 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 residents receive treatment and care in accordance with professional standards of practice by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) injection sites to one of one sampled residents (Resident 41) reviewed under the unnecessary medication- anticoagulant (medications that help prevent blood clots from forming or getting bigger) care area. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of anticoagulant such as lipodystrophy (abnormal distribution of fat), bruising and pain. Findings: During a review of Resident 41's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including muscle weakness, chronic obstructive pulmonary disease (COPD-a lung disease that block airflow and make it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 15) whose primary language was not English. This deficient practice had 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 15's admission Record, the admission Record indicated the facility readmitted Resident 15 on 1/14/2015 with diagnoses that included history of falling. Resident 15's admission Record indicated primary language: Arabic (foreign language). During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 1/21/2025, the MDS indicated Resident 15's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making were 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 observation, interview, and record review, the facility failed to: 1. Ensure that residents receive continuous oxygen as ordered by their physician for two of five sampled residents (Resident 16 and Resident 39) reviewed under the respiratory care area. This deficient practice had the potential to cause Resident 16 and Resident 39 to have shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood). 2. Ensure residents' oxygen tubing was dated as indicated in the facility's policy and procedure for two of five sampled residents (Resident 39 and 87) reviewed under the respiratory care area. This deficient practice had the potential to place the residents at increased risk of developing an infection. Findings: 1.a. During a review of Resident 16's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 6/11/2023 and readmitted on [DATE], with diagnoses including acute (appear rapidly) respiratory failure (a serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the physician's order for fluid restriction (limiting the amount of liquid a person consumes daily, often prescribed to manage kidney disease) limited to no water pitcher at bedside for one of two sampled residents (Resident 33) reviewed under dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care area. This deficient practice had the potential to place Resident 33 at risk for fluid overload (a condition where you have too much fluid volume in your body) which can result in health complications. Findings: During a review of Resident 33's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 12/4/2024 and readmitted on [DATE] with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five (5) percent. Nine medication errors out of 28 opportunities contributed to an overall medication error rate of 32.14 percent (%) affecting one of five randomly selected residents (Resident 44) observed for medication administration. The medication errors were as follows: Resident 44 received anastrazole (a medication used to treat breast cancer), bupropion (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]), carvedilol (a medication used to high blood pressure), furosemide (a medication used to treat buildup of fluid in the body), sertraline (a medication used to treat depression), Vitamin C (a type of vitamin), thiamine (a type of vitamin), multivitamin with mineral, and magnesium oxide ( a type of supplement) at times different than ordered by the physician. These failures had the potential for Resident 44 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 observation, interview, and record review, the facility failed to ensure leftover food brought to residents by family and other visitors were labeled with resident identifier and use by date for two of two (Resident 50 and 82) sampled residents. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) among the residents. Findings: a. During a review of Resident 50's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including muscle chronic kidney disease (a progressive and long-term decline in kidney function) and hypertension (high blood pressure). During a review of Resident 50`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/19/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 social services department conducted residents ' psychosocial assessments upon admission for two of three sampled residents (Resident 2 and Resident 3) and failed to make follow up calls to residents after they were discharged home for three of three sampled residents. (Resident 1, Resident 2 and Resident 3) These deficient practices had the potential to result in negative psychosocial outcomes a for Resident 2 and Resident 3 and had the potential to result in an unsafe discharge for Resident 1, Resident 2 and Resident 3. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 1/20/2025 with diagnoses that included non-displaced fracture (broken bone) of base of neck of the right femur (hip), history of falling, and difficulty in walking. During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) 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.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by failing to document efforts of calling the physician after Resident 1's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) was more than 100 beats per minute (bpm) on 1/8/2025, 1/13/2025, 1/15/2025, 1/16/2025, and 1/20/2025. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility readmitted Resident 1 on 11/4/2024 with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), presence of cardiac pacemaker (small device that's implanted [placed] in the chest to help control the heartbeat) and type two (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 interview and record review, the facility failed to ensure there was an adequate indication for the use of ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]) for one of three sampled residents (Resident 1) not diagnosed with scabies (itchy skin condition caused by infestation with small mites that live under the skin). This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility readmitted Resident 1 on 11/4/2024 with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), presence of cardiac pacemaker (small device that's implanted [placed] in the chest to help control the heartbeat) and type two (2) diabetes (a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nurse staff completed reconciliation (a process that validates the controlled substance [medication with a high potential for abuse] amount at the end of a shift is the amount expected) of controlled medications for one of four medication carts (Medication Cart A). This deficient practice had the potential to result in inaccurate reconciliation of controlled medication and placed the facility at risk for the inability to readily identify loss and drug diversion (the illegal distribution of prescription drugs for unintended purposes) of controlled medications. Findings: During a concurrent interview and record review on 12/27/2024 at 11:09 a.m., with Licensed Vocational Nurse 2 (LVN 2) for Medication Cart A, reviewed the Controlled Drugs Accountability Sheet (CDAS) for the month of 11/2024 and 12/2024. LVN 2 stated there were gaps not signed by two licensed nurses on the following dates: - On 11/5/2024: 3 p.m.-11 p.m. shift - On 11/9/2024: 7 a.m.-3 p.m. shift and 3 p.m.-11 p.m. shift - On 11/16/2024: 7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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/her need for assistance from staff) was within reach for two of six sampled residents (Resident 1 and 2). 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 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/17/2023 and readmitted the resident on 12/25/2024 with diagnoses that included acquired absence of left leg above knee and right leg above knee, pressure ulcer/injury (PU/PI) stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral (the bony region at the very base of your spine and just above the tailbone) region, obstructive uropathy (a condition in which the flow of urine is blocked ), and reflux uropathy (a condition that occurs when urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 no more than two layers of linen were used with the use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) for one of two sampled residents (Resident 1). This deficient practice had the potential to increase the resident's risk of skin breakdown. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/17/2023 and readmitted the resident on 12/25/2024 with diagnoses that included acquired absence of left leg above knee and right leg above knee, pressure ulcer/injury (PU/PI) stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral (the bony region at the very base of your spine and just above the tailbone) region, obstructive uropathy (a condition in which the flow of urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement infection control practices by failing to ensure a resident's indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) tubing was not touching the floor for one of two sampled residents (Resident 1). This deficient practice had the potential to result in the spread of germs placing the resident with an indwelling urinary catheter at risk for infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/17/2023 and readmitted the resident on 12/25/2024 with diagnoses that included acquired absence of left leg above knee and right leg above knee, pressure ulcer/injury (PU/PI) stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral (the bony region at the very base of your spine and just above the tailbone) region, obstructive uropathy (a condition in which the flow of urine is blocked ),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 having long fingernails that had the potential to result in self-injuries such as skin cuts or scratches and a negative impact on the resident's self-esteem and self-worth. Findings: During a review of Resident 1's admission Record, the document indicated the facility admitted the resident on 9/7/2024 with diagnoses that included urinary tract infection (an infection in any part of the urinary system) and adult failure to thrive (AFTT - a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/13/2024, the document indicated Resident 1's cognition (mental action or process of acquiring knowledge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 History and Physical (H&P - contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status [ability to understand and make decisions]) Examinations for two of four sampled residents (Resident 1 and Resident 3) were completed in its entirety by the physician by failing to assess for mental status. This deficient practice had the potential for inconsistent care coordination due to incomplete H&P and a delay in care and services. Findings: a. During a review of Resident 1's admission Record, the document indicated the facility admitted the resident on 9/7/2024 with diagnoses that included urinary tract infection (an infection in the any part of the urinary system) and adult failure to thrive (AFTT - 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 licensed nurse documented the administration of Tylenol (medication used to relieve pain and fever) on the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for one of three sampled residents (Resident 2) on 8/26/2024. This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services. Findings: During a review of Resident 2's admission Record, the document indicated the facility originally admitted the resident on 7/22/2022 and readmitted the resident on 8/28/2024 with diagnoses that included multiple fractures (a complete or partial break in a bone) of ribs, left side, subsequent encounter for fracture with routine healing and difficulty walking. During a review of Resident 2's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 6/22/2024, the document indicated Resident 2 had moderately impaired cognition (mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 (CNA 1) donned (put on) gloves and a gown, prior to entering a contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) room for one of three sampled residents (Resident 3). This deficient practice had the potential for the spread of infection and cross contamination among residents. Findings: During a review of Resident 3's admission Record, the document indicated the facility originally admitted the resident on 8/29/2024 with diagnoses that included unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and methicillin-resistant Staphylococcus aureus infection (MRSA- caused by a type of staph [type of bacteria] bacteria that's become resistant to many of the antibiotics used to treat staph infections). During a review of Resident 3's Minimum Data Set (MDS- an assessment and screening tool) dated 9/4/2024, the document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report two suspected cases of scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching), and one confirmed case of scabies, for three of five sampled residents (Residents 1, Resident 2, and Resident 4). This deficient practice had the potential to result in the spread of scabies 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 review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/25/2024 with diagnoses that included acute cholecystitis (swelling of the gallbladder [organ that stores and release a fluid to help digest food]) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that damage the airways or other parts 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) was provided with a discharge summary report that included information regarding Resident 1 ' s current skin condition upon discharge home. This deficient practice had the potential to result in unsafe discharge, incomplete documentation, and communication of Resident 1's stay in the facility. Findings: During a review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 5/25/2024 with diagnoses that included acute cholecystitis (swelling of the gallbladder [small, pear-shaped organ that stores and releases bile [is the fluid the liver produces that helps digest fats in the food a person eats]) and chronic obstructive pulmonary disease (COPD - common lung disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-planning tool) dated 5/31/2024, indicated Resident 1 ' s cognition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of practice by: 1. Failing to ensure licensed nurses rotated injection sites when administering insulin (a hormone that works by lowering levels of glucose [sugar] in the blood) to one (Resident 39) out of five residents sampled for unnecessary medications. 2. Failing to ensure a resident's orthostatic blood pressure (taking a blood pressure [BP] lying down flat, sitting up, and standing up to ensure a resident does not have orthostatic hypotension [a form of low blood pressure that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting]) was taken when the resident was lying flat for one (Resident 17) of five residents sampled for unnecessary medications. These deficient practices had the potential to place Resident 39 at increased risk of developing lipodystrophy (a group of conditions characterized by a complete or partial loss of fat tissue) 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 proper food handling and storage practices by failing to ensure food kept in the refrigerator designated for residents' foods was dated and maintained according to the facility's policy for four of seven sampled residents (Resident 7, 8, 29, and 61). This deficient practice had the potential to result in food borne illness (when contaminated food is consumed which causes an infection resulting illness). Findings: a. A review of Resident 7's admission Record indicated the facility admitted the resident on 8/7/2023 with diagnoses that included gastro-esophageal reflux disease (GERD- stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach). A review of Resident 7's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/22/2024, indicated Resident 7 was moderately impaired in 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 maintain accurate medical records for one of one sampled resident (Resident 45), as evidenced by licensed nurses documenting the incorrect arm for taking blood pressure readings on Resident 45. This deficient practice had the potential to result in confusion regarding Resident 45's condition and what care and services were provided to Resident 45. Findings: A review of Resident 45's admission Record indicated the facility admitted the resident on 8/20/2023 with diagnosis of end stage renal disease (ESRD- chronic irreversible kidney failure) requiring renal (kidneys) dialysis (a treatment that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly). A review of Resident 45's History and Physical (H&P- a term used to describe a physician's examination of a resident) indicated Resident 45 had the capacity to understand and make decisions. A review of Resident 45's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 2/26/2024, indicated Resident 45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3.a. A review of Resident 46's admission Record indicated the facility admitted the resident on 6/20/2021 with diagnosis including emphysema (a lung condition that causes shortness of breath from lung damage). A review of Resident 46's MDS dated [DATE], indicated the resident required oxygen while at the facility. A review of Resident 46's physician's orders, dated 6/20/2021, indicated an order to change the oxygen nasal cannula tubing every Sunday night and as needed. During a concurrent observation and interview on 5/13/2024 at 9:19 a.m., with Licensed Vocational Nurse 4 (LVN 4) and the DON, observed Resident 46's nasal cannula oxygen tubing not labeled with a date. LVN 4 and the DON stated Resident 46's nasal cannula oxygen tubing was not dated. The DON stated the nasal cannula oxygen tubing should be dated when oxygen tubing is placed on the resident. 3.b. A review of Resident 187's admission Record indicated the facility admitted the resident on 5/10/2024 with diagnosis including 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.

Based on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a patient to signal his/her need for assistance from staff) was within reach for one of 20 sampled residents (Resident 188). This deficient practice had the potential to cause a delay in resident care and for the resident's needs to remain unmet. Findings: A review of Resident 188's admission Record indicated the facility admitted the resident on 5/6/2024 with diagnoses including acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), difficulty in walking, generalized muscle weakness, and repeated falls. A review of Resident 188's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/31/2024, indicated the resident had moderately impaired cognition (thought processes) and required maximum assistance from staff for toileting hygiene. A review of Resident 188's Fall Risk Assessment, dated 5/7/2024, indicated the resident was at high risk for falls. 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 observation, interview, and record review, the facility failed to provide a homelike environment for one of six residents (Resident 8) when the paint was found peeling and/or missing in three areas of Resident 8's bedroom ceiling. The deficient practice violated Resident 8's right to a comfortable, homelike environment and had the potential to cause psychosocial harm. Findings: A review of Resident 8's admission Record indicated the facility admitted the resident on 1/22/2024 with diagnoses that included heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), depression (a mood disorder that may cause persistent sadness or loss of interest in activities), and osteoarthritis (deterioration of the joint that causes pain and stiffness) of both knees. A review of Resident 8's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 2/2/2024, indicated Resident 8 had the capacity to understand and make decisions. A review of Resident 8's Minimum Data Set (MDS, a standardized 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 develop and implement a comprehensive care plan (CP- a written document that summarizes a patient's needs, goals, and care) for one of one sampled residents (Resident 45), to include measurable objectives and timeframes to care for Resident 45's left forearm arteriovenous shunt (AV shunt- a surgical connection between an artery and a vein that allows for blood to be removed and returned during dialysis [a treatment that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly]). This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 45's admission Record indicated the facility admitted the resident on 8/20/2023 with diagnosis of end stage renal disease (ESRD- chronic irreversible kidney failure) requiring renal (kidneys) dialysis. A review of Resident 45's History and Physical (H&P- a term used to describe a physician's examination of a resident) indicated Resident 45 had the capacity to understand 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 one of 20 sampled residents (Resident 61) smoked in the facility's designated area, the westside patio, and not in the outdoor activity area that was surrounded with flammable substances. This deficient practice had the potential to result in burns damaging Resident 61's skin, fire, and explosion. Findings: A review of Resident 61's admission Record indicated the facility admitted the resident on 7/7/2022 and readmitted on [DATE] with a diagnosis including, but not limited to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and difficulty walking. A review of Resident 61's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/30/2024, the MDS indicated the resident required partial and or moderate assistance to walk 50 feet with two turns. During a review of Resident 61's care plan, dated 1/12/2023, the care plan indicated the resident…

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

Based on interview and record review, the facility failed to ensure that the physician signed the Physician Order for Life- Sustaining Treatment (POLST - a written medical that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of one sampled resident (Resident 45) on 8/20/2023. This deficient practice had a potential to cause conflict with the resident's or resident's representatives wishes regarding health care in the event of an emergency. Findings: A review of Resident 45's admission Record indicated the facility admitted Resident 45 on 8/20/2023 with diagnosis of end stage renal disease (ESRD- chronic irreversible kidney failure) requiring renal (kidneys) dialysis (a treatment that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly). A review of Resident 45's History and Physical (H&P- a term used to describe a physician's examination of a resident and includes a history of a resident's medical issues)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse 7 (LVN 7) administered aspirin (stops the production of certain natural substances that cause fever, pain, swelling, and blood clots [gel-like clumps of blood]) 325 milligrams (mg - unit of measurement) instead of aspirin 81 mg to one of 20 sampled residents (Resident 190), as ordered by the physician. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) such as developing blood clots. Findings: A review of Resident 190's admission Record indicated the facility admitted the resident on 5/2/2024 with diagnoses including cerebral infarction (stroke, damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (a severe or complete loss of strength or paralysis on one side of the body), stage three (3) chronic kidney disease (occurs when the kidneys have moderate damage and are less able to filter waste and fluid from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nurses monitored a resident's targeted behavior for the use of quetiapine (an antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of 20 sampled residents (Resident 39). This deficient practice had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition. Findings: A review of Resident 39's admission Record indicated the facility originally admitted the resident on 8/28/2021 and readmitted the resident on 5/8/2024 with diagnoses including schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves] and a mood disorder [marked disruptions in emotions]). A review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of one sampled resident's (Resident 63) insulin (a hormone that lowers the level of glucose [sugar] in the blood) stored in the refrigerator of Medication room [ROOM NUMBER] was stored under the temperature range of 36-46 degrees Fahrenheit (F- unit of temperature). 2. Label an opened medication bottle of hydromorphone solution (a drug used to relieve moderate to severe pain) with an opened by date for one of one sampled resident (Resident 187). These deficient practices had the potential to diminish the effectiveness of the medications. Findings: 1. A review of Resident 63's admission Record indicated the facility admitted the resident on 4/9/2024 with diagnosis of diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]) and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood.) A review of Resident 63's physician's orders indicated an order 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 implement its abuse prevention policy for one of four sampled residents (Resident 1) by failing to provide one to one abuse training for Certified Nurse Assistant 3 (CNA 3) who was directly involved in an abuse allegation made by Resident 1. This deficient practice placed Resident 1 at increased risk for abuse. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included cerebral infarction (stroke, occurs as a result of disrupted blood flow to the brain), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar [glucose] as a fuel), anxiety (involves persistent and excessive worry that interferes with daily activities) disorder, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood 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 notify the physician and the resident's responsible party, following an unwitnessed fall once the resident was found lying on the floor for one of two sampled residents (Resident 3). This deficient practice had the potential to have a negative effect on Resident 3's treatment if any decisions were needed at the time of the change of condition. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 8/29/2023 with diagnosis that included atrial fibrillation (an irregular and often very rapid heart rhythm), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), cord compression (condition that puts pressure on your spinal cord [the long, cylindrical structure that connects your brain and lower back]), difficulty in walking, and abnormal posture. A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/4/2023, indicated Resident 3's cognition (a mental process of acquiring knowledge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the needed care and services that were resident centered, for one of two sampled residents (Resident 3), as evidenced by: 1. Failing to ensure a Change of Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) was documented and completed after Resident 3 had an unwitnessed fall and was found lying on the ground. 2. Failing to ensure a 72-hour neuro-check (assessment to determine nervous system [brain, spinal cord, and a complex network of nerves] function) was immediately initiated after Resident 3 had an unwitnessed fall. These deficient practices had the potential to result in confusion in the care and services for Residents 3, which could place the resident at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 8/29/2023 with diagnosis that included atrial fibrillation (an…

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

Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (mattress designed to prevent and treat pressure wounds [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) was on the proper setting per manufacture's guidelines for one of two sampled residents (Resident 3). This deficient practice had the potential to place residents at risk for developing or worsening pressure wounds. A review of Resident 3's admission Record indicated the facility admitted the resident on 8/29/2023 with diagnosis that included atrial fibrillation (an irregular and often very rapid heart rhythm), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), cord compression (condition that puts pressure on your spinal cord [the long, cylindrical structure that connects your brain and lower back]), difficulty in walking, and abnormal posture. A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/4/2023, indicated Resident 3's…

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

Based on observation, interview, and record review, the facility failed to ensure licensed nurses did not leave medications at residents' bedside unattended for one of two sampled residents (Resident 3). This deficient practice had the potential to result in theft and loss of medication with the potential to harm residents by accidental administration of medications. Findings: A review of Resident 3's admission Record indicated the facility admitted the resident on 8/29/2023 with diagnosis that included atrial fibrillation (an irregular and often rapid heart rhythm), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and difficulty in walking. A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/4/2023, indicated Resident 3's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. During a concurrent observation 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 readmit one of three sampled residents (Resident 1) to the facility after hospitalization. Resident 1 was discharged to a different nursing facility after their hospitalization. This deficient practice violated Resident 1's rights to return to their facility and resulted in Resident 1's displacement in an unfamiliar facility requiring adjusting to new surroundings. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/7/2023 with diagnosis of schizophrenia (a mental disorder characterized by hallucinations [seeing things that are not there], delusions [believing something is true when it's not], and disturbances in thought, perception [process of thinking] and behavior). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/14/2023, indicated the resident understood others and was understood by others. A review of Resident 1's physician's orders 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.