Hawthorne Healthcare & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor one of eight sampled residents (Resident 10) behaviors while prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).This deficient practice had the potential to result in the use of unnecessary psychotropic medication that could cause harm to Resident 10.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included paranoid schizophrenia (a chronic mental health disorder where a person experiences intense, irrational suspicion that is characterized by disturbances in thought), major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing).During a review of Resident 10'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 implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident, (Resident 12).This deficient practice had the potential to result in the delay of the identification of medical concerns, delaying the care and services necessary for Resident 12.Findings:During a review of Resident 12's admission Record, the admission Record indicated, Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included hypothyroidism (a condition when the thyroid gland [a butterfly-shaped or H-shaped gland located in the neck below the Adam's apple] does not make enough thyroid hormones to meet your body's needs), urinary tract infection ([UTI] - an infection in the bladder/urinary tract), and diabetes mellitus ([DM] - a disorder characterized by difficulty in blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow-up on dental service for new dentures for one of one sampled resident (Resident 30).This deficient practice had the potential to result in inability to chew food and weight loss for Resident 30.Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included dysphagia (difficulty swallowing), cerebral ischemia (a condition where blood flow to the brain is reduced or blocked), and epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures).During a review of Resident 30's Dental Progress Note, dated 9/3/2025, the Dental Progress Note indicated the dentist recommended a denture for Resident 30.During a review of Resident 30's History and Physical (H&P), dated 2/13/2026, the H&P indicated Resident 30 did not have the capacity to understand and make decisions.During a review of…

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

Based on interview and record review, the facility failed to ensure two out of two randomly selected Certified Nurse Assistant's (CNA] 1 and CNA 2) received mandatory effective communications training.This deficient practice had the potential to result in inadequate staff communication skills, which may negatively impact residents' quality of care.Findings:During a concurrent interview and record review on 3/26/2026 at 3:35 p.m. with the Director of Staff Development (DSD), CNA 1 and 2's personnel records were reviewed. The DSD stated CNA 1 was hired on 7/7/2025 and did not have evidence of effective communication training on file. The DSD stated CNA 2 was hired on 3/5/2026 and did not have evidence of effective communication training on file. The DSD stated she was responsible for providing effective communication training for all direct care staff. The DSD stated it was important to provide effective communication training for all direct care staff so staff could adequately interact with residents and other staff to ensure a good working environment and residents' safety.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 implement its policy and procedure (P&P) titled, Dietary Department-Infection Control. Dietary Aide 1 did not wear a hairnet while working in the kitchen. This failure had the potential for cross contamination and increase the risk of infections among residents. Findings: During an observation on 6/4/2025 at 1:50 p.m., with the Dietary Manager, Dietary Aide 1 was observed working in the kitchen without a hairnet. During a concurrent interview, Dietary Aide 1 stated she removed her hairnet as she was coming to the kitchen door. There was no hairnet was observed in Dietary Aide 1's hand. Dietary Aide 1 did not state how the lack of a hairnet may affect residents. The Dietary manager stated that not wearing a hairnet in the kitchen increased the risk of hair falling and cross contamination to foods and utensils. During a review of the facility policy and procedure titled, Dietary Department-Infection Control, dated 2/29/2024, indicated personal cleanliness was required in sanitary food preparation, clean working…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Obtain blood pressure readings to determine if three of three sampled residents (Resident 36, Resident 65 and Resident 75) have orthostatic hypotension (a form of low blood pressure that happens when standing after lying down or sitting). This deficient practice had the potential for Resident, 36, 65, and 75 to experience a delay in interventions if they were positive for orthostatic hypotension. Findings: a. During a review of Resident 36's admission Record (Face Sheet), it indicated Resident 36 was readmitted on [DATE] with diagnoses that included failure to thrive (someone who is not developing and growing normally), muscle weakness, muscle wasting (loss of muscle mass and strength), and hypotension (low blood pressure). During a review of Resident 36's Minimum Data Set ([MDS]- a resident assessment tool), dated 10/20/2024, the MDS indicated Resident 36 had severe cognitive impairment (ability to reason, understand, remember, judge, and learn).…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure the correct sized serving scoop was used for 29 of 29 residents on mechanical soft diets. This deficient practice had the potential for resident to receive the wrong caloric intake when not following the menu, resulting in decreased nutritional intake and weight loss. Findings: During an observation on 1/23/2025 at 12:00 p.m. in the kitchen, during serving of the lunch trays, [NAME] 1 (Cook 1) scooped the mechanical soft roast beef onto resident's plates using scoop size number 12 (one-third of a cup). During a review of Cooks Spreadsheet - Winter Menus, dated 1/23/2025, indicated ground roast beef for lunch required the use of scoop number 10 (three-eighths of a cup). During a review of facility list of residents on mechanical soft diets, dated 1/24/2025, indicated there were 29 residents on mechanical soft diets. During an interview on 1/23/2025 at 12:20 p.m. with [NAME] 1, [NAME] 1 stated that the number 12 scoop was used to serve the mechanical soft meat. [NAME] 1 stated the wrong scoop 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. Update the careplan for one of four sampled residents (Resident 79) after the resident self-removed his indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine into a drainage bag) on two occasions. This failure had the potential to cause complications such as urinary tract infections (UTI - an infection in the bladder/urinary tract), bleeding, and/or pain with urination. Findings: During a review of Resident 79's admission Record, the admission Record indicated the facility admitted Resident 79 on 11/15/2024 and re-admitted on [DATE], with diagnoses that included benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal and can slow or block the flow of urine from the bladder), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a mental health condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1. Complete a change of condition after Resident 79 self-removed his indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine into a drainage bag), for the second time. This failure resulted in Resident 79 not having a detailed explanation of what occurred and if the physician and responsible party was notified. Findings: During a review of the admission record, the admission record indicated Resident 79 was admitted to the facility on [DATE] and re-admitted [DATE], with diagnoses that included benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal and can slow or block the flow of urine from the bladder), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and unease that can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, the facility failed to: 1. Provide a smoking apron to Resident 17 for one of one saampled resident (Resident 17) as indicated on his care plan. This deficiency had the potential for the resident to burn himself. Findings: During a review of the admission record, the admission record indicated Resident 17 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement of the body), schizophrenia (a mental illness that can affect thoughts, mood, and behavior), and nicotine dependence (a highly addictive substance found in tobacco usually consumed through smoking cigarettes or using e-cigarettes). During a review of the Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 17 had the ability to express ideas and wants and had the ability to understand others. The MDS also indicated Resident 17 normally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1. Label a bottle of ClearLax (a medication used to treat occasional constipation), with the date opened. This failure had the potential to result in residents being administered expired medication that may be less effective, potentially leading to inadequate bowel movement relief. Findings: During an observation on [DATE] at 08:15 AM, Licensed Vocational Nurse (LVN) 1 administered medication from an opened bottle of ClearLax that was not labeled with the date it was opened. During an interview on [DATE] at 2:15 PM with LVN 1, LVN 1 stated, That bottle should have been labeled when it was first opened to know when to remove it from the cart after 30 days. Without knowing how long ago it was opened, there is no way to know if it would possibly be effective. Residents could be constipated if it does not work anymore. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated [DATE], the P&P indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure there was a comprehensive care plan for three out of twelve Residents (Resident 33, and 4). 1. The facility failed to have a comprehensive care plan for restraints (are devices that limit a patient's movement) care plan for Resident 4. 2. The facility failed to have a comprehensive care plan for an indwelling urinary catheter ([IDC] a tubing inserted into the bladder to collect urine) for Resident 33. These deficient practice placed Residents 33 and 4 at risk of not having their needs met. Findings: a. During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), respiratory failure (life-threatening condition of breathing failure that can occur in very ill people). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. During a review of Resident 69's admission record, dated 1/26/2024, the admission record indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included, encephalopathy (damage or disease that affects the brain), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 69's History and Physical (H&P) dated 10/1/2023, the H&P indicated that Resident 69 had the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set (MDS - a standardized resident assessment…

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

Based on observation, interview, and record review, the facility failed to provide food at a safe temperature for 11 of 11 residents two of twenty sampled (Residents 23 and 243). This finding had the potential to cause food borne illness (illness from contaminated food). This failure had the potential to call meal dissatisfaction, decreased food intake and place residents at risk for unplanned weight loss. Findings: During the kitchen lunch tray line observation on 1/23/2024 at 11:39 p.m., the facility thermometer was calibrated and used take food temperatures as follows: Meatloaf: 174 degrees Fahrenheit (F) Potato: scalloped 184 F Peas: 196 F During an observation and interview of lunch tray line on 12/24/2024 at 12:52 p.m., observed [NAME] 1 retrieve Styrofoam plates from the cabinet. [NAME] 1 then proceeded to use the Styrofoam plates to serve lunch to the remaining residents. Asked [NAME] 1why he switched from regular plates to Styrofoam plates. [NAME] 1 stated that the facility ran out of regular plates. During an observation and interview of the lunch tray line on 12/24/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure there was a revised care plan for using an Incentive Spirometer ([IS] a device that measures the volume of the air inhaled into the lungs during inspiration) for one out of six sampled Residents (Resident 3). This deficient practice had the potential to affect Resident 3's provision of care. Findings: During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Parkinson (a motor system that manifest as rigidity and tremors of the body), epilepsy (a sudden alteration in behavior due to temporary change in the electrical functioning of the brain), and schizophrenia (a severe mental illness characterized by disruptions in thinking, perception, emotions, and social interactions). During a review of Resident 3's History and Physical (H&P), dated 2/13/2023, the H&P indicated, Resident 3 can make needs known but cannot make medical decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide oral hygiene for one out of six Resident (Resident 4). The failure also resulted in the potential for dental problems and compromise resident's physical health and psychosocial well-being. Findings: During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), respiratory failure (life-threatening condition of breathing failure that can occur in very ill people). During a review of Resident 4's History and Physical (H&P, date unknown, the H&P indicated, Resident 4 does not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 9/23/2023, the MDS indicated, Resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of six Residents (Resident 3) had an incentive spirometer ([IS] a device used to expand the lungs to prevent respiratory infection) at bedside. This deficient practice of not having the IS device available for Resident 3 had the potential for a respiratory infection. Findings: During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Parkinson (a motor system that manifest as rigidity and tremors of the body), epilepsy (a sudden alteration in behavior due to temporary change in the electrical functioning of the brain), and schizophrenia (a severe mental illness characterized by disruptions in thinking, perception, emotions, and social interactions). During a review of Resident 3's History and Physical (H&P), dated 2/13/2023, the H&P indicated, Resident 3 can make needs known but cannot make medical decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consent from resident representative for having bedrails up for one out of six Residents (Resident 4). This failure had the potential to put residents at risk of falls and entrapment due to the use of side rails. Findings. During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), respiratory failure (life-threatening condition of breathing failure that can occur in very ill people). During a review of Resident 4's History and Physical (H&P, date unknown, the H&P indicated, Resident 4 does not have the capacity to understand and make decisions During a review of Resident 4's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 9/23/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 use the correct sized scoop for 11 of 11 residents receiving pureed (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) diets. These failures had the potential for a highly susceptible population of residents to be at risk for receiving meals that did not meet their nutritional needs. Findings: During an observation on 1/25/2024 at 12:29 p.m., in the kitchen, while serving lunch trays, observed [NAME] 1 searching for a scoop to serve the pureed meat loaf. [NAME] 1 briefly searched for a blue scoop and asked the dishwasher to find one. When the dishwasher was unable to find a blue scoop, [NAME] 1 then used a red scoop to serve the pureed meatloaf instead. During an interview on 1/25/2024 at 1:03 p.m. with [NAME] 1, Cook1 stated that he should have used a blue scoop for the pureed meat loaf, but he could not find another blue scoop. [NAME] 1 stated that he substituted the blue scoop for a red scoop. [NAME] 1 stated that a blue scoop is equal to 2.5…

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

Based on observation, interview, and record review, the facility failed to use the correct sized scoop for 11 of 11 residents on pureed (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) diets. These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference. Findings: During an observation on 1/25/2024 at 12:29 p.m., in the kitchen, while serving lunch trays, observed [NAME] 1 searching for a scoop to serve the pureed meat loaf. [NAME] 1 briefly searched for a blue scoop and asked the dishwasher to find one. When the dishwasher was unable to find a blue scoop, [NAME] 1 then used a red scoop to serve the pureed meatloaf instead. During an interview on 1/25/2024 at 1:03 p.m. with [NAME] 1, Cook1 stated that he should have used a blue scoop for the pureed meat loaf, but he could not find another blue scoop. [NAME] 1 stated that he substituted the blue scoop for a red scoop. [NAME] 1 stated that…

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

Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for residents by failing to: 1. Discard an open package of marshmallows with an open date of 12/24/2024. 2. Remove soiled disposable gloves and perform hand hygiene before picking up dinner rolls. These deficient practices had the potential to result in foodborne illnesses. Findings: During a concurrent observation and interview on 1/23/2024 at 8:40 p.m., with the Dietary Service Supervisor (DSS 1), while in the dry goods storage area of the kitchen, observed an opened package of marshmallows with an open date of 12/24/2023. DSS 1 was asked how long opened food items can be stored in the dry storage. DSS 1 stated that opened food should be discarded after two weeks. DSS 1 stated that he would discard the marshmallows right away because the marshmallows had been opened for over 2 weeks. DSS 1 stated that serving a resident food that has been opened for over 2 weeks can make them sick from food poisoning. During 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 standard infection control practices were followed by failing to wear gloves when one of three laundry aid staff wear gloves while handing soiled linens. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for all the residents in the facility. Findings: a. During an observation on 1/25/2024 at 9:43 a.m. in the laundry area, LA 1 used non-deposal glove when handling soiled linen, then placing soiled non disposal gloves on top of an overhead shelf and reusing the same non-disposal gloves again to sort a different cart of soil linen. b. During an observation on 1/25/2024 at 9:53 a.m. in the Laundry Area, LA1 picked up linen off the floor in the laundry area and place it on top of clean linen in the laundry cart which contain clean linen. During an interview on 1/25/2024 at 11:12 a.m. with MS. stated LA 1 should not be wearing non-disposable gloves. MS stated LA 1 did not disinfect the gloves prior to using them. MS stated he observed LA 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for one of three sample residents (Resident 1) by failing to develop a refusal of wearing a WanderGuard (is discreet powerful, triggering alarms and locking monitored doors to prevent wander-prone residents from leaving unattended) bracelet care plan for Resident 1 with high risk of elopement. This deficient practice had a potential to result in inconsistent implementation of the care plan that may placed Resident 1 at risk of inadequate supervision. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with a diagnosis that included Parkinson disease (a brain disorder that causes unintended or uncontrollable movements), muscle weakness (commonly due to lack of exercise, ageing, muscle injury), reduce mobility (mobility to use transport is reduced due to physical disability). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed as a high risk for elopement (to leave a secured institution without notice or permission) and had episode of leaving the facility without notifying staff as indicated in care plan. This failure has the potential for Resident 1 sustain an accidental injury while outside the facility's premises without supervision from staff. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with a diagnosis that included Parkinson disease (a brain disorder that causes unintended or uncontrollable movements), muscle weakness (commonly due to lack of exercise, ageing, muscle injury), reduce mobility (mobility to use transport is reduced due to physical disability). During a review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care 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.