Kit Carson Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician (Medical Director, MD) took an effective role in overseeing, supervising, and assessing one of three sampled residents (Resident 1's) medical care when the MD did not assess Resident 1's right leg venous stasis ulcer (a slow-healing, open sore on the lower leg or ankle caused by poor blood circulation) after a change in condition was identified on [DATE], follow the Wound Doctor's (WD) recommendation on [DATE] that Resident 1 should be transferred to an acute care hospital for a higher level of care, or follow up in a timely manner on his own verbal order given on [DATE] for Resident 1 to be seen by a vascular surgeon (a doctor who specializes in treating diseases of the blood vessels throughout the entire body). These failures caused a delay for a consult with a vascular surgeon for debridement (the medical process of removing dead, damaged, or infected tissue from a wound to help it heal faster) and/or surgical amputation (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plans (a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive, including how, when and by whom) for two of three sampled residents (Resident 2 and Resident 3) when,1. Resident 2's fall risk care plan was not reviewed and/or revised until 3/27/26 (5 days after Resident 2 fell on 3/21/26).2. Resident 3's fall risk care plan was not reviewed and/or revised after Resident 3 fell on 3/25/26.These failures placed Resident 2 and Resident 3 at risk for not receiving the individualized and person-centered care they required to help reduce fall occurrences and mitigate the potential for injury if a fall did occur.Findings:1. A review of Resident 2's clinical document titled, admission RECORD, indicated Resident 2 was admitted to the facility with diagnosis which included spastic right hemiplegia (stiffness and weakness on only one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice for one of four sampled residents (Resident 2) when,1. The facility did not monitor Resident 2's fasting blood glucose (FSBS, measures the amount of sugar [glucose] in the blood, which serves as the body's main energy source) results before Resident 2 ate breakfast for 11 out of 13 days or ensure Resident 2 did not need further treatment to maintain safe blood glucose levels.This failure placed Resident 2 at risk for experiencing further health complications related to possible fluctuations in blood sugar (hyperglycemic [high blood sugar with can cause confusion and blurred vision] and/or hypoglycemic [low blood sugar which can cause rapid heartbeat, confusion, dizziness, headache and/or loss of consciousness]).Findings: 1. A review of Resident 2's clinical document titled, admission RECORD, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis 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 interview and record review, the facility failed to maintain a complete and accurate medical record for two of three sampled residents (Resident 2 and Resident 3) when,1. The facility's Interdisciplinary Team (IDT - a group of experts from different fields [like doctors, nurses, and social workers] who work together collaboratively to achieve a common goal, such as comprehensive patient care) failed to complete the Post Fall Follow-Up Report, after Resident 2 fell on 3/21/26 and 3/23/26;2. The facility failed to initiate the SBAR form (Situation, Background Assessment Recommendation, a simple form for communication designed to help people share important information quickly and clearly) after Resident 3 fell on 3/25/26, the facility did not complete Resident 3's IDT Post Fall Follow-Up Report that was started on 3/25/26, and the facility did not complete Resident 3's Fall Investigation Form that was started on 3/31/26 after Resident 3 fell on 3/25/26.These failures placed Resident 2 and Resident 3 at risk for ongoing falls and potential injury due to the lack of documented…

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

Based on interview, and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 1) when Resident 1's care needs for fall awareness and fall prevention were not addressed on re-admission.This failure placed Resident 1 at risk for injuring herself in another fall within the facility. Findings:During a record review of a document titled, SBAR [Situation Background Assessment Recommendation] communication form, dated, 12/17/25, the record indicated, Resident 1 was found by a Certified Nurse Assistant (CNA) on the floor lying on her back in the hallway of the facility. Resident 1 complained of pain in her lower extremities and was sent to the hospital to be evaluated.During a review of Resident 1 ' s admission RECORD, dated 12/22/25, the admission Record indicated, Resident 1 was re-admitted to the facility with diagnoses which included, .FRACTURE OF LEFT FEMUR [broken bone in left leg] .FRACTURE, HIP.MUSCLE WEAKNESS.KIDNEY DISEASE.AGE RELATED OSTEOPOROSIS [bone loss].A review of Resident 1's nurses progress note, dated 12/22/25, indicated,…

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

Based on interview and record review the facility failed to ensure residents right to privacy were maintained when two residents (Resident 3 and Resident 4) and their rooms were photographed by staff members (Certified nursing assistant (CNA) 3 and CNA 4), using their personal phones, without Resident 3 and Resident 4's knowledge and/or consent.This failure had the potential to negatively affect Resident 3 and Resident 4's psychosocial well-being.a. A review of Resident 4's electronic health record (EHR) indicated Resident 4 was no longer at the facility.A review of a facility document titled, FOCUS EDUCATION IN-SERVICE FORM, dated 11/5/25, indicated, .Observation/Remarks/Comments .taking pictures of resident and environment .corrected staff and advised to delete photo .During an interview with the Director of Staff Development (DSD) on 12/3/25 at 2:54 PM, the DSD stated photographs were taken in Resident 4's room, without obtaining consent, by CNA 4. The DSD explained Resident 4 was unable to give consent for the photographs. The DSD further stated Resident 4's Responsible Party…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of six residents (Resident 1) with an indwelling catheter (catheter; a thin, flexible tube inserted into the bladder to drain urine) received catheter care and services when:1. Resident 1's suprapubic catheter (a temporary or permanent drainage route for urine, through a small incision in the abdominal wall, from the bladder directly into a collection bag) was not changed as ordered by the physician;2. Resident 1's suprapubic catheter was not consistently monitored following suprapubic catheter changes; and3. Care plans (a personalized, written document that details a resident's specific health and personal care needs, goals, and interventions) were not in place for Resident 1's catheter changes and Resident 1's urinary tract infection (UTI - A condition in which bacteria invade and grow in the urinary tract) in June of 2025.These failures could have been the cause of Resident 1's UTI and 10 out of 10 pain, (pain scale of 1 through10; with 10 being the worst pain) which resulted in Resident 1 being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 results of the most recent federal recertification survey were readily accessible to residents, family members, and legal representatives of residents, for a census of 75, when the facility's most recent survey results were not available.This failure violated the residents' right to the examination of the most recent survey results and prevented the residents and family members from accessing the facility's last survey results within in the facility.During the Resident Council Meeting on 8/12/2025 at 10:44 AM, when asked if they knew where to find the most recent survey results, the residents who were in attendance responded that they were not aware of where to find the results of the survey and they were also not aware that survey results were available for the residents to read.During an interview on 8/14/2025 at 11:55 AM with the Infection Preventionist (IP), the IP stated he did not know where the survey results were located, and the results could be with the administrator.During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store, prepare, and distribute food in accordance with professional standards for food service safety when:1. Food items with inconsistent labeling and dating practices were found in the reach-in refrigerators;2. A box of bacon was found to be passed the use by date but was not discarded in the reach-in refrigerator;3. An opened box of Italian sausage which read keep frozen was found in the reach-in refrigerator;4. Two cartons of health shakes (nutritional supplement provides extra calories and protein), and a tray with cartons of health shakes was found in the reach-in and walk-in refrigerators which did not have a date to identify when they were pulled from the freezer and when they were supposed to be used by; 5. Produce items were found not to be fresh in the walk-in refrigerator;6. The metal material of the can opener blade was worn off;7. One dietary aide (DA) with a mustache and beard was not wearing a facial hair restraint or…

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

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 75, when:1. The facility did not complete and document a facility-wide assessment of potential Legionella (bacteria that can cause a severe lung infection called Legionnaire's disease) growth areas and did not implement adequate control measures and monitoring protocols.2. Resident 52's urinary catheter bag (a thin flexible tube used to empty the bladder and collect urine in a drainage bag) was touching the floor.3. Nebulizer face mask and tubing (equipment used with a nebulizer machine that delivers liquid medication to the lungs as a fine mist) for Resident 1 and Resident 86 were unlabeled. There was no documentation when Resident 1's nebulizer face mask/tubing was last changed. An order to monitor and change Resident 86's nebulizer mask/ tubing was not initiated.4. Personal Protective Equipment (PPE - specialized clothing and equipment used by healthcare professionals to minimize exposure to infectious agents and hazardous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain their resident call light system (system/device used by residents to call staff for assistance) when the call light system did not directly alert staff at Station 1 or a centralized staff work area for 47 of 47 residents.This failure resulted in the residents waiting longer periods of time for assistance and put their physical and emotional needs at risk for being unmet.Findings:During an observation on 8/12/25, at 8:46 AM, in Resident 1's room, Resident 1 pressed the call light to ask for assistance from staff. During an observation on 8/12/25, at 8:49 AM, in front of Resident 1's room, observed the call light outside of the room above the doorway was lit up, and no staff were observed in the hallway to come and answer the call light. During a concurrent observation and interview on 8/12/25, at 8:50 AM, at Nurses Station 1, Licensed Nurse (LN) 2 stated she did not answer the call light because she did not see it and could not hear it. LN 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that three of twenty-six sampled Residents (Resident 5, Resident 11 and Resident 37) were free from the use of chemical restraints (use of medication to restrict a person's freedom or movement) when:1. A gradual dose reduction (GDR: stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was not attempted for Resident 5 and Resident 11's antipsychotic medications (a class of medications used to treat a variety of mental health disorders),2. The use of the antipsychotic medication for Resident 5, Resident 11, and Resident 37 did not have an appropriate clinical indication, and3. The behaviors identified for Resident 5, Resident 11, and Resident 37's psychotropic medications (medications that affect the mind, emotions and behaviors that are used to treat various mental health conditions) use were not monitored every shift as ordered in June, July…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free of accidents or hazards for 2 of 26 residents (Resident 62 and Resident 46) when: 1. Resident 62's Smoking assessment was not updated and Resident 62 was left smoking and unsupervised; and,2. An oxygen in use sign was not posted at Resident 46's room entrance. These failures had the potential to place Resident 62, Resident 87, Resident 46 and other residents in the facility with a census of 75 residents, at risk of accidental burns and injuries.1. During a concurrent observation and interview on 8/11/2025 at 9:02 AM with Resident 62, Resident 62 stated she smokes cigarettes at scheduled times that were posted on her wall for 10 minutes each time. Resident 62 was observed to have a pack of cigarettes and 2 lighters on the table. A review of Resident 62's clinical record titled, admission RECORD, indicated Resident 62 was admitted to the facility with diagnoses of, but not limited to, generalized muscle weakness,…

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

Based on interview and record review, the facility failed to ensure safe monitoring and assessment of blood pressure (BP-the force of your blood pushing against the walls of your arteries as your heart pumps blood and was measured as two numbers: systolic [when the heart beats] and diastolic [when the heart rests between beats]) and heart rate (HR-frequency of your heart beats per minute) for a medication used to treat low (hypotension) BP for 1 of 26 sampled residents (Resident 3) when Resident 3's physician prescribed hold parameters (a set of numbers that guide the nursing staff when to not give (hold) a medication) for Midodrine (a medication used to treat low blood pressure) was not followed 7 times between 7/1/25 and 8/14/25.These failures had the potential to put Resident 3 at risk of adverse drug effects including hypertension (HTN -high blood pressure) and increased Resident 3's chance of having a severe medical emergency.Findings:A review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility early 2024 with diagnoses including but not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored safely, securely, and properly destroyed (discarding unused or expired medication) in two of three medication carts (a mobile cart containing medication used for administration of medication to residents) for a census of 75 when:1. Two prescription medications (drugs that require a written order from a licensed healthcare professional) of the same brand were found in a basket of over the counter (OTC -medications available without a prescription) medications that were loose in individual blister packs (a form of tamper-evident packaging where a medication is protected by sealed foil) and contained no resident label, expiration date, or indications for use; and,2. An opened multi-use bottle of cough syrup was not labeled with the date opened (date the medication was first opened); and,3. A medication's individual foil package was opened, undated and available for use; An unlabeled, opened and undated single…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu, spreadsheet and recipe were followed for the therapeutic diets (the modifications of regular diet, tailored to fit the nutritional needs of the particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician) served during the lunch meals on 8/11/25 and 8/12/25 when:1.Resident 71 with CCHO (Consistent Carbohydrate Diet or Controlled Carbohydrate Diet, this dietary approach focuses on maintaining a consistent intake of carbohydrates throughout the day), 2g Na diet (a low sodium diet, usually to manage high blood pressure and/or heart disease), received a ketchup package instead of no ketchup with meal; and,2.Eight residents (Resident 4, 11, 14, 42, 51, 52, 57, and 72) with fortified food (food products to which extra nutrients, like vitamins and minerals, have been added during processing to increase their nutritional value) with their diets did not get the fortified food items (1/2 ounce (oz., a unit of weight or volume) of melted margarine 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.

Based on interview, and record review, the facility failed to provide education regarding the benefits and potential side effects of the COVID-19 vaccine, for three of five sampled residents (Resident 9, Resident 25, and Resident 51) when all three residents' clinical record did not contain documented evidence that education regarding the risk and benefits of the COVID-19 vaccine were provided. This failure had the potential for the residents and resident's responsible parties to not be fully informed about the risks and benefits, and potential side-effects of the COVID-19 vaccination prior to receiving or declining the vaccination.Findings:During an interview on 8/13/25, at 2:46 PM, with the Infection Preventionist (IP), the IP stated the COVID-19 vaccines were offered upon admission. The IP further stated that before getting the vaccine, the staff educated or explained to the resident the indication of the vaccine, the signs and symptoms or side effects that could occur like possible inflammation. The IP stated they also educated those residents with low pain tolerance that 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 ensure 1 out of 26 sampled residents (Resident 86) with urinary catheters (a thin flexible tube used to empty the bladder and collect urine in a drainage bag) were treated with dignity and their privacy was protected, when Resident 86's urinary catheter bag (a drainage bag attached to a catheter tube that is inside the bladder to collect urine) was exposed and was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This failure had the potential to negatively effect Resident 86's self-esteem and self-worth. During an observation on 8/11/2025 at 9:16 AM, Resident 86's urinary catheter bag was seen hanging on the side of the bed without a dignity bag. A review of Resident 86's clinical record titled, admission RECORD, indicated Resident 86 was admitted to the facility with diagnoses of, but not limited to, acute cystitis without hematuria (an inflammation of the bladder without blood in the urine), generalized muscle weakness.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of twenty-eight sampled residents (Resident 11) end of life wishes, and emergent treatment desires were accurate when Resident 11's POLST (Physician Orders for Life Sustaining Treatment: a medical order signed by both a patient and physician that specifies the types of medical treatment a patient wishes to receive toward the end of life) form and electronic medical record code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) had contradictory code status choices marked.This failure resulted in conflicting code status information for Resident 11 and placed Resident 11 at risk for having emergency treatment wishes not honored. Review of Resident 11's admission RECORD indicated Resident 11 was admitted to the facility with multiple diagnoses including but not limited to cerebral infarction (medical condition that occurs when the blood flow to the brain is disrupted) and…

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

Based on observation, interview, and record review, for 1 out of 26 sampled residents (Resident 42), the facility failed to ensure: the use of physical restraint was medically indicated;a care plan was developed for the use of restraint;an informed consent was obtained for the use of restraint. This failure resulted in Resident 42 not being able to move freely and potentially exposed Resident 42 to physical and psychological impact related to restraint. Findings: A review of Resident 42's admission RECORD, indicated Resident 42 was admitted to the facility with a diagnosis of, but not limited to, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with agitation, altered mental status, and generalized muscle weakness. During a concurrent observation and interview on 8/11/25, at 9:41 AM, with Certified Nurse Assistant (CNA) 11, Resident 42 was observed sitting on a Geri chair (a specialized type of recliner designed to provide comfort, support, and positioning for individuals who need to sit 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.

Based on observation, interview, and record review, the facility failed to ensure 1 of 26 sampled residents (Resident 46) received treatment and care in accordance with professional standards of practice when the care plan for oxygen use for Resident 46, was not developed. This failure had the potential to result in worsening respiratory function, and/or other serious medical complications.Review of Resident 46's admission RECORD, indicated Resident 46 was admitted to the facility in 2023 with diagnoses including chronic combined systolic congestive and diastolic congestive heart failure (the heart struggles to both effectively eject blood and receive blood leading to a range of symptoms such as shortness of breath, fatigue, swelling in legs and ankles, etc.).During a concurrent observation and interview on 8/11/25, at 9:50 AM, Resident 46 was noted to be on oxygen 2 liter/minute (LPM) via nasal cannula (NC, a device providing extra oxygen through a tube and into the nose) via concentrator (a medical device supplying extra oxygen). Resident 46 stated they were on oxygen therapy 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.

Based on interview and record review the facility failed to provide services that meet professional standards of practice for two of twenty-eight sampled residents (Resident 5 and Resident 11) when Quarterly Abnormal Involuntary Movement Scale (AIMS - a 12-item assessment tool used to evaluate and monitor the severity of involuntary movements in individuals taking an antipsychotic medication [a class of medications use to treat a variety of mental health disorder]) were not completed for Resident 5 and Resident 11.This failure had the potential for Resident 5 and Resident 11 to experience side effects related to the use of antipsychotic medications to go unrecognized and untreated.1. Review of Resident 5's admission RECORD indicated that Resident 5 was admitted to the facility with diagnoses that included but not limited to unspecified dementia severe with psychotic disturbance (a condition where person has a progressive decline in cognitive functions like memory, thinking, language, judgment, and see or hear things those are not there or has false beliefs), unspecified mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate hydration (process of providing fluid to the body) for two of 26 sampled residents (Resident 7 and Resident 41), per facility policy and according to each resident's comprehensive plan of care (Care plan- a document detailing an individual's health needs, goals, and the steps needed to achieve those goals) when:1. Resident 7 did not have fluids available to drink at the bedside; and,2. Resident 41 did not have fluids available to drink at the bedside.These failures resulted in Resident 7 having dry mucous membranes (soft tissue that make up the inside the mouth, gums, tongue and lips), chapped lips, and dry and peeling skin on his left leg; in addition, these failures resulted in Resident 41 having dry mucous membranes, chapped and peeling lips and concentrated dark amber colored urine (deep yellow or orange-brown colored urine usually caused by dehydration) (dehydration -a harmful reduction in the amount of water in the body).Findings:1. During a concurrent observation and interview 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.

Based on observation, interview, and record review, the facility failed to ensure the provision of routine and emergency medications were provided and/or documented for two of the 26 sampled residents (Resident 66 and Resident 78), based on standards of practice and regulatory requirements when:1. Resident 66 did not receive a physician ordered, as needed (PRN), medication called Ipratropium-Albuterol (inhaled medication used to open the airways and make breathing easier) due to medication unavailability from the pharmacy; and, 2. Resident 78's intravenous antibiotic (IV antibiotics, medications administered directly into the bloodstream through a vein, typically used for serious infections) was removed from the Emergency Kit (E-kit, an emergency supply of medications that are used based on a doctor's order for urgent needs of a residents) without documentation the medication had been removed by facility staff. These failures could have resulted in increased difficulty with breathing for Resident 66 and did result in inaccurate record keeping of medications removed from the E-kit.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 special dietary requirements were implemented for two residents (Resident 53 and Resident 65) during the lunch meal observation on 8/11/25 when Resident 53 did not receive milk with lunch and Resident 65 received corn with lunch which was a documented dislike. This deficient practice had the potential to result in meal dissatisfaction and decreased meal intake that may lead to further complications or Resident 53 and Resident 56's medical status and nutritional status and/or weight loss of both residents.Findings:During an observation of the lunch meal in the dining room with a concurrent review of Resident 53's and Resident 65's meal tickets (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes) on 8/11/25, beginning at 12:30 p.m., the following was noted:1. Resident 53's meal ticket indicated, Beverages: 8 ounces (oz., unit of measure) 2% Milk, Resident 53 did not receive 8 oz. 2% milk (1 cup (8 oz.) of milk that contains 2% of fat by weight).2.…

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

Based on observation, interview, and record review, the facility failed to provide specialized eating utensils for Resident 14 and Resident 32 for the lunch meal on 8/12/25. This deficient practice may lead to Resident 14 and Resident 32 consuming their meal improperly, cause a lack of self-independence during eating and could be a dignity issue, and may cause weight loss. Findings:A review of Resident 14's admission RECORD indicated Resident 14 was admitted to the facility with diagnoses that included severe protein-calorie malnutrition and dysphagia (a medical condition characterized by difficulty or inability to swallow). A review of Resident 32's admission RECORD indicated Resident 32 was admitted to the facility with diagnoses that included severe protein-calorie malnutrition and muscle weakness. On 8/12/25 at 12:50 p.m., during a meal distribution observation in the kitchen, Resident 14's meal ticket indicated, Devices: Scoop Plate [deeper on one edge than the other to allow the user to easily scoop food onto their eating utensil], Built up utensil [Specialized forks 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 provide education regarding the benefits and potential side effects for the Pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine for one out of five sampled residents (Resident 23) when Resident 23's clinical record did not contain documented evidence that education for the pneumococcal vaccine was provided.This deficient practice violated Resident 23's right to make an informed choice to receive or not receive the pneumococcal vaccine.Findings:During an interview on 8/13/25, at 2:46 PM, with the Infection Preventionist (IP), the IP stated the pneumococcal vaccine was offered upon admission. The IP further stated before getting the vaccine, the staff educated or explained to the resident the indication of the vaccine (why a vaccine is recommended), the signs and symptoms or side effects that could occur such as inflammation. The IP stated they also educated those residents with low pain tolerance that the vaccine could be painful, fever could possibly occur, and some adverse reactions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free of accidents or hazards for two of three sampled residents (Resident 2 and Resident 3) when: 1. Resident 2 ' s and Resident 3 ' s Wander Guard devices (a monitoring device used to alert staff of a resident leaving the premises) were not checked for placement and functionality each shift (3 shifts in a 24 hour period) each day; and, 2. Resident 2 ' s and Resident 3 ' s Elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised and undetected) Risk Assessments were not completed quarterly; and, 3. Resident 3 exited the facility on 6/4/25 and was missing for an unknown period of time before staff found her in the street on 6/4/25; and, 4. Resident 3 was not reassessed for Elopement Risk after she exited the facility on 6/4/25; and, 5. Weekly checks for the facility Wander Guard systems functionality were not documented by the Maintenance Supervisor. These failures had the potential to result in Resident 2 and Resident 3 sustaining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Dietary Supervisor (DS) was onsite on a full time basis (while the DS was employed by the facility on full-time basis, the DS was onsite for less than the minimum required 35 hours per week) to carry out the functions of the day-to-day operation of food and nutrition services, and the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultation to the DS to include overseeing food safety and sanitation, food preparation, meal services, and food storage for 81 residents who received food from the kitchen. The lack of consistent oversight by qualified staff had the potential to result in lapses in the delivery of food and nutrition services, meal distribution accuracy, and safe food handling and sanitation. Findings: During an interview on 9/9/24, at 9:47 AM, the RD stated she worked two days per week, usually on Monday and Thursday. The RD stated her responsibilities included: completion of assessments (new admission, annual, quarterly, high risk), completion 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 observations, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various sizes of tray line pans and serving utensils were stacked and stored wet. 2. A significant amount of food items that was outdated and/or with incorrect and inconsistent label were found in the reach-in refrigerators. 3. Stale and expired produce food items were found available for use in the walk-in refrigerator, 4. The ice machines located in nursing station one and two were not cleaned and sanitized according to the manufactures guidelines; 5. Two refrigerators for residents' brought in food located in nursing station one and two had: -unlabeled food items; -outdated food items; -no temperatures monitoring. 6. Two microwaves located in nursing station one and two were not clean and the material of interior lining of the microwave was chipping; 7. [NAME] (CK) 1 did not have knowledge of and not following ambient (room temperature) food cooling process; 8. Dietary Aide (DA) 1 did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean environment for the residents and visitors. One out of three garbage disposal bins located outside by the kitchen had trash inside and was not securely closed with the dumpster lid. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During an observation of the dumpster on 9/9/24, at 8:08 AM, one out of three dumpster bins located outside nearby the facility kitchen had bags of trash inside and not securely closed by the dumpster lid. During an interview on 9/9/24, at 11:50 AM, the Dietary Supervisor (DS) acknowledged and stated the dumpster lid should be closed tightly all the time to prevent the attraction of pests and rodents. During an interview on 9/11/24, at 2:50 PM, the Registered Dietitian (RD) stated the garbage bin(s) needed to be closed tightly to prevent pest and rodent infestation. A review of departmental policy and procedure titled, Miscellaneous Areas, 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 honor resident's right to participate in care conference (a quarterly and annually meeting that takes place between health care professionals and the resident and/or family to discuss and plan individualized resident care and allow the resident and/or their family to voice opinions, and concerns for the care given) meetings for five of twenty four sampled residents (Resident 70, Resident 61, Resident 29, Resident 37, and Resident 77) when Resident 29, Resident 61, Resident 70 Resident 37, and Resident 77' s quarterly and comprehensive care conference meetings were not held. This failure resulted in not providing the benefit to the residents and families of participating in the planning of their individualized care needs and to voice their care concerns. Findings: 1. During an interview on 9/10/24, at 10:07 AM, Resident 29 stated he was not familiar with care conferences and never attended one in the facility. Review of Resident 29's IDT (Interdisciplinary team: a group of health care professionals with various areas of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure six of 24 sampled residents (Resident 10, Resident 21, Resident 61, Resident 70, Resident 75, and Resident 239) end of life wishes and emergent treatment desires were accurate and/or available to facility staff when: 1. Resident 70's POLST (Physician Orders for Life Sustaining Treatment: a medical order signed by both a patient and physician that specifies the types of medical treatment a patient wishes to receive toward the end of life) and documented code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) did not match; and, 2. A copy of Resident 10's, Resident 21's, Resident 61's, Resident 70's, Resident 75's, and Resident 239's Advance Directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) was not available in their medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services which met professional standards of quality for a census of 81 when: 1. The Station 1 glucometer (a device used to measure how much glucose is in the blood) quality control test (QC, a test that verifies that the device or product meets specific quality standards) logbook was not consistently completed for all active glucometer devices stored in the medication carts at Station 1; and, 2. Resident 21's bedside table was left with a medication cup containing multiple pills. These failures had the potential to result in inaccurate resident blood glucose tests, a wrong medication dose due to the inaccurate test, medication errors, and for Resident 21 to experience a reduction in medication effectiveness due to missed doses. Findings: 1. During a concurrent interview and record review on 9/10/24, at 8:30 a.m., with Licensed Nurse (LN) 1 at Station I, the glucometer logbook was reviewed. LN 1 stated the glucometer quality control test was checked nightly and the results were recorded in 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 ensure safe pharmaceutical services for a census of 81 when: 1. Disposition [destruction] of non-controlled (non-narcotic) prescription medications were not documented. 2. The emergency kit (or E-kit, a box containing emergency medications for faster and easy access when needed) in the refrigerator at nurses Station 1 had been opened and left unsealed with no documentation of the medication that was removed, and the E-kit stored in a cabinet at Station 1 was left opened/unsealed for six days. 3. Prescription drug delivery manifests (receipts) were not consistently signed or reviewed upon delivery by licensed staff. 4. Narcotic medication was signed out on the Controlled Drug Record (CDR, a paper record that kept track of opioid medication use for accountability) but not signed out in the MAR (Medication Administration Record) for Resident 66. These failures had the potential to result in drug diversion, unsafe drug destruction/disposition and acquisition, unavailability of medications when needed from the…

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

Based on interview and record review, the facility failed to ensure monitoring of Vital Signs (VS, including blood pressure (BP) and heart rate/pulse) and VS parameters (a set of VS numbers which doctors use to hold the drug to prevent adverse effects) ordered by a physician for use of high-risk medications (medications that pose significant side effects if not used and monitored safely) were followed for three out of 24 sampled residents (Resident 21, Resident 77 and Resident 13) when: 1.Resident 21's blood pressure (BP) medications were not held according to the VS parameters set by the physician for three different medications on 9/2/24 and 9/7/24. 2. Resident 77's heart and blood pressure medications were not held on 9/5/24 according to the VS parameters set by the physician resulting in Resident 77 being transferred to the emergency room due to very low blood pressure and dizziness later in the afternoon on 9/5/24. 3. Resident 13's heart medications used to control the heartbeat and rhythm were not held according to the VS parameters set by the physician on 9/6/24 and 9/9/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe use and monitoring of psychotropic medications (or mind-alerting medications) for three residents (Resident 21, Resident 37, Resident 58) prescribed psychotropic medications in a sample of 24 when; 1.Non-Pharmacological nursing interventions (Referring to therapies that do not involve drugs, a science-based and non-drug approach that can have a measurable impact on health and quality of life; includes validation therapy, meaningful activities, and /or structured care based on resident's background or interests) were not documented for Resident 21 and Resident 37 with psychotropic medication use. 2. Resident 21's behavior monitoring for use of mind-altering drugs was non-specific and the behaviors did not pose a danger to self or others. 3. Resident 37 and Resident 58's use of psychotropic medications on an as needed or PRN basis continued beyond 14 days without an assessment of use and justification for its continuous need. These failed practices could contribute to the unsafe use of mind-altering medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe medication and medical supply storage in the medication cart, treatment cart, refrigerator, and the medication room for a census of 81 when: 1. Station 1's medication refrigerator had heavy frost where insulin (drug used to treat blood sugar disease) and vaccines (use for immunization against serious diseases) were stored, and the refrigerator temperature was not documented twice a day in the medication room. 2. Glucometer (a device used to measure blood sugar) control solution (a product used to calibrate the glucometer for accurate function) and test strips (test strips are used to measure blood sugar levels by soaking blood on the tip of it) bottles were expired (manufacturer beyond use date) and not dated when first opened in the medication room at Station 1. 3. The cabinet door housing the facility's emergency kits (E-kit; a supply of medications to be used in urgent basis), was not locked and could not be locked due to 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 two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when: 1. Dietary Aide (DA) 1 was unable to verbalize the process of manual dishwashing using a two-compartment sink, and, 2. [NAME] (CK) 2 did not thaw meat using a correct procedure. These failures had the potential to place 81 out of 81 residents who received food from the kitchen at risk for food-borne illness. Findings: 1. During an interview on 9/9/24, at 2:57 PM, DA 1 verbalized the process of manual dishwashing using a two compartment sink. DA 1 stated the process had three steps, sanitizing, rinsing, and washing. DA 1 then changed her answer to the steps being washing, rinsing, and sanitizing with cueing. She stated she was not sure what the water temperatures of washing and rinsing were, but she stated the water temperatures might be similar to the dishwasher which was around 120 degrees Fahrenheit (F). She stated after the rinsing step, she would use quaternary ammonia (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 the menu was followed for residents on a therapeutic diet for the lunch meal on 9/10/24 when: 1. Sixteen residents (Residents 4, Resident 6, Resident 8, Resident 9, Resident 11, Resident 17, Resident 21, Resident 24, Resident 30, Resident 38, Resident 59, Resident 66, Resident 74, Resident 77,Resident 82, and Resident 83) with CCHO (consistent carbohydrate) diet (a diet to treat diabetic disease or control blood sugar) received the diet gelatin without whipped topping instead of with whipped topping. 2. Twelve residents (Residents 16, Resident 23, Resident 24, Resident 29, Resident 35, Resident 38, Resident 47, Resident 49, Resident 56, Resident 70, Resident 80, and Resident 82) with a low fat/low cholesterol diet (a diet to reduce risk for heart disease) and 2 grams (a unit of measurement) sodium (salt) diets (diet with limited sodium intake to prevent heart disease and hypertension) received salad with regular dressing instead of fat free dressing for a low fat/low cholesterol diet and sodium…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe infection prevention practices for a census of 81 when: 1. A glucometer was used without being cleaned and disinfected between residents during medication pass observation. 2. Nine hand sanitizer bottles were in active use while expired. These failures had the potential to result in the spread of germs, infection, and the need for additional medical interventions (medications and/or treatments). Findings: 1. During a medication pass observation on [DATE], at 12:06 p.m., at Station 2, Licensed Nurse (LN) 2 performed a finger stick blood glucose test (FSBS, poking a finger to apply a drop of blood to a test strip. The test strip is inserted into a glucometer [small electronic device which measures the blood sugar level]) on a resident. LN 2 wore gloves, cleaned the resident's left hand, placed the glucometer on the resident's bedside table, poked the resident's left middle finger, and obtained the FSBS result. LN 2 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 homelike environment was provided for 1 of 24 sampled residents (Resident 63), when Resident 63 could not store her personal belongings in her assigned closet space. This deficient practice did not ensure a homelike environment that encouraged the use of personal belongings to the extent possible. Findings: During an interview on 9/10/24 at 9:24 AM with Resident 63, Resident 63 stated that she could not use the top of her assigned closet space. Resident 63 also stated that Resident 60's belongings were placed in her section of the closet. Resident 63 further stated she did not want to move Resident 60's stuff to place her own items up there. During an observation on 9/10/24 at 9:28 AM in Resident 60's room, it was observed that Resident 60's belongings were placed in the top section of Resident 63's assigned closet space. During an interview on 9/10/24 at 11:20 AM with Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 60's stuff had always been in Resident 63's closet space. CNA 2 also stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive person-centered care plan was developed for one of twenty-four sampled residents (Resident 58), when an indwelling catheter (urinary catheter: a hollow flexible tube that is inserted into the bladder to drain urine) care plan was not developed for Resident 58. This failure had the potential for Resident 58's catheter care needs not being met which could lead to infections and complications. Findings: Review of Resident 58's admission Record indicated Resident 58 was admitted to the facility in mid-2024 with multiple diagnoses including but not limited to chronic kidney disease and retention of urine. During a concurrent observation and interview on 9/9/24 at 10:24 AM, Resident 58 was observed to have an indwelling catheter. Resident 58 stated the indwelling catheter was put in when he was in the hospital. Resident 58 stated he thought he had the catheter so that he did not have to get up to go to the bathroom. Review of Resident 58's admission note dated 7/25/24, indicated, .Pt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services were provided for one of twenty-four sampled residents (Resident 239) when Resident 239 did not receive a shower as scheduled at least twice a week. This failure resulted in Resident 239 not receiving showers and had the potential for poor hygiene, poor skin integrity, and low self-esteem for Resident 239. Findings: Review of Resident 239's admission Record indicated Resident 239 was admitted to the facility in late 2024 with multiple diagnoses including but not limited to fracture of the lower end of the left femur (leg bone), muscle weakness, and difficulty walking. Review of Resident 239's MDS (Minimum Data Set: a standardized assessment tool that measures health status in nursing home residents) assessment dated [DATE], indicated Resident 239 needed maximum assistance with shower/bathing activity. During an interview on 9/9/24 at 4:48 PM, Resident 239's Family Member (FM) 1 stated Resident 239 was supposed to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review, the facility failed to ensure access to bilateral hearing aids and to assist in arranging for audiologist (ear doctor) referral consult services for one of twenty-four sampled residents (Resident 44). This failure had the potential to impair Resident 44's ability to understand and communicate needs effectively. Findings: During a concurrent observation and interview with Resident 44, on 9/10/24, at 9:40 AM, Resident 44 was observed without hearing aids. Resident 44 stated that she thought she had hearing aids before but was not sure where she lost them and if it was before this current admission at this facility. Resident 44 stated she did not recall if she had notified the staff about the missing hearing aids because she was forgetful with her age now. During a phone interview with RP on 9/12/24, at 8:42 AM, RP stated that Resident 44 had hearing aids when she was first admitted at the facility. The RP stated that she bought the hearing aids for Resident 44. The RP stated that Resident 44 told her that the hearing aids got lost…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six residents (Resident 58) who entered the facility with an indwelling catheter (urinary catheter: a hollow flexible tube that is inserted into the bladder to drain urine) was assessed for catheterization necessity when Resident 58's record did not indicate the clinical condition for use of the indwelling catheter. This failure had the potential of unnecessary indwelling catheter use which could lead to urinary tract infections (UTI) and further complications for Resident 58. Findings: Review of Resident 58's admission Record indicated Resident 58 was admitted to the facility in mid-2024 with multiple diagnoses including but not limited to chronic kidney disease and retention of urine (the inability to eliminate all of the urine in the bladder). During a concurrent observation and interview on 9/9/24 at 10:24 AM, Resident 58 was observed to have an indwelling catheter. Resident 58 stated the indwelling catheter was put in…

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

Based on observation, interview, and record review the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for 3 of 14 residents (Resident 52, Resident 5, and Resident 43) receiving oxygen therapy when: 1. Resident 52 and Resident 5's oxygen flow rate was not followed as prescribed by the doctor; and 2. Resident 43's oxygen tubing and humidifier (a device for keeping the atmosphere moist in a room) were not dated. These failures had the potential to result in negative health impacts such as ineffective oxygen therapy and respiratory distress for Resident 52, Resident 5, and Resident 43. Findings: 1a. A review of Resident 52's admission RECORD, indicated she was admitted to the facility with diagnoses which included acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). During an observation on 9/9/24 at 12:13 PM, Resident 52's oxygen was in use at 2.75 liters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 81 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 38 opportunities which resulted in a facility wide medication error rate of 5.26 % in two out of 12 residents (Resident 45 and Resident 52) during medication administration observation. These failures resulted in unsafe medications use, medication errors, and not following the doctor's orders. Findings: 1. During a medication observation with Licensed Nurse (LN) 3, in station 2;s hallway, on 9/9/24, at 10:02 AM, LN 3 prepared and poured four medications for Resident 45 into a cup. The medications included vitamin D, aspirin and multivitamin with minerals and a medication labeled on the bottle as Mucus Relief (or guaifenesin 400mg; mg is…

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

Based on interview and record review, the facility quality assessment and assurance (QAA) committee failed to meet quarterly with all required members for a census of 81, when: 1. Four of six required committee members including the Medical Director (MD), the Director of Nursing (DON), the Infection Preventionist (IP) and the Administrator (ADM), owner, a board member or other individual in leadership role did not attend quarterly Quality Assurance Performance Improvement (QAPI: a data driven and proactive approach to improve the quality of life, quality of care and services delivered in nursing facilities) meeting on 6/28/2024, and 2. The DON and the IP did not attend quarterly QAPI meeting on 4/26/24. This failure had the potential of lack of necessary supervision, issues to go unidentified, quality care improvement activities not being evaluated, revised as needed and goals not being achieved which could lead to negative outcomes and declines in quality care of facility residents. Findings: During a concurrent interview and record review on 9/12/24 at 3:15 PM, the ADM stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision was provided to 1 of 3 sampled residents (Resident 1), when Resident 1 did not receive 1:1 supervision (a staff member assigned to watch one resident) on 12/12/23 as indicated in her fall care plan. As a result, Resident 1 fell and got a skin tear. Findings: Review of Resident 1's admission record indicated Resident 1 was admitted to the facility in late 2023 with multiple diagnoses including a fractured right humerus (upper arm bone), pain in the right arm, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, an assessment tool that measures health status in nursing home residents) dated 12/1/23, indicated Resident 1 had severely impaired cognition (impaired ability to remember, think, or make decisions). Review of Resident 1's nurses progress note dated 12/5/23, indicated, At 1430H [2:30…

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

Based on observation, interview and record review, the facility failed to protect and keep secure when not in use, confidential resident health data and records for a census of 75. This failure had the potential to expose and disclose personal and confidential health information to unauthorized individuals. Findings: During a medication pass observation on 3/6/23, at 9:34 a.m., with Licensed Nurse 8 (LN 8), LN 8's computer screen was observed unlocked and accessible to residents and staff passing by when she left to administer medications to Resident 9. During an interview on 3/6/23, at 9:37 a.m., with LN 8, LN 8 stated she should have logged off the computer system when she left the medication cart to administer medications. During a medication pass observation on 3/6/23, at 9:51 a.m., with LN 8, LN 8's computer screen was observed unlocked and accessible to residents and staff passing by when she left to administer medications to Resident 18. During an interview on 3/6/23, at 9:52 a.m., with LN 8, LN 8 stated she should have logged off the computer system when she left the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), and availability of routine and emergency drugs when: 1. Random controlled medication use audits for 5 out of 6 residents (Residents 18, 21, 22, 35, and 52) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents; 2. Three out of 13 emergency kits (E-kit, a kit containing medications and supplies for immediate use during a medical emergency) were not replaced in accordance with the facility policy and procedures (P&P); and 3. Resident 48 did not receive two doses of famotidine (a medication used to treat acid reflux). These deficiencies created the potential for the facility to be unable to…

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

Based on observation, interview and record review, the facility had a 16.6% error rate when 5 medication errors out of 30 opportunities were observed during a medication pass for 5 out of 11 Residents (Residents 1, 18, 27, 48 and 54). These failures resulted in medications not given in accordance with the physician's orders and/or manufacturer specifications which resulted in residents not receiving the full therapeutic effect of the medications. Findings: 1. During a medication pass observation on 3/6/23, at 9:51 a.m., with Licensed Nurse 8 (LN 8), LN 8 was observed preparing and administering ibuprofen (a medication to treat pain) 200 milligrams (mg, a unit of measurement), 1 tablet to Resident 18. A review of Resident 18's medical record indicated a physician's order, dated 2/2/23, for ibuprofen tablet 600 mg every 6 hours as needed for breakthrough pain. During an interview on 3/6/23, at 1:57 p.m., with LN 8, LN 8 confirmed the ordered dose for ibuprofen was 600 mg, and she administered only 200 mg to Resident 18. LN 8 confirmed the correct dose was not given as ordered 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. Opened biologicals, multi-dose inhalers and insulin (medication to lower blood sugar level) were dated with an open and discard dates to ensure they were not used beyond the discard dates and expired medications were not available for resident use and, 2. Medication carts were kept securely locked when left unattended. The deficient practices had a potential for residents to receive medications with unsafe or reduced potency from being used past their discard date, and diversion or misuse of medications from not being securely stored in medication carts. Findings: 1. On 3/6/23, at 11:59 a.m., an inspection of Medication Storage room [ROOM NUMBER] alongside Licensed Nurse 2 (LN 2) identified 1 vial Tubersol (an injectable testing solution use to test for tuberculosis) opened and unlabeled with an open date, 3 bottles FORA control solution (a test solution used to calibrate blood glucose monitors) expired 2/5/23, and 1 bottle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the policies and procedures, the facility failed to maintain the kitchen in a sanitary condition when: 1. Accumulated dust was built up on the electric wires, sprinkler pipes, and water pipelines in the kitchen, 2. Undated open food items were available for use in the refrigerator, and 3. The kitchen appliances were not maintained in a safe operating condition. These failures had the increased risk for food borne illness for a census of 75. Findings: A concurrent observation and interview was conducted on 3/6/23 starting at 9:20 a.m., with the Registered Dietician (RD) and noted the below findings in the kitchen: 1. A heavy layer of grayish black build up dust was visible on the electric wires and on the insulated waterlines from the ceiling that were connected to the back of the ice machine. There were accumulated dust on the sprinkler pipelines above the toaster oven. On the 3-door refrigerator, the electric wires were coated with heavy build up dust and the black electric unit was covered with a thick layer of dust. The grayish thread…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Resident 11 and Resident 36) were assisted with Activities of Daily Living (ADLs) when staff did not perform nail care for a census of 75. These failures resulted in fingernails that were long with blackish substance underneath them, and had the potential for Resident 11 and Resident 36 to sustain injury and/or acquire an infection. Findings: A review of Resident 11's clinical record indicated the resident had diagnoses that included dementia (memory loss that interferes with daily functions) and glaucoma (a condition that can cause vision loss). A Minimum Data Set (MDS, an assessment tool), dated 2/2/23, indicated Resident 11 had moderate cognitive impairment and required extensive assistance with personal hygiene. During a concurrent observation and interview on 3/6/23, at 10:35 a.m., Resident 11's fingernails were long with blackish substance underneath her nails. Resident 11 stated she wanted her fingernails 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 infection control practice was maintained when: 1. Hand hygiene was not performed in accordance with facility policy and procedure (P&P) during medication administration between Resident 27 and 54 and 2. A nasal cannula (a plastic tubing to deliver oxygen from the concentrator to the patient via nostrils) placed on the floor was reused for Resident 13. These failures had the potential to result in cross contamination between Resident 27 and Resident 54 and Resident 13 being exposed to dust and dirt that could lead to respiratory illnesses or aggravate the existing lung disease. Findings: 1. Resident 27 was admitted on [DATE] with diagnoses including diabetes, heart disease, depression, and muscle weakness. Resident 54 was admitted to the facility on [DATE] with diagnoses including heart failure, muscle weakness, and pain. During a medication pass observation on 3/6/23, at 9:46 a.m., with Licensed Nurse 8 (LN 8), LN 8 was observed…

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