Antelope Valley Care Center

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to develop a care plan to address Resident 1's nutrition related to early dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) schedule.This failure had the potential for delays in the delivery of necessary care, services and could potentially result in hypoglycemia (low blood sugar) to Resident 1. Cross reference F684. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/25/2026, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease…

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

Based on interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure Resident 1 was fed, had breakfast and was provided with a sack lunch (a lunch which is prepared before arriving at the place where it is to be eaten) before getting picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) center on 2/27/2026.This failure had the potential to place Resident 1 at risk of hypoglycemia (low blood sugar). Cross reference F656. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/25/2026, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease…

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

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to ensure Registered Nurse 1 (RN 1) documented interventions provided to Resident 1 when Resident 1 was picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) center on 2/27/2026, without breakfast and without sack lunch (a lunch which is prepared before arriving at the place where it is to be eaten). This failure had the potential to result in confusion in Resident 1's care and Resident 1's medical records containing inaccurate documentation.Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to ensure Registered Nurse 1 (RN 1) documented interventions provided to Resident 1 when Resident 1 was picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was discharged in a safe and orderly manner for one of three sampled residents (Resident 1), by failing to: 1. Ensure Resident 1's post-discharge destination could meet Resident 1's needs prior to the discharge on [DATE].2. Involve Resident 1's Representative in the development of the discharge plan and informed of the final discharge plan. These deficient practices had the potential for Resident 1 not to receive necessary care and services and negatively affecting Resident 1's well-being.Findings:During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 5/14/2025 with diagnoses including heart failure (a progressive condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), encounter for palliative care (specialized medical care for people with serious illnesses, focusing on relieving symptoms, pain, and stress to improve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Residents 1 and 2) by failing: To follow physician order to hold (temporarily stopping certain medications as instructed by a healthcare provider) metoprolol (medication used to treat hypertension [HTN-high blood pressure]) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110/60 millimeters of mercury (mmHg-a standard unit of pressure). On 1/9/2026, at 9 a.m., Licensed Vocational Nurse 4 (LVN 4) administered metoprolol to Resident 1 who had a blood pressure of 104/76 mmHg.To ensure LVN 3 administer pantoprazole (medication used to treat too much acid in the stomach) and insulin lispro (medication used to lower blood sugar) to Resident 1 on 1/8/2026.To ensure LVN…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was given pain medication as per physician's order.This failure had the potential to result in Resident 3's increased risk for drowsiness (sleepiness) and sedation (the use of medication to make a person calm, relaxed, or sleepy during a procedure).Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/13/2017, with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), left knee pain and shortness of breath.During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/30/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's Order Summary Report, dated 12/19/2025, the Order Summary Report indicated the following…

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

Based on interview and record review, the facility failed to notify the Physician of resident's refusal of buspirone hydrochloride (medication used to treat generalized anxiety disorder [GAD - excessive, persistent worry that interferes with daily life, not just normal stress]) for one of three sampled residents (Resident 1).This failure had potential for Resident 1's delays in the delivery of necessary care and services and had the potential to increase Resident 1's level of anxiety.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/19/2025, with diagnoses that included recurrent (reappears repeatedly over time) enterocolitis (when both your small intestine and large intestine get inflamed [swollen and irritated]) due to clostridium difficile (C. diff - a highly contagious bacteria that causes severe diarrhea), generalized muscle weakness and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 1's Order Summary Report, dated 11/20/2025,…

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

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) to address Resident 1's refusal of medication.This failure had potential for Resident 1's delays in the delivery of necessary care and services.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/19/2025, with diagnoses that included recurrent (reappears repeatedly over time) enterocolitis (when both your small intestine and large intestine get inflamed [swollen and irritated]) due to clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea), generalized muscle weakness and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 1's Order Summary Report, dated 11/20/2025, the Order Summary Report indicated buspirone hydrochloride (medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of practice for three of five sampled residents (Resident 1, Resident 2, and Resident 3) by failing to: 1. Ensure licensed nurses monitored Resident 1's respiratory (organs that are involved in breathing) status after the resident's change of condition (COC) on 11/12/2025.2. Ensure licensed nurses monitored Resident 3's respiratory status after the resident's change of condition (COC) on 11/20/2025.3. Ensure licensed nurses monitored Resident 2's gastrointestinal (stomach and intestines) status after the resident's change of condition (COC) on 11/21/2025. These deficient practices had the potential to place Resident 1, Resident 2, and Resident 3 at risk for undetected and worsening medical conditions which could negatively impact the residents' health and safety.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 12/16/2024 with…

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

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3's oxygen tubing and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.2. Ensure Resident 3 had an oxygen supplies bag for the oxygen tubing to be kept inside when not in use. These deficient practices had the potential for Resident 3 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.Findings: During a review of Resident 3's admission Record (undated), the admission Record indicated the facility admitted the resident on 11/19/2025 with diagnoses including pleural effusion (the buildup of excess fluid between the lungs and the wall lining inside the chest), asthma (a disease that affects the lungs), and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood). 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 Based on observation, interview, and record review the facility failed to implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure Restorative Nurse Assistant (RNA) 1 implemented proper use of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for one of three sampled residents (Resident 2) placed on enhanced barrier precautions (EBP-an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug resistant organisms {MRDOs}). This deficient practice had potential to result in the spread of MRDOs among residents.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 9/13/2023, and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1.Ensure two antidepressant medications, Celexa and Wellbutrin, (medications used to treat mental illness) were not used concurrently without a documented clinical rationale in one of five residents sampled for unnecessary medications (Resident 8.) 2.Ensure two antipsychotic medications, Seroquel and Abilify, (medications used to treat mental illness) were not used concurrently without a documented clinical rationale in one of five residents sampled for unnecessary medications (Resident 6.) 3.Monitor the use of Wellbutrin for adverse effects (unwanted or dangerous medication-related side effects) in the Medication Administration Record (MAR - a record of medications administered, and regular monitoring completed for a resident) for one of five residents sampled for unnecessary medications (Resident 8.) 4.Ensure the behavior manifestations for the use of buspirone (also known as Buspar, a medication used to treat general anxiety) and clonazepam (also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) by failing to: 1. Develop and implement a comprehensive care plan on the use of bilateral cushion boots (are padded, boot-like medical devices worn on both feet (bilateral) to protect and support them) per the physician's order for one of two sampled residents (Resident 93) reviewed for pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice had potential to result in a delay in the delivery of the necessary care and services and development of a pressure injury on Resident 93's heels. 2. Develop and implement a care plan timely addressing the resident's behavior of putting things in their mouth for one (1) of two (2) sampled residents (Resident 42) reviewed under the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three of three sampled residents (Residents 157, 10, and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F760. Findings: 1.During a review of Resident 157's admission Record (AR), the AR indicated the facility admitted the resident on 8/26/2024, and readmitted 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 residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) for two of five sampled residents (Residents 16 and 10) needs by: 1. Failing to follow up with the physician timely when Resident 16 was complaining of pain on urination for one of two sampled residents (Resident 16) reviewed for change of condition (COC- significant change in a patient's health or functional abilities which requires medical attention or change in their care plan). This failure had the potential to result in the resident's pain on urination to be untreated timely and worsening of the pain which may lead to development of infection. 2. Failing to reconcile Resident 10's medication (formal process of creating the most accurate and complete list of a resident's medications and comparing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for three of three sampled residents (Resident 93, 189, and 36) by failing to: 1. Keep Resident 93's bilateral cushion boots (is a medical device worn on both feet and ankles to provide cushioning, support, and protection for various foot-related issues) on the resident while in bed per physician's order. The deficient practice had the potential for delay of necessary care and services and worsening of the resident`s pressure injury. 2.Obtain a physician order prior to applying wound dressing on Resident 189's right heel. 3. Follow Resident 189`s physician order for left heel deep tissue injury (DTI- a stage of pressure injury characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of four sampled residents (Residents 93, 199, 33, and 19) reviewed for accidents by failing to ensure: 1.Residents 93, 199, and 33's floor/fall mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have equipment or furniture on top of them. 2.Conduct an interdisciplinary team (IDT-a collaborative group of healthcare professionals and staff, including the resident and their family, who work together to develop and implement a person-centered care plan) root cause analysis after Resident 19 fell on 6/25/2025. The deficient practices increased the risk of accidents such as falls with injuries on residents. Findings: 1.During a review of Resident 93’s admission Record (AR), the AR indicated the facility admitted the resident on 6/10/2025, and readmitted the resident on 8/8/2025, with diagnoses including history of falling, muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents maintained acceptable parameters of nutritional status for one of four sampled residents (Resident 13) reviewed during the Nutrition care area by failing to: 1.Ensure a change of condition (COC - a significant shift or worsening in someone's health or well-being, often requiring attention or intervention) regarding significant unplanned weight loss (a loss of five [5] percent [%] of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days) was reported to the physician, resident representative, and Registered Dietician (RD) per facility policy and procedure (P&P) on 8/1/2025. 2. Ensure the physician was notified of, and followed up on, Registered Dietician (RD) 1's recommendation for an appetite stimulant (medications that increase appetite) on 8/7/2025. 3.Ensure the interdisciplinary team met per the facility P&P following the resident's significant weight loss. 4. Develop and implement a care plan for weight loss.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for two of five sampled residents (Resident 134 and 51) reviewed under the Pain care area and one resident present during the Resident Council task (Resident 89) by failing to: 1. Ensure the licensed nurse (LN) administered oxycodone (an opioid [also called a narcotic - powerful pain-reducing medication) per the facility policy and procedure (P&P) and the physician's order when the LN failed to assess and document the resident's pain level based on the numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine), assess and document the location of pain, and implement and document non-pharmacological interventions (any treatment or therapy that does not involve medication) for pain management for Resident 134. 2. Ensure as needed (PRN) oxycodone 10 milligrams (mg -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four errors out of 32 opportunities contributed to an overall error rate of 12.5 % affecting three of six residents observed for medication administration (Resident 67, 99, and 187). The errors noted were as follows: 1.Incorrect preparation of Lokelma (a medication used for kidney failure) for Resident 187. 2.Incorrect time of administration for sevelamer (a medication used for kidney failure) for Resident 187. 3.Failure to administer metformin (a medication used to treat high blood sugar) with food per the physician order for Resident 99. 4.Failure to administer potassium chloride (a potassium supplement) with food per the physician order for Resident 67. The deficient practice of failing to administer medications in accordance with the physician's orders or professional standards increased the risk that Residents 67, 99, and 187 may have experienced 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (when the observed or identified preparation or administration of medications or biologicals are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for: 1.Three of three sampled residents (Residents 157, 10, and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and sanitary food storage and food preparation practices in the kitchen when: 1.An aerosol can of whipped cream was without a cover with the nozzle or tip exposed remained on the top shelf of the walk-in refrigerator. 2.A metal container of turkey and cheese sandwiches in the walk-in refrigerator did not indicate a preparation date. 3.One can of sliced apples with dent remained at the bottom shelf in the dry storage room with the non-dented cans. 4.Six plastic containers of food were stacked wet in the drying rack in the dishwashing room. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 167 of 177 medically compromised residents who received food from the kitchen. Findings: During an initial kitchen tour on 8/25/2025 at 8:15 a.m. with Assistant Dietary Supervisor (Asst DS), observed in the walk-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 the facility's policy regarding use and storage of foods brought to residents by family and other visitors was followed for one of one sampled resident refrigerator by failing to ensure the facility's resident refrigerator was within acceptable temperature range per facility's policy and procedure for refrigerator at equal or less than (=/< - a unit of measurement) 41 degrees Fahrenheit (F, a scale for measuring temperature). This deficient practice had the potential to result in food-borne illnesses (food poisoning) of residents and can lead to other serious medical complications and hospitalization. Findings: During an interview on 8/27/2025 at 1 p.m. with the Dietary Assistant (DA), the DA stated the kitchen staff is not responsible for checking the residents` refrigerators for food brought from home or by visitors or family members. The DS stated the refrigerator for the residents is located in the orientation room and can be accessed by nursing staff. During a concurrent observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate and complete medical records for two of three sampled residents (Resident 197 and 14) reviewed for documentation by: 1.Failing to ensure Licensed Vocational Nurse 3 (LVN 3)'s code status documentation on Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) matches the Physicians Order on [DATE] for Resident 197. 2.Failing to ensure LVN 4 documented her observation and intervention when Resident 197 was unresponsive on [DATE]. 3.Failing to account for and document the events that happened to the resident when the Census indicated Resident 14 was on Hospital Leave (is the temporary status that keeps their spot open at the Skilled Nursing Facility [SNF]) on [DATE] and [DATE]. These failures resulted in medical records containing inaccurate documentation and had the potential 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 implement infection control practices for three of 10 sampled residents (Residents 121, 26, and 12) by: 1. Failing to ensure Licensed Vocational Nurse (LVN) 11 wore personal protective equipment (PPE- gown, gloves, face shield), gown, while conducting a gastrostomy tube (G-tube-a medical device that delivers nutrition, fluids, and medications directly into the stomach through a small opening in the abdomen) assessment on Resident 121`s who was under Enhanced Barrier Precautions (EBP- an infection control intervention to reduce transmission of bacteria and other microorganisms that have developed resistance to antibiotics making infections hard to treat). 2.Failing to ensure Certified Nursing Assistant (CNA) 5 wore PPE, gown, while providing incontinence care (helping a person who cannot control their bladder or bowel movements) to Resident 26 who was on EBP. 3.Failing to ensure the laundry area was kept clean and sanitary. On 8/26/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement policies for Infection Prevention and Control Program, and Antibiotic (medication used to treat infection) Stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) Program for two of two sampled residents (Resident 106 and 202) reviewed under infection control facility task and five of five sampled residents (resident 93, 10, 12, 155, and 16) reviewed for antibiotic use by: 1.Failing to monitor Resident 106 for the adverse effects (an unintended, negative health outcome or unwanted event that occurs as a result of a treatment, medication, or exposure to a substance) of levofloxacin (an antibiotic medication used to treat infection) from 8/13/2025 to 8/17/2025 while Resident 106 was on antibiotic therapy. 2.Failing to monitor…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) performed the duties of the position by failing to implement the antibiotic (medication used to treat infection) stewardship program (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) and the infection prevention and control program for three of five sampled residents (Residents 10, 106 and 202) by: 1.Failing to ensure Residents 106 and 202 were monitored for antibiotic adverse effects (undesired or harmful effects). 2.Failing to ensure Resident 106 was vaccinated for Coronavirus Disease 2019 (COVID-19, an infectious disease that most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment) and pneumonia (an infection/inflammation in the lungs) after Responsible Party 1 (RP 1) consented (gave…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 self-administration of lidocaine (a topical adhesive patch that delivers a local anesthetic to a specific area of the body to relieve pain) was evaluated and considered safe by the interdisciplinary team (IDT-a multidiscipline group of healthcare professionals involved in periodically meeting and planning care for individual residents) for one of five sampled residents (Resident 51) reviewed during pain management. This deficient practice had the potential to result in increased risk of Resident 51 administering lidocaine patches to the wrong location due to lack of technique resulting in medical complications such as uncontrolled pain. Findings: During a review of Resident 51's admission Record (AR), the AR indicated that the facility originally admitted the resident on 8/14/2024 and readmitted on [DATE] with diagnoses including cauda equina syndrome (a condition where the nerve roots at the bottom of the spinal cord [cauda…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one (1) of one (1) sampled resident (Resident 42) reviewed under the call devices in reach care area. This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 42 when the resident was unable to call for assistance. Findings: During a review of Resident 42's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 8/15/2023, with diagnoses including generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a…

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

Based on interview and record review, the facility failed to ensure residents rights to formulate an Advance Directive (AD, a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) was respected for one of eight sampled residents (Resident 134) reviewed under the AD care area by failing to provide written information concerning the right to formulate an AD. This deficient practice had the potential to violate the resident's right to have their wishes honored regarding health care decisions. Findings: During a review of Resident 134's admission Record (AR), the AR indicated the facility originally admitted the resident on 11/12/2024, and most recently re-admitted the resident on 6/28/2025, with diagnoses that included cirrhosis of liver (permanent scarring that damages the organ that removes toxins from the body's blood supply), ankylosing spondylitis (a chronic inflammatory disease that primarily affects the spine) of the lumbar region (lower back), and diverticulitis (a 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, interview, and record review, the facility failed to immediately notify the primary physician, responsible party (RP), and Registered Dietician (RD) of a significant change in condition (COC - a significant shift or worsening in someone's health or well-being, often requiring attention or intervention) for one of four sampled residents (Resident 13) reviewed during the Nutrition care area by failing to notify per the facility policy and procedure (P&P) when the resident had significant unplanned weight loss (a loss of five [5] percent [%] of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days) on 8/1/2025. This deficient practice had the potential to result in further weight loss and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients) in Resident 13. Cross Reference F693 Findings: During a review of Resident 13's admission Record (AR), the AR indicated the facility originally admitted the resident on 10/27/2024, and most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two of two sampled residents (Resident 201 and 157) reviewed under environment facility task by: 1. Failing to ensure the resident`s bilateral floor mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have tears and were in disrepair for Resident 201. This deficient practice had the potential to negatively affect Resident 201's psychosocial well-being and make the resident feel uncomfortable in their living space. 2. Failing to ensure the resident's floor was not sticky with yellowish stains on the floor where the urinal bottle (is a portable container used to collect urine, often by people who cannot easily access a toilet) was placed for Resident 157. This deficient practice had violated the resident's right to a safe, clean, comfortable, and homelike environment. Findings: a. During a review of Resident 201’s admission Record (AR), the AR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a baseline care plan (is an initial, temporary care document that is developed within 48 hours of a resident's admission, providing essential, person-centered care instructions to staff to ensure safety and continuity of care while a more comprehensive plan is developed) on the use of urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) with appropriate indication for one of three sampled residents (Resident 199) reviewed for urinary catheter. The deficient practice had a potential for delays in the delivery of necessary care and services and development of urinary tract infection (UTI, an infection in the bladder/urinary tract) in Resident 199. Findings: During a review of Resident 199's admission Record (AR), the AR indicated the facility admitted the resident on 8/23/2025, with diagnoses including muscle weakness, difficulty walking, and acute kidney failure (when the kidneys suddenly stop working properly, usually over hours or days). During a review…

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

Based on interview and record review, the facility failed to ensure the comprehensive care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) is reviewed and revised by the interdisciplinary team (IDT, is a group of people from different fields of expertise who work together and coordinate their efforts to solve a complex problem or reach a common goal) for one of two sampled residents (Resident 93) by failing to resolve the care plan on stage three (3) sacral coccyx pressure injury (a deep wound affecting the skin and fatty tissue below it, where the fat layer is visible but the bone, tendon, or muscle is not exposed). This deficient practice had the potential to negatively affect the provision of care and services for Resident 93. Findings: During a review of Resident 93's admission Record (AR), the AR indicated the facility admitted the resident on 6/10/2025, and readmitted the resident on 8/8/2025, with diagnoses including pressure ulcer of sacral region stage three (3), muscle weakness, and difficulty of…

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

Based on observation, interview, and record review, the facility failed to provide care and services necessary to maintain safe and good nutrition for one (1) of three (3) sampled resident (Resident 101) reviewed for activities of daily living (ADLs - routine/tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) care area by failing to ensure Certified Nursing Assistant (CNA) 3 provided assistance to Resident 101 with meals as indicated in the meal ticket. This deficient practice placed Resident 101 at risk for weight loss, dehydration (a condition that occurs when the body loses more fluids than it takes in), or nutritional problems, and accidents such as choking. Findings: During a review of Resident 101's admission Record, the admission Record indicated the facility originally admitted the resident on 5/27/2025, and readmitted in the facility on 6/7/2025, with diagnoses including generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents who were incontinent of bladder (a loss of control over when urinating, causing urine to leak out accidentally) received services and assistance for two of three sampled residents (Residents 157 and 188) reviewed for bladder and bowel incontinence by failing to label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) of the residents with the name and room number. The deficient practices had the potential to cause cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to to another) and increase the risk of urinary tract infection (UTI, an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra) due to the switching of urinals. Findings: 1.During a review of Resident 157's admission Record (AR), the AR indicated the facility admitted the resident on 8/26/2024, and readmitted the resident…

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

Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of EF for one (1) of two (2) sampled resident (Resident 18) reviewed for tube feeding by failing to ensure the EF was started timely as ordered by the physician. This deficient practice had the potential to result in altered nutritional status such as dehydration (a condition that occurs when the body loses more fluids than it takes in), malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough of the right things), and complications associated with enteral feeding like gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea which may lead to weight loss. Findings: During a review of Resident 18's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 parenteral fluids (liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one (1) of one (1) sampled resident (Resident 177) reviewed during a random observation by failing to ensure Registered Nurse (RN) 1 labeled the intravenous (IV - thru the vein) antibiotic (medication used to treat infection) bag with the date and time it was administered. This deficient practice placed Resident 177 at risk for developing complications such as inflammation of the vein and infection. Findings: During a review of Resident 177's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 4/14/2022 and readmitted in the facility on 7/21/2025, with diagnoses including chronic osteomyelitis (a bone infection not completely cured after treatment which can linger for months or years),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Residents 173 and 52) reviewed for respiratory care by failing to ensure: 1.Resident 173's suction canister (is a container used with a medical suction machine to collect and store fluids removed from a patient's body) was changed every seven (7) days and labeled with the date it was last changed. 2.Resident 173's suction tubing (a flexible tube, typically for medical or industrial use, that connects a vacuum source to a device or catheter to remove fluids, secretions, or debris from a specific area) dated 3/18/2025 was discarded and changed every (7) days. 3.Resident 52's oxygen tubing had a label including the date and time of when it was last changed. The deficient practices had the potential for the residents to develop complications such as shortness of breath and desaturation (low levels of oxygen 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 interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) treatment, received services consistent with professional standards of practice for one (1) out of one (1) sampled resident (Resident 16) reviewed under the dialysis care area by failing to ensure the post dialysis assessment was completed on 8/23/2025. This deficient practice placed the resident at risk for unmonitored development of complications related to renal disease (a condition when the kidneys get damaged and unable to properly filter waste and extra fluid from the blood) like swelling, high blood pressure and shortness of breath. Findings: During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 11/19/2018, and readmitted in the facility on 7/11/2024, with diagnoses including End Stage Renal Disease (ESRD - irreversible kidney failure), dependence on renal dialysis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide trauma-informed care (a framework for understanding and responding to the effects of trauma in individuals, families, and communities) for one of two sampled residents (Resident 42) reviewed for behavior-emotional care area by: 1.Failing to ensure appropriate referrals were provided to Resident 42 when the resident had a history of trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) in the past. 2.Failing to complete a timely trauma-informed care assessment. 3.Failing to conduct an interdisciplinary team (IDT - professionals from various disciplines who collaborate to address a patient's complex needs, aiming for a coordinated and comprehensive care plan) meeting to address the resident's specific needs These deficient practices may result in delayed identification of underlying trauma-related issues, which could compromise Resident 42's…

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

Based on interview and record review, the facility failed to provide necessary behavioral health care and services for one of two sampled residents (Resident 42) reviewed for behavior-emotional care area when the facility failed to conduct a behavioral interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) meeting on the use of Seroquel (an antipsychotic medication used to treat several kinds of mental health conditions) and escitalopram (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]). This deficient practice had the potential to negatively affect the delivery of care and services the resident needed. Cross reference F656 Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 8/15/2023 with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1.Accurately account for one dose of oxycodone/APAP (a controlled medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) affecting Resident 7 in one of five inspected medication carts (Station 2 Cart C.) 2.Administer one dose of lidocaine (a topical adhesive patch that delivers a local anesthetic to a specific area of the body to relieve pain) four percent (% - one part in every hundred) for one of five sampled resident (Resident 51) reviewed during pain management care area. This deficient practice of failing to maintain accountability of controlled substances increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations (medications with a high risk for diversion) and the risk that Resident 7 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one opened Humulin 70/30 (a medication used to control high blood sugar) insulin pen was labeled with an open date as required by the manufacturer's specifications affecting Resident 172 in one of five inspected medication carts (Station 3 Cart A.) The deficient practice of failing to label open insulin pens with an open date increased the risk that Resident 172 may have insulin that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 2:20 p.m. of Station 3 Cart A with the Licensed Vocational Nurse (LVN 10), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1.One opened Humulin 70/30 pen for Resident 172 was…

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

Based on interview and record review, the facility failed to administer the pneumococcal vaccine (helps protect children and adults from various types of pneumococcal bacteria causing lung infection) to two of five sampled residents (Residents 106 and 202) after the two residents had provided their consent to receiving the vaccine and the physician ordered the vaccine administration. These failures placed Resident 106 and Resident 202 at a higher risk of acquiring and transmitting pneumonia (an infection/inflammation in the lungs) to other residents in the facility. Findings: 1.During a review of Resident 106's admission Record, the admission Record indicated the facility admitted Resident 106 on 8/12/2025, with diagnoses including hemiplegia (total paralysis [unable to move or feel] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of your body that can affect your arm, leg, or face) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage and death), unspecified organism…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer Coronavirus Disease 2019 (COVID-19 - an infectious disease that most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment) vaccine to one of five sampled residents (Resident 106) after the residents had provided their consent to receiving the vaccine. This failure placed Residents 106 at a higher risk of acquiring and transmitting COVID-19 to other residents and staff in the facility. Findings: During a review of Resident 106's admission Record, the admission Record indicated the facility admitted Resident 106 on 8/12/2025, with diagnoses including hemiplegia (total paralysis [inability to move or feel] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of your body that can affect your arm, leg, or face) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage and death), unspecified organism (unconfirmed) pneumonia (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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) received medication as prescribed by failing to:1. Ensure Resident 3 received Eliquis (a prescription that prevents blood clots from forming and stops existing clots from getting bigger).2. Ensure Resident 3 received Femara (a medication that helps treat certain types of breast cancer)3. Ensure Licensed Vocational Nurse (LVN) 1 signed off the Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering Resident 3's medications.These deficient practices had the potential for Resident 3 to be negatively affected.Findings:During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident on 7/2/2025 with diagnoses including chronic obstructive pulmonary disease (COPD--a chronic lung disease causing difficulty in breathing), with exacerbation (a worsening of symptoms or a flare-up of a disease or condition), other specified type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 topical cream for pain (Diclofenac Sodium- medicated gel to treat pain) was not left at the resident's bedside drawer for one of three sampled residents (Resident 2) and that and Resident 2 was assessed for self-administration of Diclofenac Sodium. This deficient practice had the potential to place other residents at risk to have access to Diclofenac Sodium and misuse the medication.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 9/27/2024 and readmitted on [DATE] with diagnoses including malignant neoplasm of rectum (cancer that starts as a growth of cells in the rectum {last several inches of the large intestine}) and hypotension (low blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 2 was intact with thought process and required supervision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the call light of one of three sampled residents (Resident 1) was within reach. This deficient practice had the potential for Resident 1's needs to be not met when Resident 1 calls for help. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on10/29/2024 and readmitted on [DATE] with a diagnosis of hypertensive (high blood pressure) and history of falling. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/22/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a record review of Resident 1's Care Plan titled actual fall, dated 6/27/2025, the Care Plan intervention indicated keep call light within reach.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's pain was managed as indicated in the facility's Pain Assessment and Management policy for one of six sampled residents (Resident 6) by failing to: 1. Ensure Resident 6's pain medication, morphine sulfate extended release (medication to manage moderate to severe pain) scheduled every 12 hours for pain management, was administered according to the physician order. 2. Ensure Resident 6's pain medication, oxycodone with acetaminophen (medication to manage severe pain) 10-325 milligrams (mg - unit of measurement), scheduled every four hours as needed, was administered according to the physician order. 3. Ensure Resident 6's pain medication, oxycodone with acetaminophen (medication to manage moderate pain) 5-325 mg, scheduled every four hours as needed, was administered according to the physician order. 4. Ensure Resident 6's pain medication, acetaminophen (medication used to treat mild pain and to reduce fever) 325 mg, scheduled every four hours as needed, was administered according to the physician order.…

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

Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented by failing to: 1. Ensure Resident 1 had a care plan that addressed the resident's possession of a vaping device (a battery-powered device that simulates smoking). 2. Ensure Resident 1's care plans were accurately and completely documented. These deficient practices had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition such as worsening of Resident 1's respiratory diseases. Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 5/15/2025 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), asthma (a disease that affects the lungs), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor…

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

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Licensed Nurses documented the level of care provided to Resident 1 after the resident was found in possession of a vaping device (a battery-powered device that simulates smoking). This deficient practice resulted in incomplete information on Resident 1's medical records and had the potential for delayed medical interventions. Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 5/15/2025 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), asthma (a disease that affects the lungs), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow). During a review of Resident 1's History and Physical (H&P- a medical examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for three of four sampled residents (Resident 2, Resident 3, Resident 4), when the facility failed to inform Resident 2, Resident 3, and Resident 4 verbally and in writing of the findings of the investigations and the actions that were taken to correct the identified problems. This deficient practice had the potential to violate the rights of Resident 2, Resident 3, and Resident 4. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including difficult walking, low back pain, and muscle weakness (generalized). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required substantial assistance (helper does more than half the work)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary treatment and services for one of four residents (Resident 1) at risk for developing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow its Policy and Procedures (P&P) titled, Pressure Injury Risk Assessment, that indicated to do weekly skin assessments for the first four weeks. This deficient practice had the potential for Resident 1's wounds to worsen. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including muscle weakness (generalized), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and end stage renal disease (ESRD- irreversible kidney failure). During a review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 4) by failing to: 1. Ensure Resident 4 ' s oxygen tubings were dated when it was changed. 2. Ensure Resident 4 ' s oxygen tubings were kept inside an oxygen supplies bag when not in use. 3. Ensure Resident 4 ' s oxygen tubings were not touching unclean surfaces. These deficient practices had the potential for Resident 4 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections. Findings: During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/5/2021 with diagnoses including shortness of breath, osteoarthritis (condition that causes the joints to become very painful and stiff), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a record review of Resident 4 ' s Minimum Data Set (MDS – a resident assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control precautions when two Licensed Vocational Nurses (LVN 1 and LVN 2 ) were inside an enhanced barrier precaution (interventions designed to reduce the transmission of infections) room changing a gastrostomy tube (a flexible tube inserted through the abdominal wall into the stomach) feeding, without personal protective equipment (equipment worn to minimize exposure to hazards that cause illness) for one of five resident samples (Resident 1). This deficient practice could have resulted in the spread of infections to staff, visitors, and staff. Findings: A record review of Resident 1 ' s admission Record, admission Record indicated the resident was admitted on [DATE] with diagnosis including moyamoya disease (a disease that constricts arteries in the brain), atherosclerosis (the buildup of fats), gastrostomy (a surgical procedure that creates an opening in the stomach) malfunction, dysphagia (inability to swallow),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the attending Medical Doctor (MD) 1 of one of three sampled residents (Resident 1) who had a significant change of condition (COC - a major decline in a resident's health status) when Resident 1's last recorded urine output (refers to the amount of urine produced and excreted by the body over a specific period of time) was on 3/10/2025 at 7:39 p.m. in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, which indicated the facility will notify the resident's attending physician when there was a significant change in the resident's condition, or when there was a need to transfer the resident to a general acute care hospital (GACH). This deficient practice resulted to a delay in transferring Resident 1 to GACH 1 on 3/12/2025 at 3:08 a.m. who was diagnosed with acute urinary retention (the inability to fully empty your bladder, meaning urine stays inside instead of being passed out) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor one of three sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - an infection in the bladder/urinary tract), who had no urinary output (refers to the amount of urine produced and excreted by the body over a specific period of time). This deficient practice resulted to Resident 1 being transferred to General Acute Care Hospital (GACH) 1 on 3/12/2025 at 3:08 a.m. and was diagnosed with acute urinary retention (the inability to fully empty your bladder, meaning urine stays inside instead of being passed out) and urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/7/2025 with diagnoses including UTI, benign prostatic hyperplasia (BPH- a common condition in men where the prostate gland grows larger than normal, but not due to cancer, potentially causing urinary…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA). 2. Ensure an ADM was present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT)/Operations Manager (OM) was performing administrative tasks without the presence of the ADM at the facility. These deficient practices resulted in the facility operating without a licensed ADM that had the potential to negatively affect the facility ' s functions. Findings: During an observation and concurrent interview on 3/13/2025 at 9 a.m., observed ADM 1 ' s license was posted at the facility ' s lobby. The Assistant Operation Manager (AOM) stated ADM 2 was attending a corporate conference and had not been in the facility since 3/10/2025. During a record review of the Department Head Directory on 3/13/2025 at 9:15 a.m., the Department Head Directory indicated ADM 2 was the facility ' s ADM. During an 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 one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: 1. Ensure Resident 1's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to appropriate setting per manufacturer's guidelines. 2. Ensure Resident 1 had the correct number of bed linen layers between the resident and the LALM. 3. Ensure Resident 1's oxygen nasal cannula (a device used to deliver supplemental oxygen) was not pressing on the resident's face. 4. Ensure Resident 1 had the foam dressing (used to prevent pressure ulcers) per physician orders. These deficient practices had placed Resident 1 at risk for the development of pressure ulcers. Findings: During a record review of Resident 1's admission Record, 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 one of six sampled residents (Resident 1) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to: 1. Ensure Resident 1's urine output was monitored for presence of sediments. 2. Ensure Resident 1's urinary catheter stoma (a surgically created opening on the abdomen that allows waste to be diverted from the body to the outside) had a wound dressing (a material placed directly on a wound to protect it and help it heal). 3. Ensure Resident 1's urinary catheter drainage bag was not touching the floor. These deficient practices resulted to Resident 1's urinary catheter drainage bag with yellow, cloudy urine with visible sediments during an observation on 1/14/2025 at 11:58 a.m. On 1/17/2025, Resident 1's Laboratory Results Report, dated 1/17/2025, of the resident's urinalysis (urine test) indicated a white blood count (measures the number of white blood cells [WBCs - a part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document blood pressure before holding (not administering) amlodipine (medication used to treat high blood pressure) per physician order. This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included chronic respiratory failure (happens when not enough oxygen passes from your lungs to your blood) with hypoxia (low levels of oxygen in your body tissues), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and acute bronchiolitis (airway inflammation and obstruction). During a record review of Resident 1's Minimum Data Set (MDS - a 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 interview and record review, the facility failed to ensure that one of four sampled residents (Resident 4) who had a urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services by failing to ensure the physician's order was followed when Resident 1 had a change in condition. This deficient practice had the potential to result in uncontrolled pain and may cause a delay in wound healing. Findings: During a record review of Resident 4's admission Records, the admission Record indicated the facility admitted Resident 4 on 3/12/2024, with diagnoses that included unspecified (unconfirmed) obstructive (a condition in which the flow of urine is blocked) and reflex uropathy (a condition that occurs when urine flows backward from the bladder into the ureters and kidneys), benign prostatic hyperplasia (BPH- a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination) without urinary tract symptoms. During a record review of Resident…

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

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) who was prescribed Vancomycin (an antibiotic [medicines that fight bacterial infections] used to treat and prevent various bacterial infections) intravenous solution (IV- fluids given directly into the blood stream) received the full prescribed dose. Resident 2 missed the prescribed Vancomycin for 15 days. This deficient practice had the potential for Resident 2's infection to worsen. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 5/26/2024 and readmitted the resident on 9/21/2024 with diagnoses including gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) not elsewhere classified, sepsis (a life-threatening blood infection) unspecified organism, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/2024,…

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.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free of any significant medication error when the facility failed to administer Vancomycin (an antibiotic [medicines that fight bacterial infections] used to treat and prevent various bacterial infections) intravenous solution (IV- fluids given directly into the blood stream) received the full prescribed dose. Resident 2 missed the prescribed Vancomycin for 15 days. This deficient practice had the potential for Resident 2's infection to worsen. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 5/26/2024 and readmitted the resident on 9/21/2024 with diagnoses including gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) not elsewhere classified, sepsis (a life-threatening blood infection) unspecified organism, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2's Minimum Data Set (MDS - a…

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

Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 4) received proper assistive devices to maintain hearing abilities by failing to ensure Resident 4 was wearing hearing aids as prescribed by the physician. This deficient practice had the potential to affect Resident 4 psychosocially when Resident 4 is unable to hear. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 12/1/2023 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), general anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 4's Resident's Clothing and Possession form dated 12/1/2023, the form indicated the resident had hearing aids. During a review of Resident 4's Minimum Data…

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

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services for one of four residents (Resident 2) at risk for developing pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow the manufacturer guideline for low air loss mattress. This deficient practice had the potential for Resident 2's wounds to worsen. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 5/26/2024 and readmitted the resident on 9/21/2024 with diagnoses including gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) not elsewhere classified, sepsis (a life-threatening blood infection) unspecified organism, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (intentional bodily injury) by a resident for one of three (Resident 1) sampled residents when on 9/17/2024, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 hit Resident 1 on the shin with a closed fist. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 3/19/2024, with a diagnosis of non-traumatic intracerebral hemorrhage in hemisphere (a life-threatening type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the brain tissue), subcortical (part of the brain below the cerebral cortex [outer layer of your brain's surface]). During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure on abuse reporting by failing to report immediately, but no later than two hours after the allegation is made, an allegation of resident to resident abuse, to the State Survey Agency (SSA), the Ombudsman and the local law enforcement agency for two of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in a delay of notifying the necessary agencies and may have placed the residents at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 3/19/2024, with a diagnosis of non-traumatic intracerebral hemorrhage in hemisphere (a life-threatening type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the brain tissue), subcortical (part of the brain below the cerebral cortex [outer layer of your brain's surface]). During a review of Resident 1 ' 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 residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of five sampled residents (Residents 90, 118, and 49) investigated during review of physical restraints care area by failing to obtain a consent for use of bed rails (bars or boards that are attached to the side of a bed to help people move around and reduce the risk of falling) and perform quarterly bedrail assessment for entrapment. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position 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 develop and implement a comprehensive person-centered care plan (reflect shared decisions made with patients, caregivers and families about tests, interventions, treatments, and other activities needed to achieve the goals of care) for four (Resident 63, 171, 107, and 170) out of 36 sampled residents by: 1. Failing to ensure Resident 63 had a care plan (CP) addressing the resident's urinary tract infection (UTI - a condition that happens when bacteria overcome the body's defenses in the urinary system) and the use of ceftriaxone (a type of antibiotic used to treat bacterial infection and can be administered into one of the muscles or through a needle placed in one of the veins). This deficient practice had the potential to result in staff not knowing about the resident's change of condition and treatment. 2. Failing to ensure Resident 171 had a CP for providing Responsible Party 1 (RP 1) caregiver training (a hands-on strategies and skills caregivers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1.2. During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, and readmitted the resident on 7/18/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that causes high blood sugar levels because the body doesn't produce enough insulin or doesn't use it properly), dysphagia (difficulty swallowing), and generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed). During a review of Resident 165's History and Physical (H&P), dated 7/22/2024, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 165's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (lowers blood sugar) including insulin. 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 Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) for four of five sampled residents (Resident 63, 49, 52, and 55) investigated during review of pressure injury by failing to: 1. Ensure Resident 63's weekly Comprehensive Skin Evaluation/Assessment was done for the week of 8/25/2024 to 8/31/2024. 2. Set Resident 49 and 52's Low Air Loss Mattress (LALM, a type of air mattress that helps prevent and treat pressure wounds by regulating temperature and moisture levels of a patient's skin) according to the resident's weight. 3. Ensure Resident 55 were not placed on multiple layers of bed linens while on a low air loss mattress. These deficient practices had the potential for the development and worsening of pressure ulcers/injuries. Findings: 1. During a review of Resident 63's admission Record, the record indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for five of nine sampled residents (Resident 79, 15, 161, 50, and 111) reviewed under the Accidents care area, by failing to: 1. Ensure Resident 79's albuterol inhaler (medication that is breathed in to relieve shortness of breath) was not left at bedside and readily available for use by residents. 2. Ensure Resident 15 was identified as a smoker, had a smoking evaluation completed including a smoking risk assessment with interventions, and that the resident did not have smoking items readily available at bedside. 3. Ensure Resident 161's sensor pad alarm (a device that triggers an audible alarm when a patient attempts to rise off the pad) in bed was properly functioning for one (1) out of seven (7) sampled residents during a random observation. 4. Complete an assessment prior to use of the sensor pad alarm, reassessment for the continued use of the bed alar, obtain informed consent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents who need respiratory care are provided care consistent with professional standards of practice for three of seven sampled residents (Resident 16, 32, and 34) investigated during review of respiratory care area by failing to: 1.Ensure Resident 16 was administered oxygen (O2) per physician's order, oxygen was documented when administered, and oxygen was monitored while in use. 2. Ensure Resident 32 and 34 were administered oxygen per physician's order. These deficient practices had the potential to place residents at risk for respiratory distress. Findings: 1.During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 8/25/2024 with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues) and Coronavirus disease -2019 (COVID-19, 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 accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Residents 50 and 55 in two of five inspected medication carts (Station 1 Cart A and Station 3 Cart C.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Residents 50 and 55 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of Station 1 Cart A, on 9/14/24 at 3:12 PM, with the Licensed Vocational Nurse (LVN 1) the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 50's H&P, dated 8/23/2024, the H&P indicated the resident has fluctuating capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. During a review of Resident 50's Order Summary Report, dated 8/23/2024, the Order Summary Report indicated a physician's order to give Ativan oral tablet 0.5 mg my mouth two times a day for anxiety. During a concurrent interview and record review on 9/20/2024 at 9:38 a.m., with Quality Assurance Nurse 1 (QAN 1), QAN 1 reviewed Resident 50's Order Summary Report. QAN 1 stated there was no monitoring of anxiety behavior, side effect, and adverse effect for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for five (5) out of 5 sampled residents (Residents 36, 165, 5, 90 and 118 ) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) the insulin administration sites investigated under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: 1.1 During a review of Resident 36's admission Record indicated the facility admitted the resident on 11/13/2023 and readmitted the resident on 4/6/2024 with diagnoses including but not limited to urinary tract…

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

6. During a concurrent observation and interview on 9/14/2024 at 4:50 p.m., with the Infection Preventionist (IP), observe at nurse's station 1, medication cart 1 was unlocked, The IP stated medication carts must be locked at all times when not in use so residents and unauthorized staff will not have access to the medications in the cart. During an interview on 9/16/2024 at 12:44 p.m., with Registered Nurse 1 (RN 1), RN 1 stated medication carts must be locked at all the times when not in use to prevent residents from having access to medications which may result in residents experiencing adverse (unwanted) reactions. During a review of the facility policy and procedure (P&P) titled, Storage of Medications, last revised on 8/8/2024, the P&P indicated compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Based on observation, interview, and record review the facility failed to: 1. Label open latanoprost eye drops with 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 adequate oversight of the Food and Nutrition Services when the Registered Dietitian (RD) did not have oversight in the kitchen and Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS) did not carry out function of food services by failing to ensure: a. Staff reported the out-of-range temperatures of the reach-in refrigerator from 9/11/2024-9/14/2024. b. Recipe for creamed corned was available for staff and ensuring staff followed recipes for creamed corn for mechanical soft diets (diet consisted of food that are chopped half inches ([in] a unit of measurement) and puree cold cereal for puree diets (diet consisted of food with smooth, pudding-like consistency) producing inconsistent, watery, and lumpy foods. c. Staff followed spreadsheet portion sizes. Salisbury steak were only two (2) ounces ([oz] unit of measurement), three (3) oz instead of four (4) oz. d. Staff thawed meat safely in the preparation sink. This failure had a potential to result in inaccurate food textures, ineffective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen staff were routinely trained and evaluated for competency skills when staff: a .Failed to report out of range temperatures on 9/11/2024-9/13/2024 of the reach-in refrigerator and failed to verbalize safe refrigerator temperatures. b. Failed to serve 5 residents creamed corn for mechanical soft diet (diet consisted of food that are chopped half inches ([in] a unit of measurement). c. Failed to follow recipes for creamed corn and puree cold cereals. d. Failed to followed spreadsheet portion sizes for Salisbury steak. Residents were given two (2) to three (3) ounces ([oz], unit of measurement) instead of 4 oz. e. Failed to thaw ham in the sink safely. This failure had a potential to result in inaccurate food textures, ineffective therapeutic diets, difficulty in swallowing, chewing, eating and food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) of 169 of 179 residents who are on Puree diet and Mechanical soft diets and regular diets (diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 81 of 81 residents on regular texture (diet with no texture restriction) and 5 of 62 residents on mechanical soft (diet consisted of food that are chopped half inches ([in] a unit of measurement) or less and restrict food that are difficult to chew or swallow) when: a. Staff served 5 residents on soft mechanical diet confetti corn instead of creamed corn. b. Staff served two (2) to three (3) ounces ([oz], unit of measurement) instead of four (4) oz Salisbury steak to regular and large portions diet. c. [NAME] did not follow recipe for confetti corn. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss. Cross reference F804. Findings: a. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024, the Fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food by methods that conserved flavor and appearance when: a. There was no recipe for creamed corn cereal and cook did not follow puree cold cereal recipe resulting to watery and lumpy cold cereal. b. Cooks did not follow the recipe for confetti corn and its was missing green bell peppers affecting color contrast presentation. c. Staff did not use parsley as garnish indicated on the menu spreadsheet. d. Puree eggs were bland and lacking in flavor. This deficient practice placed 169 of 179 facility residents on regular consistency texture (texture with no restriction) and texture modified diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Cross reference to F803 and F805 Findings: a. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024, the Fall Menus indicated residents on mechanical soft diet and dysphagia mechanical soft would receive ½ cup ([c], household measurement) of creamed corn. During 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.

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (diet with consisting with soft, pudding like consistency foods) received watery, lumpy cold cereals as cook did not follow the recipe for puree cold cereal. This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 14 of 169 residents on puree diets. Findings: a. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/15/2024), the Fall Menus indicated residents on pureed International Dysphagia Diet Standardization initiative ([IDDSI], a global initiative to standardized diet of people with difficulty swallowing) included the following foods: Apple juice 4 ounces ([oz], a unit of measurement) Puree raisin bran ½ cup ([c], a household measurement) Puree Baked Italian Omelet 1/3 c. Puree Danish 1/3 c. Milk 8 oz. During a concurrent test tray (process of tempting and tasting the food) and interview on 9/15/2024 at 8:17 a.m. with 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 and sanitary food storage and food preparation practices in the kitchen when: a. The thermometers inside the walk-in refrigerator and reach-in refrigerator were broken. b. There was an expired tuna salad dated 9/13/2024. c. Two (2) sliced turkey packs were at 44.4 degrees Fahrenheit ([°F] a degree of temperature) and 42.3°F inside the walk-in refrigerator and sliced cheese was at 47°F was in the reach-in refrigerator. The reach-in refrigerator roof had dirt buildup. d. Shelves in the walk-in freezer and dishwashing area were rusty and not smooth. e. Six (6) chopping boards had scratches and chopping board racks had grease buildup. f. Cook was wearing two (2) gold bracelets during food preparation. g. There was no running water in the sink during thawing of two (2) packets of ham and it was not submerged in water. h. Staff did not clean and sanitize the thaw sink in between thawing of ham and washing of raw vegetables. i. Broken plate warmer had dirt and food debris. j. Thirty five out of 50…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 6. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 50's H&P, dated [DATE], the H&P indicated that resident has fluctuating capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. During a review of Resident 50's Order Summary Report, dated [DATE], the Order Summary Report indicated an order for oxygen at two liters per minute (LPM, a unit of measure for volume and time) via nasal cannula to keep oxygen saturation at/above 93% for shortness of breath (SOB) and wheezing (a high-pitched whistling sound made while breathing). May titrate up to two to five LPM to maintain saturation between 88-90 % every shift. During a concurrent observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain the kitchen reach-refrigerator by the trayline area (an area where food was assembled) in a safe operating condition. This deficient practice had the potential to result in food stored in the danger zone temperatures (a temperature range in which disease-causing bacteria grow best) that could lead to foodborne illness in 169 of 179 medically compromised residents who received food from the kitchen. Cross reference F812 Findings: During an observation on 9/14/2024 at 8:16 a.m. in the reach-in refrigerator area by trayline, reach-in refrigerator containing peanut butter and jelly sandwiches, milk, cheeses, and other food items had inside thermometer that was at 45 degrees Fahrenheit ([°F], a degree of temperature). During concurrent observation, interview and record review on 9/14/2024 at 11:25 a.m. with the Dietary Supervisor (DS), Cold Storage Temperature Log, dated 9/2024 was reviewed. The Cold Storge Temperature Log indicated, the reach-in refrigerator temperature on 9/11/2024 was at 42°F, 45°F 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 honor the resident's right to a dignified existence for one of two sampled residents (Resident 165) investigated during review of dignity care area by failing to ensure Certified Nursing Assistant 1 (CNA 1) did not stand over Resident 165 while assisting the resident during a meal. The deficient practice had the potential to affect the resident's self-esteem and loss of dignity. Findings: During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, with diagnoses including hemiplegia (a condition that causes paralysis or weakness on one side of the body), hemiparesis (a condition that causes partial paralysis or weakness on one side of the body), and dysphagia (difficulty swallowing). During a review of Resident 165's History and Physical (H&P), dated 7/22/2024, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 165's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2024,…

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.

Based on observation, interview, and record review, the facility failed to assess if a resident was capable and trained to perform self-administration of medication safely before leaving a nasal spray (a liquid medicine that is sprayed into the nose to deliver medication) at bedside for one of 61 sampled residents (Resident 50) who were observed during resident screening. This deficient practice had the potential to violate the resident's right to be assessed for capacity and to be informed of their ability to self-administer medications and had the potential to result in unsafe medication administration. Cross reference to F689 Findings: During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 50's History & Physical (H&P), dated 8/23/2024, the H&P indicated the resident has fluctuating capacity to understand and make decisions. During a review…

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

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of two residents (Resident 55) investigated during review of environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings: During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 7/31/2017 with diagnoses that included spinal stenosis(a narrowing of the spinal canal in the lower back that may cause pain or numbness in the legs) of the lumbar region (the lower back), legal blindness (a level of visual impairment that limits the activities performed by individuals without assistance), hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 immediately inform the resident representative when the physician ordered to transfer the resident to general acute care hospital 1 for one of three sampled residents (Resident 49) investigated under hospitalizations. This deficient practice had violated the resident's responsible party's right to be inform of the care services provided. Findings: During a review of Resident 49's admission Record, the record indicated the facility admitted the resident on 1/4/2024, and readmitted the resident on 5/13/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide) with hypoxia (low levels of oxygen in the body tissues), asthma, and shortness of breath. During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/1/2024, the MDS indicated the resident had the ability to makes self-understood and understand others. During a review of Resident 49's Progress Notes, dated 2/20/2024,…

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.

Based on interview and record review, the facility failed to provide the notification of transfer or discharge to the resident or resident representative and send a copy of the notification to the ombudsman (a long-term care resident advocate) for one of one sampled resident (Resident 51) investigated during review of hospitalization care area. This deficient practice had the potential for Resident 51 to have an unsafe discharge. Findings: During a review of Resident 51's admission Record, the record indicated the facility admitted the resident on 12/26/2023 and readmitted in the facility on 3/18/2024 with diagnoses including but not limited to acute and chronic respiratory failure with hypoxia (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), stage three (3) pressure ulcer (also known as bed sores, a localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear), and generalized muscle weakness. During a review of Resident 51's History and Physical (H&P) dated 3/19/2024,…

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 residents who had a Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure all residents to a nursing facility are evaluated for serious mental disorder [clinically significant disturbance in an individual's cognition, emotional regulation, or behavior] and receive the services they need) Level I pre-screen that was negative and were later identified with a serious mental disorder were referred for a Level II evaluation (provides a determination of an individual's mental health needs) for two of two sampled residents (Residents 55 and 26) reviewed under the PASSAR care area. This deficient practice had the potential to result in residents not receiving services specified by the State that exceed the services ordinarily provided by the nursing facility that may include hiring additional staff or contractors such as qualified health/intellectual disability professionals. Findings: a. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the services, care, and equipment for residents with limited range of motion (ROM, a full movement of a joint) for one of one sampled resident (Resident 170) by failing to: 1. Provide Resident 170 with controlled ankle motion (CAM, an orthopedic device prescribed for the treatment and stabilization of severe sprains) as evaluated by the resident's physical therapist. 2. Develop care plan interventions addressing the resident's mobility with the use of CAM boot. This deficient practice had the potential to result in a decline in the resident's mobility. Cross refence F656 Findings: During a review of Resident 170's admission Record, the record indicated the facility originally admitted the resident on 7/30/2024 and readmitted the resident on 8/10/2024 with diagnoses including end stage renal disease (ESRD, the kidneys cease functioning on a permanent basis), difficulty in walking, and history of falling. During a review of Resident…

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

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, a condition that happens when bacteria overcome the body's defenses in the urinary system) for one out of one sampled resident (Resident 51) investigated during a random observation by: 1. Failing to ensure the resident's indwelling urinary catheter (a device that drains urine from the urinary bladder into a collection bag outside of the body) drainage bag was hanging on the side of the bed below the resident's bladder. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI. 2. Failing to ensure indwelling urinary catheter tubing was secured with a securement device per facility policy and procedure. This deficient practice had the potential for the resident's catheter tubing to be pulled accidentally causing trauma ad discomfort which may lead to development of UTI. Findings: During a review of Resident 51's…

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

Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate care and services to prevent complications of enteral feeding for one (1) out of 1 sampled resident (Resident 52) investigated under the tube feeding care area when Resident 52's medication piston syringe (a type of syringe used to administer medication and irrigate the feeding tube) was not rinsed properly after use. This deficient practice had the potential for the resident to experience gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: During a review of Resident 52's admission Record, the record indicated the facility admitted the resident on 9/5/2017 and readmitted the resident on 6/11/2024 with diagnoses including but not limited to gastrostomy (G-tube, a surgical procedure used to insert a tube through the abdomen and into the stomach), chronic respiratory failure (chronic…

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

Based on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of four sampled residents (Resident 68) reviewed under the dialysis care area by failing to ensure licensed nurses performed and documented assessments before and after Resident 68's hemodialysis sessions. This deficient practice placed the resident at risk for a delay in care and services and a delay in detecting complications resulting from HD. Findings: During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 11/19/2018 and readmitted the resident on 7/11/2024 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), dependence on renal dialysis, hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and diabetes mellitus (a chronic condition that affects the way 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 2. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2022, with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure) and hypothyroidism (when the thyroid {a large cartilage of the larynx [area of the throat containing the vocal cords]} gland doesn't make enough thyroid hormone). During a review of Resident 111's History & Physical (H&P), dated 9/14/2023, the H &P indicated the resident has the capacity to make decisions. During a review of Resident 111's MDS, dated [DATE], the MDS indicated that resident needs partial/moderate assistance during oral hygiene, upper body dressing, personal hygiene, and substantial/maximal assistance during toileting hygiene, lower body dressing, putting on/taking off footwear, and dependent assistant during shower. During a review of Resident 111's care plan titled, Nutrition Risk, revised on 6/18/2024, the care plan indicated the goals that included…

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

2.During a review of Resident 129's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 8/12/2024, with diagnosis of Wernicke's encephalopathy (an acute neurological condition characterized by a clinical triad of ophthalmoplegia (weakness in the muscles that control eye movement), ataxia (poor muscle control that causes clumsy movements), and confusion). During a review of Resident 129's History & Physical (H&P), dated 8/23/2024, indicated that resident has the capacity to understand and make decisions. During a review of Resident 129's Change of Condition Evaluation dated on 9/10/2024, the change of condition evaluation indicated Resident 129 had abdominal pain and urinary retention. The physician gave orders to insert foley catheter (a flexible tube that is inserted into the urethra to drain urine from the bladder), make an appointment for urology (branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) consult, and obtain Complete Blood Count (CBC, a blood test 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 develop and implement policies and procedures that provides coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) vaccines to all residents and staff that chooses to receive them by failing: 1. To complete the COVID-19 Consent Form for one of three sampled residents (Resident 1) whose responsible party consented for Resident 1 to receive it (COVID-19 vaccine). 2. To maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status for four of four sampled staff (LVN 1, LVN 2, CNA 1, and CNA 2). This deficient practice had the potential to result in increased risk of infection and placed Resident 1 and other residents at risk for severe illness, hospitalization, or complications from the virus. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 10/5/2023 and readmitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for one of one sample resident (Resident 4) by failing to administer ketoconazole (medication used to treat infections caused by a fungus or yeast) as ordered. This deficient practice had the potential to result in decreased efficacy and potential for the infection to worsen. Findings: A review of Resident 4 ' s admission Record indicated the facility originally admitted the resident on 8/1/2023 and readmitted on [DATE] with diagnoses including bronchitis (an inflammation of the airways leading into your lungs) and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body tissues). A review of Resident 4 ' s History and Physical, dated 2/8/2024, 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 observation, interview, and record review, the facility failed to implement infection prevention and control program by failing to implement staff coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) screening and antigen testing policy and procedure including appropriate timing, documentation, and submission of the staff ' s COVID-19 antigen test results. These deficient practices had the potential to result in increased of transmission of COVID-19 infections among residents and staff. Findings: During a concurrent observation and interview on 9/4/2024 at 9:10 a.m., entered testing area through hallway from the kitchen area. The Director of Staff Development (DSD) stated all staff are tested before the start of their shift and signed off by her or the DSD Assistant. During a concurrent observation and interview on 9/4/2024 at 9:23 a.m., the DSDA provided the completed testing forms filled out and signed off for the 7 a.m. to 3 p.m. shift as of 9:23 a.m. During a concurrent interview and record review of the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility ' s governing body established and implemented policies and procedure from 6/15/2023 to 8/29/2024 for the use or non-use of video surveillance cameras installed in the facility. This deficient practice placed the residents at risk for privacy concerns. Findings: During an observation on 8/27/2024 from 8:36 a.m. to 10:30 a.m., observed multiple video surveillance cameras installed in the hallway of all three nursing stations including near kitchen, dining area, and activity room hallways where multiple residents were seen passing by. During an interview on 8/27/2024 at 11:25 a.m., the Director of Nursing 2 (DON 2) stated their company (facility) had stopped paying the old company who was managing their old video surveillance system because they would not grant access to their new employees. The DON 2 stated the Administrator (ADM) spoke with the person who was running their video surveillance system because they would not give her access to the video surveillance system. The DON 2 stated no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for one of two sampled residents (Resident 2) by failing to ensure Resident 3 ' s television volume level was not at maximum level, particularly during sleeping hours/quiet time per facility ' s policy. This deficient practice had the potential to affect the comfort of Resident 2 and placed the Resident 2 at risk for difficulty sleeping, irritability, and at risk for conflict among roommates. Findings: A review of Resident 2 ' s admission Record indicated the facility originally admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso) and injury of cervical (neck) spinal cord. A review of Resident 2 ' s Admission/readmission Evaluation/Assessment, dated 8/19/2024, indicated the resident was alert, cognitively intact, with adequate vision and hearing, and paralysis of the extremities and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide prompt resolution of grievances for one of two sampled residents (Resident 2) by failing to take the appropriate interventions to resolve Resident 2 ' s grievance related to his roommate ' s television volume at maximum level, particularly during sleeping hours. This deficient practice had the potential for Resident 2 ' s grievances to go unnoticed causing frustration and distress to the resident; and had the potential to result in a delay of care and services. Findings: A review of Resident 2 ' s admission Record indicated the facility originally admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso) and injury of cervical (neck) spinal cord. A review of Resident 2 ' s Admission/readmission Evaluation/Assessment, dated 8/19/2024, indicated the resident alert, cognitively intact, adequate visions and hearing, and paralysis of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to maintain hearing abilities by not assisting in arranging provision for one of one sampled resident (Resident 3) by failing to follow through Resident 3 ' s hearing test appointment as ordered. This deficient practice had the potential to result in worsening of Resident 3 ' s condition and could affect the resident's daily activities and overall well-being. Findings: A review of Resident 3 ' s admission Record indicated the facility originally admitted the resident on 12/31/2018 and readmitted on [DATE] with diagnoses including paraplegia (paralysis that occurs in the lower half of the body) and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy). A review of Resident 3 ' s Social History Assessment, dated 4/8/2024, indicated resident ' s cognition was intact and Resident 3 was…

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

Based on interview and record review, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice to one of two sampled residents (Resident 5) by failing to obtain a physician order for Resident 5 ' s breathing treatment (involve inhaling medications using a nebulizer/humidifier device [a small machine that turns liquid medicine into a mist that can be easily inhaled]) when a resident had a change in condition. This deficient practice had the potential to place Resident 5 at risk for receiving unnecessary breathing treatment not indicated for the resident's current medical condition. Findings: A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 7/28/2024 with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body tissues) and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow) with (acute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of three sampled residents (Resident 1) when on 8/20/2024 in Resident 1 ' s room observed red stains on ceiling above Resident 1 ' s bed. This deficient practice had the potential to negatively impact the psychosocial wellbeing of Resident 1 by not providing a homelike environment. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnosis including injury at unspecified level of cervical spinal cord (cervical portion of the spine includes the top portion of the spinal cord, comprising seven vertebrae [C-1 to C-7] in the neck), quadriplegia (paralysis of all four limbs or of the entire body below the neck), and muscle weakness (generalized). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 7/3/2024, indicated 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 implement its infection control policy to one of four sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore a gown while providing perineal care (also known as peri-care, washing the genitals and anal area) to Resident 2, who was placed on Enhanced Barrier Precautions (EBP- an infection control method that uses personal protective equipment [PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents, such as antibiotics] between residents in skilled nursing facilities). This deficient practice had the potential to result in an increased risk for MDRO transmission. Findings: During a review of Resident 2's admission Record indicated the facility admitted the resident on 4/14/2022 and readmitted the resident on 4/25/2024 with diagnoses including pressure ulcer (damage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of six sampled residents (Residents 1, 2, and 3) by: 1. Failing to ensure staff held furosemide (medication used to treat fluid retention) on 6/9/2024 at 9 a.m., metoprolol ( medication used to treat high blood pressure) on 6/9/2024 at 9 a.m., and 6/22/2024 at 9 p.m., and midodrine (medication used to treat low blood pressure) on 6/17/2024 at 10 p.m., 6/19/2024 at 6 a.m. and 6/25/2024 at 10 p.m., per Resident 1's Physician's Order, dated 5/22/2024, to hold furosemide and metoprolol for systolic blood pressure (sbp - pressure in the arteries when the heart beats) below 110 and hold midodrine for sbp more than 120. 2. Failing to ensure staff held amlodipine (medication used to treat high blood pressure) on 6/3/2024, 6/8/2024, 6/9/2024, 6/11/2024 and 6/23/2024 at 10 a.m. per Resident 2'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 implement infection control measures for one of three sampled residents (Resident 1) during a Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) by: 1. Failing to ensure Resident 1 was monitored for signs and symptoms of COVID-19 twice per shift (eight-hour work schedule) as per facility's policy and procedure. 2. Failing to ensure Physical Therapist 1 (PT 1) wore protective mask inside the facility while talking to Certified Occupational Therapist Assistant 1 (COTA 1). These deficient practices can potentially result in the spread of infections including COVID-19 to residents and staff. Findings: a. A review of Resident 1's admission Record indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) was free from abuse by Resident 7. On 6/26/2024 at 1 p.m., Certified Nursing Assistant 1 (CNA 1) and CNA 2 heard Resident 6 and Resident 7 screaming at each other and on 6/26/2024 at around at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 7 punched Resident 6's chest. This deficient practice resulted to Resident 6 being subjected to physical abuse by Resident 7 while under the care of the facility. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 6/14/2023, with diagnoses that included chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (when a person's respiratory symptoms significantly worsen) and generalized anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly investigate a resident-to-resident physical abuse for two of three sampled residents (Resident 6 and Resident 7) by: 1. Failing to interview and obtain a written witness statement from Licensed Vocational Nurse 1 (LVN 1). 2. Failing to document attempts to interview Resident 8, who was Resident 6 and Resident 7's roommate. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 6/14/2023, with diagnoses that included chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (when a person's respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to safely discharge on e of three sampled residents (Resident 1) who was intellectually disabled (a condition that limits intelligence and disrupts abilities necessary for living independently) and with history of schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and bipolar disease (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) by: 1. Failing to ensure Resident 1 was discharged to a setting that would meet the resident ' s needs on 5/30/2024. 2. Failing to provide an Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) Care Conference (an opportunity to review the on-going work with the resident and allow the resident, their family, and/or responsible party to voice opinions and concerns, and to involve them with plans of care) for resident, family, and responsible party to address plan of discharge and…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of three sampled residents (Resident 2) by failing to ensure the resident ' s urinary collection bag (collects urine) was covered with privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 2. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/1/2023 with diagnoses that included unspecified (unconfirmed) paraplegia (are unable to move their toes, feet, legs, and sometimes the abdomen often caused by injury), benign prostatic hyperplasia (when the prostate and surrounding tissue expands), and generalized muscle weakness. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 3/5/2024, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 2 needed maximum assist from staff for toileting, dressing and…

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

Based on observation, interview, and record review, the facility failed to ensure there were appropriate number of linens and pads between the resident and the air mattress per manufacturer ' s guidelines for one of three sampled residents (Resident 3). This deficient practice had placed Resident 3 at risk for development of pressure ulcers (PU-a localized injury to the skin and or underlying tissue usually over a bony prominences as a result of pressure or pressure in combination with shear). Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 8/28/2021 with diagnoses that included hemiplegia (a severe or complete loss of strength in one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left non-dominant side and low back pain. A review of Resident 3 ' s Minimum Data Set (MDS - a standardized 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.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) by: 1. Failing to ensure intervention was documented when Resident 1 had an 87 percent (%-unit of measurement) oxygen saturation (percentage of oxygen in the blood) on 5/30/2024 as per physician ' s order. 2. Failing to ensure Social Service staff documented late entry (documentation which is not made as soon as possible after an event has occurred) notes as per facility ' s policy on documentation. These deficient practices had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into the resident's medical record. Findings: 1a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/25/2022 with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation (COPD- a common lung disease causing restricted airflow and breathing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revised care plan for one of six sampled residents (Resident 5). This deficient practice had the potential for the resident to not receive appropriate care and treatment. Findings: A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnosis including injury at unspecified level of cervical spinal cord (the neck region of the spinal column or backbone), quadriplegia (paralysis of all four limbs or of the entire body below the neck), and generalized muscle weakness. A review of Resident 5 ' s Care Plan, developed on 2/13/2024 and revised on 2/15/2024, for Resident 5 ' s potential to be verbally aggressive related to ineffective coping skills, and poor impulse control, indicated Resident 5 to provide positive feedback for good behavior, allow time for the resident to express self and feelings towards situation. A review of Resident 5 ' s Care Plan, developed 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 ensure one of three sampled facility employees, Certified Nursing Assistant 1 (CNA 1), was competent to provide nursing services, by failing to evaluate competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skills necessary to care for the residents' needs. This deficient practice had the potential to negatively impact the residents ' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: A review of CNA 1 ' s employee file indicated the hire date of 9/13/2023 and the facility was not able to provide the new hire competency skills assessment documentation for CNA 1. On 4/5/2024 at 2:19 p.m., during a concurrent interview and record review, CNA 1 ' s employee file was reviewed with the Director of Staff Development (DSD). The DSD stated CNA 1 ' s Orientation and Skills Checklist was not done and…

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

Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 3), who was placed on contact isolation precautions (intended to prevent transmission of infectious agents by direct or indirect contact with the patient or the patient ' s environment), by failing to ensure items inside an isolation room were not taken out and brought to other areas of the facility. Certified Nursing Assistant 2 (CNA 2) took Resident 3 ' s used pitcher to nurse station 3 and touched areas in the unit while refilling the resident ' s used pitcher. This deficient practice placed other residents at risk for exposure and contracting infections. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 6/9/2023 with diagnoses including spinal stenosis (a narrowing of the spinal canal in the lower part of the back), epipidymo-orchitis (swelling or pain in one or both testicles, usually from an infection or virus), and osteoarthritis (degenerative joint disease, in which 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 licensed staff failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and failed to document the assessment in the Pre (before)- and Post (after)-Dialysis Communication Form for three of three sampled residents (Resident 1, 2, and 3) during review of dialysis care. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/4/2024 with diagnoses including dependence on renal dialysis and end stage renal disease (ESRD - the kidneys cease functioning on a permanent basis). A review of Resident 1's Minimum Data Set…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive care consistent with professional standards and receive services to promote wound healing by: 1. Failing to provide wound care treatment on 10/13/2023 despite doctor's order on 10/12/2023. Wound care treatment was provided on 10/16/2023, three days after the doctor's order. 2. Failing to provide wound care treatment on 10/22/2023, 12/3/2023 and 12/24/2023 as per doctor's order. 3. Failing to ensure weekly wound assessment was done and documented as per facility's policy. The Skin and Wound Evaluation was documented on 10/19/2023 followed by 10/31/2023, missing one week in between. These deficient practices had the potential to place Resident 1 at risk for worsening of wound and had the potential to develop a wound infection. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 1/17/29023 with diagnoses that included Alzheimer's Disease (the most common type of dementia, a progressive disease beginning with mild memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow the comprehensive care plan on at risk for fall for one of three sampled residents (Resident 1) who needed two-person assistance from staff for locomotion (movement) and required assistive device (wheelchair and front wheeled walker (FWW-device used for walking) during ambulation when Family Member 1 (FM 1) walked with Resident 1 in the facility's parking lot. This deficient practice resulted to Resident 1's fall in the facility's parking lot on 5/26/2023. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 1/17/2023 with diagnoses that included Alzheimer's Disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), malignant (the tumor is cancerous and is likely to spread) neoplasm (abnormal growth of tissue) of unspecified (unconfirmed) part of bronchus (air passage) or lung, unspecified osteoarthritis (tissues in the joint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that were patient centered for one of four sampled residents (Resident 7) who was ordered Restorative Nursing Assistant (RNA - provides rehabilitative care to individuals recovering from illnesses or injuries) to walk with a front-wheeled walker (FWW- an assistive device with two front wheels used for stability when walking) with two-person assist but refused for about three months and no longer could walk; however, no further evaluation was made and was not provided with range of motion (ROM - full movement potential of a joint [where two bones meet]) exercises. This deficient practice had the potential for the resident for contracture (a fixed tightening of muscle, tendons, ligaments, or skin) and further decline. Findings: A review of Resident 7's admission Record indicated the facility admitted the resident on 1/17/2023 with diagnosis including unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person'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 follow physician's order for two of five sampled residents (Residents 1 and 2) as indicated in Medication Administration Record (MAR) by: 1. Giving Resident 1 spironolactone (medication used to high blood pressure) despite physician order to hold the medication if systolic blood pressure (sbp- measures the pressure in the arteries when heart beats) was below 110 millimeters mercury (mmHg-measurement of pressure) on 10/1/2023 and 10/15/2023. 2. Giving Resident 1lisinopril (medication used to high blood pressure) on 10/11/2023 at 9 a.m. and hydralazine (medication used to treat high blood pressure) on 10/11/2023 at 2 p.m., despite physician's order to hold the medication for sbp less than 110 mmHg. These deficient practices had the potential to result in further drop of resident's blood pressure (bp- pressure of circulating blood against the wall of blood vessels). Findings: a. A review of Resident 1's admission Record (Face Sheet) indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical record for two of five sampled residents (Resident 1 and Resident 5) by not: 1. Ensuring licensed nurses document administration of spironolactone (medication used to treat high blood pressure) accurately and per physician's order for Resident 1 on 10/2/2023, 10/6/2023 and 10/8/2023 at 9 a.m. 2. Ensuring licensed nurses document administration of lisinopril (medication used to treat high blood pressure) accurately and per physician's order for Resident 5 on 10/6/2023 and 10/12/2023 at 9 a.m. These deficient practices had the potential to result in inadequate management of resident's high blood pressure and the medical records containing inaccurate documentation can result in the delay of delivery of care. Findings: a. A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 9/26/2023 with diagnoses including alcoholic cirrhosis of the liver (occurs after years of heavy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident ' s right to be free from physical and verbal abuse for two of five sampled residents (Resident 4 and Resident 5) when on 9/15/2023 at 5:30 p.m.: 1. Resident 5 used racial slur against Resident 4. 2. Resident 4, in response to the racial slur, punched Resident 5. These deficient practices resulted in Resident 4 and Resident 5 experiencing verbal and physical abuse. Findings: a. A review of the admission Record indicated the facility admitted Resident 4 on 5/25/2023 with diagnosis of unspecified schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified mood (affective) disorder. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/23/2023, indicated Resident 4 had the ability to understand and be understood. The MDS further indicated Resident 4 required staff supervision with bed mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comfortable, sanitary and odor free environment to a resident who was eating lunch in the room for one of three (Resident 1) sampled residents. The deficient practice had the potential for Resident 1 to lose appetite and violated her right to have a sanitary and odor free environment while eating. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 8/3/2022 and the facility readmitted the resident on 9/21/2022, with diagnoses including adjustment disorder (an emotional or behavioral reaction to a stressful event or change in life) with depressed mood (feeling sad, irritable, and empty), absence of right leg below knee, and muscle wasting (thinning of muscle mass) and atrophy (decrease in size of a body part). A review of Resident 1 ' s History and Physical (H&P), dated 6/28/2023, indicated Resident 1 had the capacity to make decisions, alert, and oriented. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse for two (Resident 9 and Resident 10) of four sampled residents when: 1. Resident 9 slapped Resident 10 on her left upper thigh. 2. Resident 10 grabbed Resident 9 ' s purse and pulled Resident 9 ' s hair. These deficient practices resulted in Resident 9 and Resident 10 experiencing physical abuse. Findings: A review of the admission Record indicated the facility admitted Resident 9 on 2/17/2023 with diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone) of vertebra (one of the little bones in your spinal column) cervical (having to do with any kind of neck, including the neck on which the head is perched and the neck of the uterus) region, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alleged abuse to the State Survey Agency no later than 2 hours after the allegation occurred for two of four sample residents (Resident 9 and Resident 10). This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse. Findings: A review of the admission Record indicated the facility admitted Resident 9 on 2/17/2023 with diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone) of vertebra (one of the little bones in your spinal column) cervical (having to do with any kind of neck, including the neck on which the head is perched and the neck of the uterus) region, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels situated away…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services to meet the needs of a resident by failing to administer morphine (an opioid medicine prescribed for severe pain when other pain-relief medicines are not effective or cannot be used) medication as ordered by the physician for one of two sampled residents (Resident 13). This deficient practice had the potential to result in an increased pain and can lead to a decreased quality of life, increased distress, and potential complications. Findings: A review of Resident 13's admission Record indicated the facility readmitted the resident on 9/12/2023 with diagnosis including chronic pain syndrome (a condition characterized by prolonged and ongoing experience of pain beyond the expected healing time) and cervicalgia (a pain that occurs around the neck). A review of Resident 13's History and Physical, dated 6/27/2023, indicated the resident has the capacity to understand and make decisions. A review of Resident 13's Minimum Data Set (MDS, a standardized 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its infection control and prevention program for nine out of nine sampled residents (Residents 2, 3, 7, 8, 9, 10, 11, 12, and 15) by: failing to ensure: 1. Failing to ensure Resident 3's oxygen tubing was labeled with the date of when it was last changed. 2. Failing to ensure Residents 2, 3, 11, and 12 wore a face mask during a Coronavirus-19 (COVID-19, highly contagious respiratory disease that can spread from person to person through droplets released when an infected person coughs, sneezes, or talks) outbreak. 3. Failing to ensure Residents 7, 8, 9 and 10 maintained six feet distance from each other in the Activity Room. 4. Failing to ensure the Activity Room had no more than 24 persons as indicated on the maximum occupancy sign posted by the Activity Room entrance door. 5. Failing to ensure the ice and the ice scooper were kept in a closed container. 6. Failing to ensure Resident 15's Responsible Person (RP) 1 was educated 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 develop and implement a baseline care plan addressing the primary diagnosis of coronavirus disease 2019 (COVID-19, highly contagious respiratory disease that can spread from person to person through droplets released when an infected person coughs, sneezes, or talks) for one of five sampled residents (Resident 4). This deficient practice had the potential for delayed provision of necessary care and services related to COVID-19 for Resident 4. Findings: A review of Resident 4's admission Record indicated the facility admitted Resident 4 to the facility on 9/1/2023, with a primary diagnosis of COVID-19. Other active diagnosis included recurrent depression (persistent sadness), chronic obstructive pulmonary disease ([COPD] narrowing of the airway causing difficulty breathing), chronic respiratory failure with hypoxia (not enough oxygen in the body), atelectasis (collapse of a lung), and shortness of breath ([SOB] difficult breathing). A review of Resident 4's History and Physical Reports (H&P), dated 3/23/2023 at 2:08 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards to four out of five sampled residents (Residents 1, 16, 17 and 18) by: 1. Failing to ensure Resident 1's low bed (a bed that can go 9 to 10 inches off the floor to help prevent injuries due to falls) were left in the lowest possible position. 2. Failing to ensure Residents 16, 17, and 18's room was free from water spills on the floor. These deficient practices place the residents at risk for falls and injuries. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/15/2019 and readmitted the resident on 8/16/2023, with diagnoses including functional quadriplegia (a form of paralysis that affects all four limbs, plus the torso), cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). 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 confidential personal information for one of nine sampled residents (Resident 9) was protected. The clinical records of Resident 9 were left unattended on the medication cart computer. The computer with visible clinical records of ten residents were unattended on the hallway in Station 1. This deficient practice had the potential to violate residents' rights for privacy and confidentiality of personal and medical records. Findings: A review of Resident 9's admission Record indicated the facility admitted the resident on 11/2/2022 and readmitted the resident on 6/9/2023 with diagnoses including spinal stenosis (a condition where the small spinal canal which contains the nerve roots and spinal cord became compressed), epididymo-orchitis (an inflammation of the tube that stores and carries sperm, and/or of the testicle [male sex glands]), and urinary tract infection (an infection in any part of the urinary system). A review of Resident 9's Minimum Data Set (MDS – a standardized assessment 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 ensure the results of the investigation on a resident-to-resident physical abuse allegation was reported to the State Survey Agency (SSA) within five working days of the incident for two of nine sampled residents (Resident 7 and Resident 8). The facility failed to provide the SSA with the five-day investigation report. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect other residents from abuse. Findings: A review of Resident 7's admission Record indicated the facility admitted the resident on 10/9/2022 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), generalized anxiety disorder (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), and essential hypertension (abnormally high blood pressure that's not the result of a medical condition). A review of Resident 7's Minimum Data Set (MDS – a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provision of pharmaceutical services for one of nine sampled residents (Resident 9) by failing to ensure the medication carts were locked and medications were not left unattended. These deficient practices had the potential for medication contamination and non-authorized access to the resident's medications. Findings: A review of Resident 9's admission Record indicated the facility admitted the resident on 11/2/2022 and readmitted the resident on 6/9/2023 with diagnoses including spinal stenosis (a condition where the small spinal canal which contains the nerve roots and spinal cord became compressed), epididymo-orchitis (an inflammation of the tube that stores and carries sperm, and/or of the testicle [male sex organ]), and urinary tract infection (an infection in any part of the urinary system). A review of Resident 9's Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 8/5/2023, indicated the resident's cognitive (involving conscious intellectual activity such as…

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

Based on interview and record review, the facility failed to ensure the Controlled Drug Record form (CDR/Narcotic run sheet- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for one of three sampled residents (Resident 1). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted Resident 1 on 4/22/2021 and readmitted the resident on 9/12/2022 with diagnoses including muscle weakness, difficulty walking, and chronic pain syndrome (CPS-when people have symptoms beyond pain alone, like depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [is an emotion characterized by feelings of tension,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1). The facility failed to develop and implement individualized care plan with interventions addressing Resident 1 ' s food dislikes as identified by the Director of Nursing (DON) and the Dietary Supervisor (DS) and as indicated in the resident ' s medical records. As a result, on 7/27/2023 Resident 1 was served food identified as one of the resident ' s food dislikes. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 4/22/2021 and readmitted on [DATE], with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with foot ulcers (wounds), muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates). 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 Based on interview and record review, the facility failed to ensure residents ' food preference was followed for one of three sampled residents (Resident 1). The facility served Resident 1 with food that were on the resident ' s dislike list. This deficient practice had the potential to result in decreased meal satisfaction and affect Resident 1 ' s nutritional status. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 4/22/2021 and readmitted on [DATE] with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with foot ulcers (wounds), muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates). A review of Resident 1 ' s Physician Orders, dated 5/1/2023, indicated regular diet (diet that does not have restrictions). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool),…

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

Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of three sampled residents (Resident 2) by failing to perform hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) and change gloves after touching unclean surfaces while administering medications. This deficient practice placed Resident 2 at risk for exposure and contracting infections. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 4/16/2019 with diagnoses including atherosclerosis (a condition that develops when a sticky substance called plaque builds up inside the artery), hypothyroidism (a condition where the thyroid gland does not make enough thyroid hormones to meet the body ' s needs), and chronic kidney disease (a condition in which the kidneys were damaged and cannot filter blood as well as they should). A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/13/2023, indicated the resident ' s cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pain management regimen were provided as ordered for two of two sampled residents (Resident 7 and Resident 18), by failing to ensure: 1. Documentation of the pre and post pain assessments for one of four sampled residents (Resident 7) 2. Administration of pain medication for the appropriate pain scale as indicated by the physician's orders for one of four sampled residents (Resident 7). 3. Resident 18's Percocet (pain medication) and Tylenol (pain medication) medications were administered in accordance with the physician's orders. These deficient practices had the potential to result in confusion on the delivery of care and services rendered and may lead to inaccurate assessment and inadequate management of residents' pain. Findings: a. A review of Resident 7's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (a syndrome where pain remains after illness or injury),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the Narcotic and Hypnotic Record (NHR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for three of three sampled residents (Resident 7, Resident 349, and Resident 350). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) gave Spiriva (a breathing treatment) that was documented as given in the Medication Administration Record (MAR) on 3/9/2022 for 1 (Resident 23) of 2 residents investigated during the medication storage observation. This deficient practice had the potential for residents not receiving a breathing treatment medication and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of eight residents (Resident 27 and 37) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to: 1. Ensure Resident 37's physician order for Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed (PRN) had a duration (length of time). 2. Ensure Resident 37's physician order for Xanax had a specific behavior. 3. Ensure Resident 27's physician order for venlafaxine (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest)] had a specific behavior. 4. Ensure the correct behavior was being monitored for the use of venlafaxine for Resident 27. These deficient practices had the potential to result in adverse reaction (any unexpected or dangerous reaction to a drug) or impairment in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control measures for four of four sampled residents (Resident 126, Resident 21, Resident 26, and Resident 121) by failing to: 1. Ensure Resident 126's and Resident 26's nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) tubings were labeled with the date they were last changed. 2. Ensure Registered Nurse 3 (RN 3) performed hand hygiene (alcohol-based hand rub) after handling soiled dressings during Resident 21's wound treatment. 3. Ensure the indwelling catheter drainage collection bag (catheter, a tube inserted into the abdomen or urethra [duct to conduct urine out of the body] that empties into a collection bag that collects the urine) and tubing were not touching the floor for Resident 121. These deficient practices had the potential to result in contamination of Resident 121's and Resident 26's care equipments and had the potential to transit infectious microorganisms to Resident…

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

Based on observation, interview, and record review, the facility failed to promote resident rights by not feeding three of three sampled residents (Residents 5, 21, and 32) at eye-level. This deficient practice had the potential to affect the resident's self-worth. Findings: a. A review of the admission record indicated Resident 5 was readmitted to the facility, on 08/20/2020, with diagnoses that included hyperlipidemia (condition in which there are high levels of fat particles in the blood), chronic kidney disease (longstanding disease of the kidneys), hemiplegia (hemiparesis - mild or partial weakness or loss of strength on one side of the body) and hemiparesis (hemiparesis - mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of physician's order indicated Resident 5 was to receive a mechanical soft with finely chopped meat and veggies texture with thin/regular liquid consistency. A review of Resident 5's care plan,…

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

Based on interview and record review, the facility failed to develop and implement a person-centered care plan for the use of Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) for one of 32 sampled residents (Resident 37). This deficient practice had the potential for Resident 37 to not receive the proper and necessary care. Findings: A review of the admission record indicated Resident 37 was admitted to the facility, on 11/29/2018, with diagnoses that included generalized anxiety disorder, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (elevated blood pressure). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 01/03/2022, indicated Resident 37 had the ability to make self-understood and to understand others. A review of Resident 37's physician's orders indicated an order for Xanax 0.5 mg (milligram) give one tablet by mouth every 12 hours as needed for anxiety, ordered on 01/30/2022. 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 two of two sampled residents (Residents 7 and 21) care plans were reviewed and revised to reflect the current status and interventions being provided to the resident. This deficient practice placed the resident at risk of unrecognized change of condition and delay necessary intervention. Findings: a. A review of the admission record indicated Resident 7 was admitted to the facility, on 02/03/2015, with diagnoses that included chronic pain syndrome (a syndrome where pain remains after illness or injury), malignant neoplasm of right female breast (breast cancer), and hemiplegia (muscle weakness or partial paralysis on one side of the body). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 02/21/2022, indicated Resident 7 had the ability to make self-understood and to understand others. A review of Resident 7's physician's orders indicated an order for Norco 7.5-325mg (milligram) give one tablet by…

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

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of pressure ulcers (PU, damage to tissue caused by prolonged pressure over a bony prominence) by failing to ensure air mattress (mattress t o prevent pressure ulcers) setting was set to resident's weight, for one of one sampled resident (Resident 21). This deficient practice had the potential to cause worsening of pressure ulcers. Findings: A review of the admission record indicated Resident 21 was readmitted to the facility, on 03/04/2019, with diagnoses including Alzheimer's disease (a brain disease that slowly destroys brain cells), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and dysphagia (difficulty or discomfort in swallowing). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/13/2021, indicated Resident 21 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and 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 residents receiving enteral nutrition (delivery of nutrients directly into the stomach) were provided care and nutrition as assessed and ordered by the residents' physician for (Resident 51 and 344), by failing to ensure: 1. The nursing staff hung the prescribed feeding formula as ordered for Resident 51. This deficient practice had the potential to result in Resident 51 not receiving the prescribed amount of caloric intake. 2. The head of the bed was elevated while the Resident 344 was receiving enteral nutrition via gastrostomy tube (g-tube, a surgically placed device that passes through the abdominal wall into the stomach). These deficient practices had the potential for the enteral nutrition feeding to back up from the stomach and go into the lungs, placing Resident 344 at risk for aspiration (fluid in the lungs). Findings: a. A review of the admission record indicated Resident 51 was readmitted to the facility, on 05/14/2021,…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received the correct flow rate (refers to the amount of oxygen gas being delivered to the body, measured in liters per minute) of oxygen as ordered by the physician, for one of three sampled resident (Resident 89). This deficient practice placed Resident 89 at risk for receiving more oxygen than required which may lead to side effects such as headaches, lethargy, and confusion. Findings: A review of the admission record indicated Resident 89 was admitted to the facility, on 12/29/2017, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation, and dependence on supplemental oxygen. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/3/2022, indicated Resident 89…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 347) was free from unnecessary medications by failing to document a specific indication for the use of Xarelto (brand name for rivaroxaban, an anticoagulant medication used to treat or prevent blood clots). This deficient practice placed Resident 347 at risk for receiving an anticoagulant without an adequate indication and had the potential to lead to side effects including bleeding and bruising easily. Findings: A review of Resident 347's admission Record indicated the resident was admitted on [DATE] with diagnoses that included, but not limited to, calculus (stone) of gallbladder with acute and chronic cholecystitis (inflammation of the gallbladder) without obstruction and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). A review of Resident 347's Physician's Order, indicated the following order: rivaroxaban tablet 15 milligrams (mg - unit 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 one of one sampled resident (Resident 345) was free from significant medication error by administering as needed (PRN) morphine (medication used to help relieve moderate to severe pain) oral solution sublingually (under the tongue) to Resident 345 for whom the medication was not ordered. This deficient practice had the potential to result in adverse side effects (any unexpected or dangerous reaction to a drug) from Resident 345 receiving morphine that includes drowsiness and difficulty breathing. Findings: A review of Resident 345's admission Record indicated the resident was admitted on [DATE] with diagnoses that included, but not limited to, age-related osteoporosis (disease that causes a loss of bone density and weakens the bones) with current pathological fracture (break in a bone that is caused by an underlying disease) of vertebra (one of bony or cartilaginous segment composing the spinal column) and wedge compression fracture (break in 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 the glucometer (portable device that measures the blood glucose [sugar] levels) test strips were labeled with the open date for one of six medication carts (Medication Cart A). This deficient practice had the potential for glucometer test strips to be used beyond its discard date, resulting in inaccurate glucose test results. Findings: During an inspection of Medication Cart A located in Station 2 with Licensed Vocational Nurse 4 (LVN 4), on 3/10/2022 at 11:39 a.m., observed an opened bottle of glucose test strips without a date of when it was opened. During a concurrent observation and interview, on 3/10/2022 at 11:39 a.m., LVN 4 observed and verified the bottle of glucometer strips in Medication Cart A was opened and unlabeled without a date. LVN 4 stated the container of glucometer test strips should have been labeled with the open date since the test strips need to be used within 90 days of opening. LVN 4 stated the nurse who opens a new glucose test strip container is responsible for labeling with…

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