Desert Canyon Post Acute, LLC

Based on interview and record review, the facility failed to maintain documentation and demonstrate evidence of ongoing Quality Assurance and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) program by: 1. Failing to provide documentation of the written QAPI plan (guides the nursing home's quality efforts and serves as the main document to support implementation of QAPI). 2. Failing to provide documentation of data collection and analysis at regular intervals to include falls, which was identified by the facility as a problem issue in the facility. These deficient practices had the potential for systemic failures to go uncorrected and no improvement to the facility's delivery of care for all residents. Findings: During the Entrance Conference conducted on 2/23/2026 at 8:09 a.m. with the Assistant Director of Nursing (ADON), the ADON was provided the Entrance Conference Worksheet (information needed from the facility, including the QAPI Plan). During a concurrent interview and record review on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (a disease that is spread from one person to another through a variety of ways that include: contact with blood and bodily fluids; breathing in an airborne virus; or by being bitten by an insect), and infections by failing to ensure: 1. Resident 41's call light (a button, cord, or remote device in a hospital or nursing home room that allows a patient or resident to electronically alert nurses or staff that they need assistance) that was inside the trash can was sanitized before handing it off to the resident for use observed during random screening of residents. 2. Resident 37's call light that was on the floor was sanitized before handing them off to the resident for use during random screening of residents. 3. Certified Nursing Assistant (CNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the residents for two of four sampled residents (Residents 41 and 37) reviewed under environment task. The deficient practice had the potential for residents unable to summon health care worker for help as needed. Findings: 1. During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted the resident on 4/5/2021, and readmitted the resident on 7/2/2025, with diagnoses including muscle weakness, difficulty walking, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 1/19/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rights to request, refuse, and / or discontinue treatment for one of two sampled residents (Resident 2) reviewed under the Advance Directives (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) care area by failing to ensure medical records were updated with a current copy of the resident's Durable Power of Attorney (DPOA or POA, a type of 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 2's admission Record (AR), the AR indicated the facility admitted the resident on [DATE] with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities 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 document a significant change of condition (COC, is the formal written record of any significant, non-temporary change in a resident's physical, mental, or emotional health [e.g., sudden confusion, falls, weight loss]) on a resident's physical condition that had deteriorated for one of one sampled resident (Resident 5) by failing to inform the resident's representative/family member when the resident fell at the facility on 10/31/2025. This deficient practice had violated the resident's responsible party's right to be informed of the resident's accident and the facility's intervention to mitigate the situation. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on 2/2/2024, and readmitted the resident on 11/11/2025, with diagnoses including metabolic encephalopathy (a broad term for temporary or permanent brain dysfunction caused by chemical imbalances in the body, rather than direct…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures for one (1) of five (5) sampled resident (Resident 12) reviewed for unnecessary medications by failing to ensure there was a physician's order for the behavior manifestations monitoring, adverse side effects (unwanted or dangerous medication-related side effects) monitoring, and non-pharmacological approach attempted for the use of clonazepam (also known as Klonopin, a medication used to treat panic attacks and control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] by slowing down the overexcited brain). This deficient practice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure regarding transfers and discharge by failing to ensure that necessary medical information was communicated to the receiving hospital for one (1) of one (1) sampled resident (Resident 90) reviewed for hospitalization. This deficient practice placed Resident 90 at risk for a delay in the continuity of care and receiving the services and treatment the resident needed. Findings: During a review of Resident 90's admission Record, the admission Record indicated the facility admitted the resident on 1/14/2026, with diagnoses including sepsis (a life-threatening blood infection), acute respiratory failure (a condition that occurs when the lungs cannot release oxygen into the blood resulting to shortness of breath, confusion, drowsiness, and bluish discoloration of the lips, skin, or extremities), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 90'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 interview and record review, the facility failed to ensure the PASRR was completed accurately for one of four sampled residents (Resident 10) reviewed under Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) when Resident 10 was admitted with a serious mental illness and was taking a psychotropic medication (medication that alters brain chemistry to manage mental health conditions by affecting mood, thoughts, behavior, or perception). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated that the facility admitted the resident on 2/11/2025 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition characterized by persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) for one of 21 sampled residents (Resident 5) reviewed for accidents by failing to develop and implement a care plan when the resident fell on [DATE]. This deficient practice had the potential to result in a delay of nursing care and medical interventions for the residents. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on 2/2/2024, and readmitted the resident on 11/11/2025, with diagnoses including metabolic encephalopathy (a broad term for temporary or permanent brain dysfunction caused by chemical imbalances in the body, rather than direct physical injury), cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary services to maintain good grooming and personal hygiene for two of two sampled residents (Resident 13 and 19) by failing to: 1. Ensure Resident 13's nails were trimmed per family requests and plan of care. 2. Ensure Resident 19's right hand fingernails were cleaned as dirt and dead skin had accumulated under the free edge of the nails from the resident scratching himself. These deficient practices had the potential to result in resident infections caused by abrasions from long fingernails and uncleaned free edge fingernails. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted the resident on 3/24/2015, with diagnoses including vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received services and assistance for one (1) of one (1) sampled resident (Resident 40) reviewed for urinary tract infection (UTI- an infection in the bladder/urinary tract) by: 1. Failing to ensure Resident 40's urinal bottle (portable container for collecting urine) was labeled with the name of the resident and the date it was last changed. 2. Failing to ensure Resident 40's urinal bottle was changed per facility practice. These deficient practices had the potential for the resident to experience cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and to develop UTI due to potentially contaminated urinal bottle and switching of urinal bottle with other residents. Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility admitted the resident on 8/20/2022, 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.

Based on observation, interview, and record review, the facility failed to ensure the staff providing care and services to a resident who had a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) were aware of, competent in, and utilized facility protocols regarding feeding tube nutrition and care for one of one sampled resident (Resident 6) reviewed for tube feeding by failing to ensure Resident 6's old piston syringe (is a large, reusable plastic syringe used to deliver formula, water, or medication directly into the stomach through a feeding tube) for gastrostomy tube (g-tube, a soft, flexible tube surgically inserted through a small opening in the skin of the abdomen directly into the stomach) medication administration and feeding dated 2/22/2026 was discarded after 24 hours of use. The deficient practices had the potential to result in altered nutritional status that can lead gastrointestinal (GI,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of one sampled resident (Resident 5) reviewed for hydration by failing to ensure that Resident 5's peripheral intravenous (IV, within a vein) line (a small, flexible plastic tube (catheter) inserted through the skin into a small vein-usually in the hand, arm, or foot-to deliver fluids and medications directly into the bloodstream) had the date and initials of the licensed nurse who inserted the IV line or changed the IV dressing. The deficient practices had the potential for complications associated with intravenous therapy (a medical technique that delivers fluids, medication, or nutrients directly into a person's bloodstream through a vein) and catheter-related infections. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for three of three sampled residents (Residents 83, 6, and 7) reviewed for respiratory care by failing to ensure: 1. Resident 83's Bilevel Positive Airway Pressure (BIPAP, a non-invasive device used to help people breathe more easily, typically while sleeping or in a hospital setting) tubing was labeled with the date it was provided or last replaced. 2. Resident 6's nebulizer (a typically, electric or battery-powered device that transforms liquid medicine into a fine, breathable mist) mask and tubing dated 2/10/2026 was discarded and replaced with a new nebulizer mask and tubing dated 2/23/2026. 3. Resident 7's oxygen via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) was not touching the floor. The deficient practices had the potential for the residents to develop complications such as shortness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain management consistent with professional standards of practice and the residents' goals and preferences for one of one sampled resident (Resident 11) by failing to ensure as needed pain medication was administered per physician's orders and according to parameters for Resident 11. These deficient practices had the potential to result in side effects from unnecessary administration of narcotics including constipation and mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily), general activities, and mobility. Findings: During a review of Resident 95's admission Record (AR), the AR indicated that the facility originally admitted the resident on 3/6/2022 and readmitted on [DATE] with diagnoses including Parkinsonism (a progressive brain disorder that causes problems with movement, balance, and muscle control),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled residents (Resident 86) reviewed under the Dialysis care area by failing to provide communication with the HD Center (a specialized outpatient facility that provides HD) and ensure that licensed nurses (LN) performed and documented assessments before and after Resident 86's hemodialysis sessions. These deficient practices 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 86's admission Record (AR), the AR indicated the facility admitted the resident on 2/15/2024, with diagnosis that included End Stage Renal Disease (ESRD -irreversible kidney failure), dependence on renal (kidney) dialysis, hypertension (HTN, high blood pressure), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side 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 accurately account for one dose of tramadol (a controlled medication used to treat pain) affecting Resident 95 in one of two inspected medication carts (Medication Cart 1). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications (medications with a high risk for diversion) and that Resident 95 could have received too much or too little medication due to lack of documentation resulting in serious health complications such as drug overdose (occurs when a substance is taken in quantities that pose severe health risks or death). Findings: During a review of Resident 95's admission Record (AR), the AR indicated that the facility originally admitted the resident on 3/6/2022, and readmitted on [DATE], with diagnoses including Parkinsonism (a progressive brain disorder that causes problems with movement, balance, and muscle control), heart failure (a condition where…

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

Based on observation, interview, and record review, the facility failed to prepare the menu to meet a resident`s nutritional needs for one of four residents (Resident 25) on puree diet (a texture modified diet that consists of smooth, pudding-like consistencies that are easy to swallow) by failing to have the puree broccoli recipe available and followed which indicated to perform International Dysphagia Diet Standardization Initiative (IDDSI, a standardized framework used to classify food textures and liquid thickness for people with dysphagia) testing (methods to confirm the flow or textural characteristics of a particular food or liquid) to ensure appropriate texture standards for residents with dysphagia (difficulty swallowing). This deficient practice resulted in Resident 25's lunch plate on 2/23/2026, containing broccoli that wept (release of moisture, forming liquid on the surface) potentially resulting in the resident choking (when food gets stuck in your airway, blocking the flow of the air to your lungs) on the food. Findings: During a review of Resident 25's admission…

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

Based on observation, interview, and record review, the facility failed to ensure residents receive food that accommodates their intolerances, preferences, and appealing options of similar nutritive value for one of six sampled residents (Resident 44) when during dining observation facility task on 2/25/2026, the resident was served two well done eggs out of three eggs instead of over easy per resident's preferences and two burnt toasts for breakfast. The deficient practice failed to accommodate the resident preference, which resulted in the resident becoming upset and delayed the resident's breakfast because the food had to be re-prepared correctly. Findings: During a review of Resident 44's admission Record (AR), the AR indicated the facility admitted the resident on 1/19/2026, with diagnoses including type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (a life-threatening blood infection), and muscle weakness. During a review of Resident 44's History and Physical (H&P), dated 1/20/2026, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the facility did not transfer or discharge a resident in an unsafe manner for one of three sampled residents (Resident 1) when Resident 1 was transferred to recuperative care (a short-term, supportive housing program for people experiencing homelessness who are recovering from an illness or injury but are not sick enough to need a hospital anymore) prior to confirming recuperative care would accept Resident 1. This deficient practice resulted in Resident 1's admission to the hospital after recuperative care did not accept Resident 1's transfer.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 7/15/2025, and readmitted on [DATE], with diagnoses including Guillain-Barre Syndrome (a condition where the body's immune system mistakenly attacks its own nerves, causing weakness, tingling, and sometimes paralysis) and hypertension (high blood pressure).During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary treatment and services for one of five samples residents (Resident 3) 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) to prevent pressure ulcers from developing, by failing to: 1. Perform the Wound Weekly Monitoring Assessment when Resident 4's wound was not assessed on the week of 9/23/2025.2. Wound care orders were not ordered for five (5) days when Resident 4 had a wound from 9/24/2025 to 9/28/2025.3. On 9/29/2025 Resident 4 was noted with a Change in Condition (COC) with wound increased in size and the Medical Doctor (MD) was not informed to provide an updated of treatment. These deficient practices had the potential for Resident 3's wound to worsen. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 4/19/2021 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 interview and record review, the facility failed to inform the attending physician (MD) and the Responsible Party (RP) for one of five sampled residents (Resident 3) when Resident 3 was noted with a Change of Condition (COC) on 9/29/2025. This deficient practice had the potential for a delay in Resident 3's care and violated the RP's right to be notified.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 4/19/2021 with diagnoses including type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (a condition characterized by partial paralysis or weakness on one side of the body, which can affect the arm, leg, and face) following cerebral infarction (the death of neural [brain] tissue as a result of ischemia), and contracture of muscle (the permanent shortening of a muscle or…

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

Based on observation, interview and record review, the facility failed to maintain a clean and sanitary environment for one of five sampled residents (Resident 4) when on 12/1/2025 Resident 4's bedside fan was noted with thick gray dust. This deficient practice had the potential to negatively impact Resident 3's well-being. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 4/3/2019 with diagnoses including pneumonia (an infection/inflammation in the lungs), bronchiectasis (a chronic lung condition where your airways [bronchi] become permanently damaged, widened, and thickened, like stretched-out tubes, making it hard to clear mucus, which traps germs and causes repeated infections and a chronic cough), and dysphagia (difficulty swallowing). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 8/30/2025, the MDS indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 was dependent (helper does all of the effort) with eating, oral hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practices were followed for one of five sampled residents (Resident 4) for food brought from outside of the facility when: 1. Resident 4's food was not properly labeled with use by date. 2. Resident 4's food was not discarded after 48 hours per facility's policy and procedure (P&P). These deficient practices had the potential for Resident 4 to consume food that was unsafe and that can cause foodborne illness (any illness resulting from eating contaminated/spoiled foods). During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 4/3/2019 with diagnoses including pneumonia (an infection/inflammation in the lungs), bronchiectasis (a chronic lung condition where your airways [bronchi] become permanently damaged, widened, and thickened, like stretched-out tubes, making it hard to clear mucus, which traps germs and causes repeated infections and a chronic cough), and dysphagia (difficulty swallowing). During a review of Resident 4'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 observation, interview and record review, the facility failed to implement its infection control measures for three of three sampled residents (Residents 1, 2, and 3) during a respiratory virus season (a specific period, typically during the fall and winter months, when common respiratory illnesses like influenza [flu-a contagious {spread from one person to another by direct or indirect contact}-respiratory illness caused by influenza viruses], Coronavirus Disease 2019 [COVID-19-a highly contagious respiratory disease thought to spread from person to person through droplets], and Respiratory Syncytial Virus [RSV-common respiratory virus that primarily affects infants and young children, but can also cause illness in older adults and people with underlying health conditions] become more prevalent [widespread] and circulate widely in the population) by failing to wear a mask while inside the facility. These failures had the potential for the spread of respiratory diseases (flu, COVID-19 and RSV) to other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 related to infection control program for three of three sampled Residents (Resident 1, 2, and 3), by failing to: 1. Implement surveillance and monitoring measures to prevent the recurrence and spread of bed bugs (a small, wingless, parasitic insects that hide in places like mattresses and furniture, feed on human blood, and their bites can cause itchiness and allergic reactions) in the facility when on 10/9/2025 bed bugs were found in Room A (Resident 1, 2, and 3's shared room). 2. Contact Department of Public Health to report an unusual occurrence (Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety, or health of patients, personnel or visitors) when on 10/9/2025 bed bugs were found in Room A. These deficient practices had the potential to cause the spread of bed bugs in 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 that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was reviewed and revised for three of three sampled residents (Residents 1, 2, and 3) by failing to ensure Residents 1, 2, and 3's care plans were revised after a bed bug (a small, wingless, parasitic insects that hide in places like mattresses and furniture, feed on human blood, and their bites can cause itchy welts on the skin) was found in Resident 1's bed mattress in Room A (Resident 1, 2, and 3's shared room) on 10/9/2025. This deficient practice had the potential to delay provision of person-centered care for Residents 1, 2, and 3. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 10/19/2022 and readmitted on [DATE], with diagnoses including diabetes mellitus type two (DM II-a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 1 when unable to call for assistance.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 10/30/2025, with diagnoses including sepsis (a life-threatening blood infection), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior characterized by mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 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 two (2) of three (3) sampled residents (Residents 1 and 2) reviewed for physical restraints during a random observation by:1. Failing to complete a restraint assessment quarterly for the continued use of the restraint bed against the wall according to the facility policy and procedure for Resident 1.2. Failing to ensure Resident 2 did not have pillows tucked under the fitted sheet on the right side of the bed.These deficient practices had the potential to result in the restriction of Resident 1 and Resident 2's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written notice indicating the reason for room changes for three of three sample residents (Resident 1, Resident 2, and Resident 3). This deficient practice resulted to Residents 1, 2, and 3 feeling violated their right to refuse for room changes. Cross reference F837. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 11/7/2022 and readmitted on [DATE] with diagnosis that included type 2 diabetes mellitus (body doesn't produce enough insulin [acts like a key that unlocks your body's cells so they can use sugar]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/3/2025, the MDS indicated Resident 1's thought process was intact and required set-up assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update the facility's policy and procedure for a room change affecting three of three sampled residents (Residents 1, 2, and 3). This deficient practice resulted to Resident 1, Resident 2, Resident 3 feeling their right to refuse for a room change was violated. Cross reference F559. Finding: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 11/7/2022 and readmitted on [DATE] with diagnosis that included type 2 diabetes mellitus (body doesn't produce enough insulin [acts like a key that unlocks your body's cells so they can use sugar]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/3/2025, the MDS indicated Resident 1's thought process was intact and required set-up assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity to one of five sample residents (Resident 4) by not fully covering Resident 4 and exposing his incontinence brief while walking with physical therapist in the hallway. This deficient practice could lead Resident 4 to feel uncomfortable, lose dignity, and lose modesty. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 4/10/2025 with a diagnosis of hypotension (having abnormally low blood pressure {the force of your blood pushing against the walls of your arteries as your heart pumps blood throughout your body}). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 4's thought process was intact 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 concurrent observation and interview on 4/24/2024 at 9:32 a.m., with…

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

Based on observation, interview, and record review, the facility failed to ensure the facility's emergency exit was not blocked by a Hoyer lift (a device that helps caregivers safely lift and move people) and wheelchair, and an emergency cart was not parked in both sides of the hallway. These deficient practices had the potential for the delay of care during an emergency. Findings: During a concurrent observation and interview on 4/25/2025 at 8:59 a.m., during a facility tour with License Vocational Nurse 2 (LVN 2), in Station A, observed with LVN 2 that a Hoyer lift was parked in the right side in front and close to emergency exit door, an emergency crash cart was parked on the right side beside the utility room, and two wheelchairs parked in between the right side of the hallway. LVN 2 stated that the Hoyer lift should not be parked in front of the emergency exit. LVN 2 stated wheelchairs and carts should be parked in one side of the hallway. LVN 2 stated they (Hoyer lift, wheelchairs, and carts) are blocking the hallways and exit door and could cause delay in the care 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.

Based on observation, interview, and record review, the facility failed to accurately document a Fall Risk Assessment for one of three sampled residents (Resident 1) after Resident 1 had a fall. This deficient practice had the potential for Resident 1 to have inaccurate assessment of the fall that can affect provision of nursing care. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2024 with diagnoses that included muscle weakness (generalized), difficulty in walking, and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/23/2024 indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required supervision (helper provides verbal cues and touching) with showering and set up (helper set ups or cleans up) with toileting and was independent (Resident completes the activity by themselves with no assistance from a helper) with eating, oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s right to be free from verbal abuse (at type of abuse that uses language) for two of two sampled residents (Resident 2 and Resident 3), when on 2/11/2025, both Resident 3 and Resident 2 called each other derogatory words (unflattering, unkind, or demeaning). This deficient practice resulted in Resident 2 and Resident 3 being subjected to verbal abuse while under the care of the facility. Residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (when someone has few or no social connections or support, and lacks relationships with others). Findings: a. During a review of Resident 2 ' s admission Record, the admission Record indicated…

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

Based on interview and record review, the facility failed to employ a qualified Activity Director (AD) that met the qualifications as per facility's job description for Activity Director for one of two staff. This deficient practice had a potential for residents residing in the facility not being assisted and receiving activity related necessary care to attain highest practicable well-being. Findings: During an interview on 1/17/2025, at 11:05 a.m., with the Director of Nursing (DON), the DON stated AD was hired by the Administrator (ADM). During an interview on 1/17/2025 at 11:25 a.m., with the ADM, the ADM stated the facility provided the training and orientation when AD was hired. During a concurrent interview and record review on 1/17/2025 at 11:29 a.m., with the AD, AD's Job Description was reviewed. The Job Description indicated, The Activities Director plans, oversees and leads the residents' activities in accordance with Federal, State and company requirements. Completes, in writing, a comprehensive assessment of each Resident's past and present leisure interests, physical…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure care plan was developed on Resident 1's refusal of medication. This deficient practice had the potential for delayed provision of necessary care and services. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/15/2024, with diagnoses that included sepsis (a life-threatening blood infection), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure). During a record review of Resident 1'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 11/23/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS – a 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 interview and record review, the facility failed to provide an ongoing activity program that is resident centered for one of three sampled residents (Resident 2). This deficient practice had the potential to affect Resident 2's sense of self-worth and psychosocial well-being. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 12/28/2024, with diagnoses that included unspecified (unconfirmed) fracture of right patellar (break in the bone of the kneecap), unspecified dementia (a progressive state of decline in mental abilities) and history of fall. During a record review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 1/4/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 2 was dependent to staff for toileting, and showering. During an interview and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an ongoing activity program that is resident-centered for one of three sampled residents (Resident 1). This deficient practice had the potential to affect Resident 1's sense of self-worth and psychosocial well-being. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/15/2024, with diagnoses that included sepsis (a life-threatening blood infection), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure). During a record review of Resident 1's History and Physical (H&P) dated 11/23/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS – a resident assessment tool) dated 12/13/2024, the MDS indicated Resident 1's cognitive (mental action or process of…

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

Based on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 1) who was on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to ensure Treatment Nurse 1 (TN 1) wore protective gown while proving wound care. These deficient practice had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) of infection among residents and staff. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/15/2024, with diagnoses that included sepsis (a life-threatening blood infection), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure). During a record review of Resident 1's History and Physical (H&P) 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's licensed nursing staff failed to provide care in accordance with professional standards for three of three sampled residents (Residents 21, 43, and 28) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as 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 21's admission Record, the admission Record, indicated the facility admitted the resident on 1/11/2021, and readmitted the resident on 11/10/2023, 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 2. During a review of Resident 42's admission Record, the admission Record indicated the facility originally admitted the resident on 2/11/2022 and readmitted Resident 42 on 4/21/2023 with diagnoses including history of falling, difficulty in walking, and generalized muscle weakness. During a review of Resident 42's History and Physical (H&P) dated 5/15/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 42's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set-up assistance with eating and oral hygiene, supervision with toileting, total assistance with tub/shower transfers, and partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 was using bed and wheelchair alarm daily. During a review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were completely assessed for the use of bed rails for two of seven sampled residents (Residents 22 and 184) investigated under the accidents care area and for one of three sampled residents (Resident 44) investigated under bedrails care area when the facility failed to: 1. Indicate Resident 22's and Resident 184's recommendations for use of bed or side rails (adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes, mattress, or bed frame) on their Bed/Side Rail Entrapment Assessment. 2. Indicate Resident 44's recommendation and the reason for use of grab bars (safety devices that help people maintain their balance, reduce fatigue, and prevent falls) on the Bed/Side Rail Entrapment Assessment. These failures placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for three of three sampled residents (Residents 21, 43, and 28)) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as 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 F658 Findings: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and 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: 1.Ensure the Treatment Nurse (TN) performed hand hygiene after doffing (removing) used disposable gloves and prior to donning (putting on) new disposable gloves while providing wound care treatment for one of one sampled resident (Resident 16) reviewed during the Pressure Ulcer/Pressure Injury (PU or PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care area. 2. Ensure the nasal cannula (NC - tubing connected to a device that gives additional oxygen [O2] through the nose) was changed weekly and labeled with the date last changed for one of two sampled residents (Resident 237) reviewed under the Respiratory Care area and one randomly sampled resident…

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

Based on observation, interview, and record review, the facility failed to provide 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 of two sampled residents (Resident 237) reviewed under the Environment facility 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 237's admission Record, dated 11/21/2024, the admission Record indicated the facility admitted Resident 237 on 11/15/2024 with diagnoses that included cerebral infarction (CVA - a stroke, loss of blood flow to a part of the brain), vascular dementia (a progressive state of decline in mental abilities), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 237's Admit/Readmit Assessment form, dated 11/15/2024, the Admit/Readmit Assessment form indicated Resident 237 was alert…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral feeding for one (1) out of 1 sampled resident (Resident 43) investigated under the tube feeding care area by failing to ensure the licensed nurse (LN) hang the correct EF formula. This deficient practice had the potential for the resident to experience increase in blood sugar and gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: During a review of Resident 43's admission Record, the admission Record indicated the facility originally admitted Resident 43 on 11/29/2023 and readmitted the resident on 3/14/2024, with diagnoses including type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrostomy status (GT - a surgical opening fitted with a device to allow feedings to be…

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

Based on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents were consistent with professional standards of practice for one of two sampled residents (Resident 33) investigated under respiratory care by failing to ensure the nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask and tubing (this allows the medicine to enter the lungs directly) were kept in a plastic bag with the name of the resident and the date it was provided. The deficient practice had a potential for Resident 33 to develop complications such as respiratory infections of using a nebulizer caused by improper handling of the mask and tubing. Findings: During a review of the Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 6/1/2020, with diagnoses including cerebral infarction (also known as stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (difficulty swallowing), and personal history of coronavirus disease 2019…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 handling of medications and maintain a safe and secure storage by failing to discard one (1) of nine (9) sampled residents (Resident 35) medication in bubble pack (a packaged container with compartments that can contain medications) with a broken seal and covered with paper tape. This deficient practice had the potential for medication error and contaminate medications stored inside the medication cart. Findings: During a concurrent observation and interview on 11/20/2024 at 2:47 p.m. during an inspection of Medication Cart 2 in the presence of Licensed Vocational Nurse 2, LVN 2 confirmed Resident 35's midodrine (a medication used to treat low blood pressure that causes severe dizziness and fainting) bubble pack slots number 10, 11, 12, 13, 14, 15, and 16 with a broken seal was stored in Medication Cart 2. LVN 2 stated the process prior to dispensing medications that can affect the blood pressure (BP), the licensed nurse should check the BP first and if the measurement did not meet the parameter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the entire medication regimen of the resident was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of seven sampled residents (Residents 67 and 285) investigated under unnecessary medications review by: 1. Failing to monitor Resident 67's hours of sleep for two consecutive night shifts on 11/17/2024 and 11/18/2024 in relation to the use of Trazodone (antidepressant, a prescription medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest] and other mental health conditions) for inability to sleep. 2. Failing to specify Resident 285's behavior to monitor on the use of pimavanserin (antipsychotic, a type of drug used to treat symptoms of psychosis [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality]) per the physician's order. These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 during the inspection of one (1) of two medication carts (Medication Cart 2) reviewed during the Medication Storage and Labeling task by failing to ensure one open bottle of glucose test strips was labeled with the date it was opened in accordance with the manufacturer's requirements. This deficient practice had the potential to result in inaccurate blood glucose readings on the residents. Findings: During a concurrent observation and interview on 11/20/2024 at 1:50 p.m., of Medication Cart 2 in the presence of Licensed Vocational Nurse 2 (LVN 2), observed 1 opened bottle of glucose test strips and did not indicate a label of when it was opened. LVN 2 stated she did not know when the bottle of glucose test strips was first opened. LVN 2 stated the licensed nurses (LN) were supposed to indicate the date of when the glucose test strips was opened. LVN 2 stated the purpose of indicating the date is for the staff to be aware of when to discard the unused glucose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 each resident receives and the facility provides drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for one of five sampled residents (Resident 53) investigated during dining observation by serving regular milk that the resident indicated on his diet preference as a dislike. The deficient practice had the potential for Resident 53 who was on renal diet (a diet that limits the amount of sodium, protein, potassium, and phosphorus in the food) to develop excess phosphorus leading to low level of calcium levels causing bone fractures (a partial or complete break in the bone). Cross Reference F808 Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 3/15/2024 and readmitted the resident on 11/18/2024, with diagnoses including end stage renal disease (irreversible kidney failure), Crohn's disease (a chronic inflammatory bowel disease [IBD] that…

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

Based on observation, interview, and record review the facility failed to ensure residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his her goals and preferences for one of five sampled residents (Resident 53) investigated during dining observation by failing to follow the physician's diet order of double portions with all meal and serving regular milk that is listed as a dislike on the resident's meal ticket. The deficient practice had the potential for the resident for weight loss and increased phosphorus leading to low level of calcium levels causing bone fractures (a partial or complete break in the bone). Cross Reference F807 Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 3/15/2024 and readmitted the resident on 11/18/2024, with diagnoses including end stage renal disease (irreversible kidney failure),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. One tomato was found on the floor in the walk-in refrigerator. 2. A separate thermometer probe was not kept inside the reach-in freezers. 3. Three bags of cereal were not labeled with the receive date or expiration date in the dry storage area. 4. Food items that indicate to refrigerate after opening were stored in the dry storage area. 5. Drink pitchers were placed in the drying area stacked on top of other drink pitchers while wet. These failures had the potential to result in harmful bacterial 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 82 of 86 residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Supervisor (DS), on 11/19/2024, at 8:10 a.m., inside the kitchen's walk-in refrigerator, a tomato laid on the floor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent verbal abuse for two of four sampled residents (Resident 1 and Resident 2) when on 8/24/2024 Resident 2 had an exchange of verbal profanity with Resident 1. Resident 1 and Resident 2, who were roommates, were not separated until 9/6/2024. This deficient practice had the potential for further abuse for Resident 1 and Resident 2. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 6/9/2024 and was readmitted on [DATE] with diagnoses including major depressive disorder (a serious mental health condition that causes a persistent low mood or loss of interest in activities, which interferes with daily life), muscle weakness, and acute (very serious, extreme, or severe) respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 7/9/2024, indicated Resident 1 could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 and Resident 2) when on 8/24/2024 Resident 2 had an exchange of verbal profanity with Resident 1. This deficient practice had the potential to result in unidentified abuse and placed Residents 1 and 2 at risk for further abuse. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 6/9/2024 and was readmitted on [DATE] with diagnoses including major depressive disorder (a serious mental health condition that causes a persistent low mood or loss of interest in activities, which interferes with daily life), muscle weakness, and acute (very serious, extreme, or severe) respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of Resident 1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 2 sampled residents ' right to be free from misappropriation of property was maintained by the facility. Resident 1 ' s cell phone was taken by another resident. This deficient practice resulted in Resident 1 to not have his personal phone and make calls to his family. Findings: During a record review of Resident 1 ' s admission Record, it indicated the resident was admitted on [DATE] with medical history including cerebral infarction, anemia, hyperlipidemia, schizophrenia, dysphagia, muscle weakness, anxiety disorder, hypertension, gastritis, sciatica, dysphagia, and benign prostatic hyperplasia. During a review of Resident 1 ' s Minimum Data Set (a standardized care screening tool) dated June 4, 2024,the MDS indicated the resident was moderate cognitively impaired. Resident 1 was dependent on staff with toilet hygiene, dressing, and personal hygiene. During a review of Resident 1 ' s Change of Condition dated 8/17/2024, it indicated…

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

Based on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for two of ten sampled residents (Resident 1 and Resident 3) by failing to: a. Ensure the Social Service Director (SSD) documented the correct date of Resident 1 and Resident 2's altercation in Resident 1's clinical record. The SSD also failed to document Resident 1's refusal of a psychologist (a person that specializes in helping treat people's cognitive, emotional, and social process and behaviors) and psychiatrist (a medical doctor that specializes in the field of psychiatry [field of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders]) evaluation. b. Ensure the Emergency Medical Services (EMS) time of notification and the time Resident 3 was taken to General Acute Care Hospital 1 (GACH 1) was documented in Resident 3's clinical record. The facility also failed to ensure Resident 3's Attending Physician 1 (MD 1) and Family Member 1 (FM 1) were notified of Resident 3's change of condition (COC) 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 a safe, functional, and comfortable environment for seven of nine sampled residents (Residents 1, 2, 3, 4, 5, 6, and 7), by failing to monitor daily temperatures on 7/1/2024, 7/2/2024, and 7/3/2024. This deficient practice had the potential to result in unsafe temperatures related to summer weather, compromising the health & safety of the residents, staff, and visitors. Findings: During an observation on 7/3/2024 at 3:30 p.m. in the hallway, two large fans were observed actively blowing air in an angle facing the ceiling. During an observation on 7/3/2024 at 3:32 p.m. in Resident 1 ' s room, a portable air-conditioning ([AC] a machine that forces cool air into a building) unit was actively operating. During an observation on 7/3/2024 at 3:45 p.m. in Resident 2 and 3 ' s room, a portable AC unit was actively operating. During an observation on 7/3/2024 at 3:48 p.m. in Resident 4 and 5 ' s room, a portable AC unit was actively operating. During an observation on 7/3/2024 at 3:58 p.m. in 6 and 7 ' 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 protect the resident's right to be free from verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology) by staff. On 6/9/2024 at 1:30 p.m., the Admissions Coordinator (AC) stated the Facility [NAME] yelled at Resident 1 to shut up. This deficient practice resulted in Resident 1 feeling humiliated and verbalizing not feeling safe in the facility. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/26/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), 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), and anxiety disorder (persistent and excessive worry…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled resident (Resident 1) to address the following: 1. Resident 1 refused lactulose (medication used to constipation [when your bowel movements become less frequent, and stools become difficult to pass]) nine times from 5/4/2024 to 5/9/2024. 2. Resident 1 refused shower twice in a week from 5/3/2024 to 5/9/2024. These deficient practices had the potential for delayed provision of necessary care and services. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 5/3/2024 with diagnoses that included other cirrhosis of liver (is permanent scarring that damages your liver and interferes with its functioning that can lead to liver failure), other ascites (a condition in which fluid collects in spaces within your abdomen) and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). A review of Resident 1's admission Assessment indicated the resident was alert 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 implement infection control measures for one of three sampled residents (Resident 2) by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) wore protective gown during incontinent care (care provided to resident with no bladder and bowel control) and linen change. Residents 2's was on enhanced barrier precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]). 2. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) was notified that Resident 2 was on enhanced barrier precaution. These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection among residents. Findings: A review of Resident 2's admission Record indicated the facility admitted 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 interviews and record reviews, the facility failed to notify the Power of Attorney (POA-a person legally or non-legally appointed to make decisions on behalf of a patient who lacks capacity) of one of three sampled residents (Resident 1) regarding the progression of an abrasion (the surface layers of the epidermis [skin] has been broken) over Resident 1 ' s coccyx (the small bone at the end of the spine tailbone). As a result, Family Member 1 was not provided information to request additional care interventions. This deficient practice violated the resident ' s rights and/or the representative ' s right to be fully informed of Resident 1 ' s change of condition. Findings: A review of Resident 1's admission Record indicated the facility initially admitted the resident on 7/28/2023 and readmitted the resident on 1/24/2024 with diagnoses including dementia (a set of symptoms that over time can affect memory, problem-solving, language and behavior), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply…

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

Based on observation, interview, and record review, the facility failed to implement infection control measures for three of five sampled staff (Certified Nursing Assistant 1 [CNA 1], CNA 2 and Payroll Coordinator [PC]), while the facility had Coronavirus Disease 2019 outbreak (a sudden rise in the incidence of a disease) by failing to: 1. Ensure CNA 1 and PC wore the N95 (disposable respirators that can help reduce your exposure to airborne particulates of all sizes, from large visible dust to particles that cannot be seen, such as viruses) mask with lower strap secured behind the neck, while inside the facility. 2. Ensure CNA 2 wore a fit tested N95 mask while inside the facility. This deficient practice had the potential to result in the spread of COVID-19 infection. Findings: a. During a concurrent interview on 2/12/2024 at 8:03 a.m., the Assistant Director of Nursing (ADON) stated the facility had COVID-19 outbreak with five positive residents inside the facility. The ADON stated all staff should be wearing N95 (disposable respirators that can help reduce your exposure to…

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

Based on observation, interview, and record review, the facility failed to ensure the call light button was within reach of the resident for one of five sampled residents (Resident 1). This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2024 and readmitted the resident on 1/12/2024 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), ataxia (a group of disorders that affect co-ordination, balance, and speech), muscle weakness (generalized) and difficulty in walking. A review of Resident 1 ' s Care plan for assistance in the following areas: bed mobility, transfer, walk in room/corridor, locomotion on unit and off unit, dressing, eating, toilet use, personal hygiene and bathing related to CVA left hemiparesis, 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 observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one out of five sampled residents (Resident 4) by failing to ensure Resident ' s bathroom sink have running water. This deficient practice had the potential to result in an unsanitary and unhomelike environment for Resident 4 due to not having access to running water in the bathroom sink. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 9/4/2022 and readmitted the resident on 12/29/2023 with diagnoses including fracture of shaft of humerus (breaking the bone in your upper arm) left arm, peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and muscle weakness (generalized). A review of Resident 4 ' s care plan developed on 12/29/2023 indicated Resident 4 required assistance in the following areas: bed mobility, transfer, walking in room and corridor, locomotion on unit and off unit, dressing,…

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

Based on observation, interview, and record review, the facility failed to ensure that one of eight sampled residents (Resident 8) had a functional eyeglass. The facility was not able to provide a replacement for the Resident 8 ' s broken eyeglasses. This deficient practice had the potential to result in Resident 8 ' s decreased ability to read, write, and do activities safely. In addition, based on the Reasonable Person Concept (refers to a tool to assist the survey team ' s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 8 ' s impaired cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to delay of medical services may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope) and feelings of helplessness (the belief that there is nothing that anyone can do to…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of eight sampled residents (Residents 8), by failing to ensure Licensed Vocational Nurse 2 (LVN 2) perform hand hygiene (hand washing with soap and water or use of alcohol-based hand sanitizer) before and after changing gloves and after touching unclean surfaces. LVN 2 also did not disinfect the pulse oximeter (a device used to measure the saturation of oxygen carried in the red blood cells) used on Resident 8. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: A review of Resident 8 ' s admission Record indicated the facility admitted the resident on 11/14/2023 with diagnoses including chronic obstructive pulmonary disease (COPD – a group of diseases that cause airflow blockage and breathing -related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse properly by not covering three of six green dumpsters (large trash container designed to be emptied into a truck) from 7:30 a.m. to 9:41 a.m. while waiting for trash to be picked up by the garbage truck. This deficient practice had a potential to attract birds, flies, insects, and pests, and possibly spread infection to all 88 facility residents. Findings: During an observation of the dumpster area outside of the facility entrance, on 11/14/2023 at 7:30 a.m., observed three out of six green dumpsters that were not covered. During an observation of the dumpster area outside of the facility entrance, on 11/14/2023 at 8:39 a.m., observed three green dumpsters that were not covered. During a concurrent observation of the dumpster area outside the facility entrance and an interview with the Housekeeping Supervisor (HS), on 11/14/2023 at 8:41 a.m., the HS stated three dumpsters were not covered. The HS stated the last time the outside vendor picked up the garbage was on 11/13/2023 in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs and preferences for six of 58 residents (Resident 2, 21, 68, 36, 5, and 64) by failing to: 1. Ensure the call light was within reach for Residents 2, 21, 68, and 36. 2. Ensure Resident 5 and Resident 64's call light was operative and within reach. These deficient practices had the potential for residents not being able to call for facility staff assistance, possibly delay necessary care and services, and increase the risk for injury or fall. Findings: a. A review of Resident 2's admission Record indicated the facility initially admitted the resident on 10/19/2022 and readmitted the resident on 2/25/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), heart failure (a condition in which the heart cannot pump blood well enough to meet the body's needs), and generalized muscle weakness.…

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

Based on interview and record review, the facility failed to ensure residents had the right to receive mail for two of 16 sampled residents (Resident 74 and Resident 85). Resident 74 and Resident 85 stated they do not receive mail on Saturdays. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being. Findings: During the with Resident Council meeting on 11/14/2023, at 1:49 p.m., Resident 74 and Resident 85 stated they do not receive mail on Saturdays. During an interview with the Activities Director (AD) on 11/15/2023 at 9:45 a.m., the AD stated that she does not work on the weekends and she checks the residents' mailbox on Monday mornings to check for mail delivered during the weekend. The AD stated that residents do not receive their mail on Saturdays and sometimes there are packages left in the resident mailbox when she checks on Mondays. The AD stated that residents should be receiving their mail on Saturdays because if they are mailed medical forms, they should be able…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and transmit the Minimum Data Set (MDS - a standardized assessment and care screening tool) Discharge Assessments for three of three sampled residents (Resident 81, 82, and 83) investigated under the Resident Assessment task. These deficient practices had the potential to result in care that does not address the resident's specific care needs. Findings: a. A review of Resident 81's admission Record indicated the facility admitted the resident on 5/23/2023 with diagnoses including chronic (long-term) systolic (congestive) heart failure (a condition that occurs when the heart does not pump blood effectively) and cardiogenic shock (a life-threatening condition resulting from inadequate tissue perfusion due to the dysfunction of the heart which can lead to organ failure). The admission Record indicated the facility discharged the resident on 6/30/2023. A review of Resident 81's physician order, dated 6/26/2023, indicated an order to transfer the resident to General Acute Care Hospital 1 (GACH 1) for further evaluation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for four of 58 residents (Resident 31, 33, 54, and 69) by failing to: a. Develop Resident 31's care plan for smoking that indicated interventions that are complete and specific, including addressing storage of Resident 31's smoking material (e.g., cigarettes, lighters). b. Develop and implement Resident 33 and 69's care plan on the use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). c. Develop and implement Resident 54's care plan on the use of oxygen via nasal cannula (a device that gives additional oxygen through the nose). These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: a. A review of Resident 31's admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team (IDT) for two of 58 sampled residents (Resident 68 and Resident 65) by: 1. Failing to update Resident 68's care plan for fall after the resident had an unwitnessed fall on 8/30/2023, 9/1/2023, and 9/8/2023. The deficient practice had the potential for Resident 68 to have repeated falls that could result to injuries and even death. 2. Failing to revise Resident 65's care plan for nutrition. This deficient practice placed the resident at risk for complications related to nutritional and hydration status. Findings: a. A review of Resident 68's admission Record indicated the facility admitted Resident 68 on 7/20/2022 and readmitted Resident 68 on 9/16/2023, with diagnoses including seizures (a sudden, uncontrolled burst of electrical activity in the brain), difficulty walking, and muscle weakness. A review of Resident 68'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 provide the necessary care and services to ensure residents' abilities of daily living do not diminish to one of nineteen sampled residents (Resident 33) by failing to provide feeding assistance to Resident 33 who had hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction affecting left non-dominant side. This deficient practice placed Resident 33 at risk for complications related to nutritional and hydration status. Findings: A review of Resident 33's admission Record indicated the facility admitted Resident 33 on 4/19/2021, with diagnoses including hemiplegia and hemiparesis following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, dysphagia (difficulty swallowing), and muscle weakness. A review of Resident 33'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 h. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 12/19/2022 with diagnoses including chronic kidney disease, hypotension (low blood pressure), muscle weakness, and dependence on renal dialysis (blood is put through a filter outside the body, cleaned, and then returned to the person). A review of Resident 7's History and Physical dated 12/21/2022, indicated the resident has the capacity to understand and make decisions. A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/20/2023, indicated the resident was cognitively intact (able to understand and make decisions) and required extensive assistance and one-person physical assistance with walking in room and corridor, dressing, toilet use, and personal hygiene. Resident 7 required limited assistance and two-person physical assistance with transfers and supervision and setup help only to one-person physical assistance with bed mobility, locomotion off unit, and eating. 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 provide respiratory care consistent with professional standards for three of three sampled residents (Resident 11, 54, and 23) by: 1. Failing to apply Resident 11, 54, and 23's nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) properly to ensure the residents receive oxygen as ordered by the physician. These deficient practices had the potential for Resident 11 and 54 not to get enough oxygen in the system causing shortness of breath leading to hypoxia (low levels of oxygen in the body). 2. Failing to ensure Resident 23's oxygen tubing was kept off the floor. This deficient practice had the potential for bacteria to grow in Resident 23's nasal cannula tubing resulting in respiratory infections. Findings: a. A review of Resident 11's admission Record indicated the facility admitted the resident on 8/31/2021 and readmitted the resident on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide individual food preferences to two out of 2 sampled residents (Resident 18 and 86). This deficient practice had the potential to cause psychosocial harm to the residents and decrease food intake resulting to weight loss. Findings: a. A review of Resident 86's admission Record indicated the facility admitted the resident on 9/11/2023 with diagnoses including heart failure (a condition when the heart does not pump enough blood for the body's needs), diabetes mellitus type 2 (DM, a chronic condition that affects the way the body processes blood sugar [glucose]), and hypothyroidism (when thyroid glands does not produce enough thyroid hormones for the body's needs). A review of Resident 86's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/18/2023, indicated Resident 86 was cognitively intact (able to understand and make decisions), able to eat with supervision, and needed one-person physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food and drinks designed to meet individual needs when: 1. Two of 88 residents (Residents 6 and 16) did not receive fortified diet (adding foods such as butter, margarine, soup to the diet to increase calories and protein) during lunch meal. 2. One of one resident (Resident 65) on moderately thickened liquid's (a honey thick consistency, fluid slowly drips in dollops off the end of the spoon) was not thickened appropriately. These deficient practices had the potential to cause weight loss for Residents 6 sand 16; and may cause coughing, choking (to keep from breathing the normal way), and death to Resident 65. Findings: a.1 A review of Resident 6's admission Record indicated the facility admitted the resident on 8/28/2008 and readmitted the resident on 10/29/2008 with diagnoses including heart failure (a condition when the heart does not pump enough blood for the body's needs), chronic obstructive pulmonary disease (COPD, a lung…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Two 400 pans (4-inch deep pans) four 600 pans (6-inch deep pans), and two carts for storing clean dishware had sticker and/or tape residues. b. Two freezer bottom shelves and gaskets (a rubber attached to outer edge of the refrigerator use for airtight seal) had dust and dirt residues. c. Freezer and refrigerator temperature logs were left blank on 11/12/2023. d. Clean pink pitchers were not protected from spill from the handwashing sink (issue of possible cross-contamination, the transfer of harmful bacteria from one place to another). e. Pots and pans were not air dried. f. Red buckets containing sanitizer and wipe cloths were not separated from food and clean kitchen utensils (issue of possible cross-contamination) g. Ice machine baffle (slanted component used to keep ice from falling out of the bin when the door is opened) had white slimy particles and internal parts of the ice machine had black sealant residues…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 measures for seven of eight sampled residents (Resident 11, 63, 23, 46, 57, 500, and 28) and one of one linen cart (Linen Cart 1) by: 1. Failing to ensure the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) drainage bag (to collect urine) was not touching the floor for Resident 11. 2. Failing to ensure the oxygen tubing was not touching the floor for Resident 11. These deficient practices had the potential for contamination of residents' equipment and placed the residents at risk for infection. 3. Failing to ensure Linen Cart 1 was covered when not in use. This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents. 4. Failing to report positive coronavirus disease (COVID-19 - a respiratory infectious disease caused by the SARS-CoV-2 virus capable of producing severe symptoms) cases to the State…

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

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for one of 58 residents (Resident 65), when Certified Nursing Assistant (CNA) 10 was observed standing over Resident 65 while spoon-feeding the resident. This deficient practice had the potential to affect the resident`s sense of self-worth and self-esteem. Findings: A review of Resident 65's admission Record indicated the facility admitted Resident 65 on 7/12/2022, with diagnoses including type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), generalized weakness, and history of falling. A review of Resident 65's Minimum Data Set (MDS - an assessment and care screening tool), dated 8/9/2023, indicated Resident 65 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), required extensive assistance with bed mobility, and was totally dependent on staff for transferring between surfaces. A review of…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's self-administration of medications was appropriate and safe for one of 58 sampled residents by failing to ensure Resident 39's Medication Self-Administration Assessment was completed prior to leaving medications at the resident's bedside. This deficient practice had the potential to result in unsafe medication administration or omission. Findings: A review of Resident 39's admission Record, indicated the facility originally admitted Resident 39 to the facility on 5/19/2021, and readmitted the resident on 6/3/2021, with diagnoses including unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). A review of Resident 39's Minimum Data Set (MDS- and assessment and care screening tool), dated 8/23/2023, indicated Resident 39's cognition was severely impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their…

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

Based on observation, interview, and record review, the facility failed to provide a resident written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) when the resident was transferred to a general acute care hospital (GACH) for one of three (Resident 32) residents reviewed under closed records. This deficient practice had the potential to result in Resident 32 and their representative being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference. Findings: A review of Resident 32's admission Record indicated the facility admitted the resident on 1/26/2019 and readmitted the resident on 4/26/2023 with diagnoses including end stage renal disease (ESRD - he last stage of long-term kidney disease when the kidneys can no longer support the body's needs), and generalized muscle weakness. A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care screening…

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

Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards for two of 13 sampled residents (Resident 33 and Resident 11), by 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Resident 33. 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). 2. Failing to provide Resident 33 a straw for drinking liquids. 3. Failing to consult with the pharmacist before opening the tamsulosin (Flomax, medication used to help relax the muscles in the prostate and the opening of the bladder) timed-release capsule (designed to release medication over a sustained period, usually 8 to 24 hours) and administering it to Resident 11. Findings: a. A review of Resident 33's admission Record indicated the facility admitted Resident 33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition for one of 58 sampled residents (Resident 65) by failing to Ensure Resident 65 was not in a reclined position while being assisted with feeding by Certified Nursing Assistant (CNA) 10. This deficient practice resulted in Resident 65 coughing after eating a spoonful of food and drinking the provided beverage; and had the potential for Resident 65 to aspirate (breathe in foreign objects, such as liquid or food, into the lungs) and possibly result in aspiration pneumonia (inflammation and infection of the lungs or large airways that occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed). Findings: a. A review of Resident 65's admission Record indicated the facility admitted Resident 65 to the facility on 7/12/2022 with diagnoses including type two diabetes mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria, often from the skin or rectum, enter the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract) to one out of thirteen sampled residents (Resident 21) by failing to: 1. Attach a leg strap/statlock (a device to secure the catheter to prevent tugging and pulling) to secure the urinary catheter (a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter) of the resident. 2. Keep the urinary catheter bag (collects urine from the catheter) off the floor. The deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a performance review (also known as performance evaluation [PE] - a formal and productive procedure to measure an employee's work and results based on their job responsibilities) at least once every 12 months for one of three sampled Certified Nursing Assistants (CNA) (CNA 11) reviewed under sufficient and competent nurse staffing task. This deficient practice had the potential to result in missed opportunities to address CNA 11's performance issues that could impact resident safety and satisfaction. Findings: During a concurrent interview and record review on 11/15/2023 at 4:09 p.m., with MDSN 1, CNA 11's employee file was reviewed. MDSN 1stated the last performance evaluation (PE) filed for CNA 11 was dated 2/14/2022. MDSN 1 stated there was no PE completed for CNA 11's for the year 2023. During an interview on 11/16/2023 at 2:26 p.m., with the Director of Nursing (DON), the DON stated CNA performance evaluations are done annually. The DON stated the responsible person to complete PEs is the Director of 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 administer medications in accordance of professional standards of practice for one of three sampled residents (Resident 11) by failing to consult with the pharmacist before opening the tamsulosin (Flomax, medication used to help relax the muscles in the prostate and the opening of the bladder) timed-release capsule (designed to release medication over a sustained period, usually 8 to 24 hours) and administering it to Resident 11. This deficient practice had the potential to result in alteration of the drug's absorption and cause adverse consequences including stomach lining irritation and sudden drop in the blood pressure, which could lead to dizziness or fainting, Findings: A review of Resident 11's admission Record indicated the facility originally admitted the resident on 8/31/2021 and readmitted the resident on 10/10/2023 with diagnoses including acute respiratory failure with hypoxia (a serious condition that makes it difficult to breathe on your own) and unspecified pulmonary fibrosis (a disease where…

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

Based on observation, interview, and record review the facility failed to ensure safe provision of pharmaceutical services by failing to label the date of when Anoro Ellipta (a brand of prescription medication used to treat chronic obstructive pulmonary disease [COPD - refers to a group of diseases that cause airflow blockage and breathing-related problems] administered by inhalation) was opened for one out of nine residents (Resident 56) during investigation of Medication Storage and Labeling. This deficient practice placed the Resident 56 at risk for medication errors. Findings: A review of Resident 56's admission Record indicated the facility admitted the resident on 1/29/2021 and readmitted the resident on 2/8/2021 with diagnoses including cerebral infarction (also known as stroke - a condition that occurs when a clot blocks the blood supply to the brain), acute respiratory failure with hypoxia (a condition that makes it difficult to breathe independently with low oxygen level), and COPD. A review of Resident 56's Minimum Data Set (MDS - a standardized assessment and care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evaluate the overall number of facility staff available to meet the resident care needs by failing to determine sufficient staffing ranges for the provision of quality care. This deficient practice had the potential to result in a delay of necessary care and services to the residents. Cross-reference to F725 Findings: During an interview, on 11/16/2023 at 10:24 a.m., the Director of Nursing (DON) stated they had completed the Facility Assessment (determines the resources necessary to care for residents competently during the day-to-day operations and emergencies) two months ago with Administrator 2 (ADM 2). During an interview and concurrent record review of the Facility Assessment, dated 4/27/2023, on 11/16/2023 at 2:19 p.m., the DON stated the facility assessment was not complete as there was no staffing information documented. The DON stated ADM 2 should have completed it. The DON stated the purpose of the facility assessment is to determine the demographics of the residents and to ensure proper staff-to-patient ratios…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nurse documented the notification to the physician and dialysis center (a hospital-based or independent unit approved and licensed to provide outpatient dialysis services) of a resident's refusal for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment for one out of three residents (Resident 32) investigated for closed records. This deficient practice had the potential to result in the medical records containing inaccurate documentation. Findings: A review of Resident 32's admission Record indicated the facility admitted the resident on 1/26/2019 and readmitted the resident on 4/26/2023 with diagnoses including end stage renal disease (ESRD - he last stage of long-term kidney disease when the kidneys can no longer support the body's needs), and generalized muscle weakness. A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/31/2023, indicated the resident had an intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 functioning call light system (device used to alert facility staff assistance as needed by residents) was provided for two of 58 sampled residents (Residents 5 and 64) when their call light was not functioning after pressing the call light button to activate the call light system. This deficient practice resulted in Resident 64 feeling helpless and had a possibility to delay provision of care to the residents. Findings: a. A review of Resident 5's admission Record indicated the facility admitted the resident on 5/1/2021 and readmitted the resident on 7/27/2022 with diagnoses including parkinsonism (a disorder of the central nervous system that affects movement, often including tremors). A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/1/2023, indicated the resident had severe cognitive impairment (when a person has trouble remembering, learning new things,…

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

Desert Canyon- F757 Unnecessary Drugs Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 1) receive non-pharmacological approach (interventions that do not involve the use of medications to treat pain) prior to the administration of pain medications. This deficient practice had the potential to place Resident 1 at risk of receiving unnecessary pain medications. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 8/9/2023 with diagnoses including secondary malignant neoplasm of the brain (a cancer that has started in another part of the body and has spread to the brain), atherosclerosis of aorta (a material called plaque [fat or calcium] has built up on the inside wall of a large blood vessel called the aorta), and cerebrovascular disease (a group of conditions that affect the blood flow and blood vessels in the brain). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/15/2023, indicated that Resident 1 had impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) receive non-pharmacological approach (interventions that do not involve the use of medications) prior to the administration of an anti-anxiety medication (a class of psychotropic medication [any drug that affects behavior, mood, thoughts, or perception] used to prevent or treat anxiety symptoms or disorders). This deficient practice had the potential to place Resident 1 at risk of receiving an excessive dose of psychotropic medications. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 8/9/2023 with diagnoses including secondary malignant neoplasm of the brain (a cancer that has started in another part of the body and has spread to the brain), atherosclerosis of aorta (a material called plaque [fat or calcium] has built up on the inside wall of a large blood vessel called the aorta), and cerebrovascular disease (a group of conditions that affect the blood flow and blood vessels in the brain). 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 ensure safe and sanitary food preparation practices in the kitchen when: - One cook wiped the pole above the kitchen utensils container by the tray line full of dust - Eleven flies were observed flying in the kitchen and landing on surfaces, trays, utensils, and dishes. This deficient practice 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 by consuming potentially contaminated food in 85 out of 85 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), in the trayline area (area for food assembly in the kitchen) on 8/15/2023 at 12:43 p.m., observed Dishwasher (DW) wiping the dusty pole under a grey utensil ' s container by the tray line while trayline lunch service was happening. The utensil container had napkins, spoons, forks and knives. DSS stated, DW should not be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a person centered comprehensive care plan when one of three sampled residents (Resident 3) asked to put the bedside table (table use to hold food) containing uncovered food inside the restroom. This deficient practice had the potential to result in food borne illnesses (illness caused by consuming contaminated foods or beverages) for Resident 3. Findings: A review of Resident 3 ' s admission Record indicated the facility initially admitted the resident on 10/10/1997 with diagnoses that included unspecified focal traumatic brain injury with loss of consciousness (damage to the brain), morbid obesity (excessive body weight and body fat) due to excess calories and anemia (a condition in which the body does not have enough healthy red blood cells). A review of Resident 3 ' s Minimum Data Sheet (MDS - a standardized care assessment tool), dated 8/11/2023, indicated the resident is cognitively (a mental process that take place in the brain, including thinking, attention, language, learning, memory 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.