Mirage Post Acute

Based on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 1) by failing to:1. Ensure Certified Nursing Assistant (CNA) 1, CNA 2 and CNA 3 wear a gown when providing incontinent (the loss of control over the bladder or bowels) care to Resident 1, who was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO- a germ that is resistant to many antibiotics] in nursing homes).2. Ensure EBP signage was posted outside of Resident 1's room.These failures had the potential to spread and expose other residents, staff, and visitors to infection.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/10/2026, with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), unspecified (unconfirmed) multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells 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 interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Residents 1, and 2) by failing:1. To ensure Licensed Vocational Nurse 4 (LVN 4) follow physician order to hold (to temporarily pause or skip a dose as instructed by a healthcare professional) losartan (medication used to treat hypertension [HTN- high blood pressure]) for Resident 1's systolic blood pressure (sbp- the top or first number in a blood pressure reading. It measures the maximum pressure the blood exerts against the artery walls when the heart beats and pumps blood throughout the body) below 110 millimeters mercury (mmHg-standard unit of measurement for pressure) on 5/14/2026, at 9 a.m.2. To ensure LVN 3, LVN 5 and LVN 6 follow physician order to hold clonidine (medication used to treat HTN) and hydralazine (medication used to treat HTN) for…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity for one of the three sampled residents (Resident 4) by failing to ensure Resident 4 was provided with silverware (eating utensils such as forks, knives, and spoons) with breakfast tray. On 6/8/2026, Licensed Vocational Nurse (LVN) 1 provided disposable utensils to Resident 4.This failure had the potential to negatively affect Resident 4's self-esteem and self-worth.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 2/27/2026, with diagnoses that included sacral (tailbone) stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), mild protein-calorie malnutrition (a condition where the body receives inadequate protein and/or calories, leading to measurable but generally reversible physical changes) and adult failure to thrive (a syndrome characterized by unintended weight loss, decreased appetite, poor nutrition, and 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 promptly notify one of three sampled residents (Resident 3) Responsible Party (RP) 1 of Resident 3's change in condition on 6/1/2026, before Resident 3 was transferred to the General Acute Care Hospital (GACH).This failure had violated RP's 1's right to be informed and had the potential to increase RP 1's level of anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/27/2023, with diagnoses including unspecified (unconfirmed) Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought). The admission Record indicated RP 1 was Resident 3's responsible party.During a review of Resident 3's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and…

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

Based on interview and record review the facility failed to notify the resident's Responsible Party (RP - when signing admissions paperwork for a hospital, nursing home, or assisted living facility, the responsible party is the person designated to make medical or administrative decisions for the resident) of the transfer and the reasons for the move in writing for one of three sampled residents (Resident 3).This failure had the potential for incomplete information conveyed to residents or RP 1 and could have violated resident and RP 1's rights to appeal (the process in which cases are reviewed by a higher authority) transfer or discharge.Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/27/2023, with diagnoses that included unspecified (unconfirmed) Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought). The admission Record indicated RP 1 was Resident 3's responsible…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 4) by failing to ensure the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) was set according to Resident 4's weight as per physician order and manufacturer's guidelines (the official recommendations and standards set by the company that built a product that outline the proper procedures for installation, operation, maintenance, and troubleshooting, ensuring the product functions safely, efficiently, and within its warranty limits).This failure had the potential for the worsening of Resident 4's pressure ulcers.Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 2/27/2026, 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 that resident's was free of unnecessary medication for one of three sampled residents (Resident 3) by failing to ensure Licensed Vocational Nurse (LVN) 8 and LVN 9 adequately monitor and document for the manifested behavior of restlessness for a resident who received antianxiety medications (medications used to treat symptoms of anxiety, such as excessive worry, panic attacks, fear, and physical tension).This failure had the potential to result in Resident 3 receiving unnecessary medications and not receiving the adequate care and treatment necessary for physical, mental and psychosocial well-being.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/27/2023, with diagnoses that included unspecified (unconfirmed) Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident…

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

Based on interview and record review, the facility failed to maintain accurate and complete medical records for one of three sampled residents (Resident 2) by failing to ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) forms were completed prior to transferring Resident 2 to the dialysis center and upon return to the facility.This failure had the potential to cause confusion in the care and the medical records containing inaccurate documentation.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/7/2024, with diagnoses that included unspecified (unconfirmed) nontraumatic subdural hemorrhage (bleeding in the space between the brain and skull without a history of head injury), sacral (tailbone) stage four pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and dependent on renal dialysis (a life-sustaining treatment that performs the filtering functions 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 implement its infection control measures for one of three sampled residents (Resident 4), by failing to ensure Licensed Vocational Nurse 1 (LVN 1) wear a gown when assisting Resident 4 who was on enhanced barrier precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO- a germ that is resistant to many antibiotics] in nursing homes) to turn and sit on the edge of the bed.This failure had the potential to spread and expose other residents, staff, and visitors to infection.Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 2/27/2026, with diagnoses that included stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 4's…

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

Based on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctor's offices, hospitals, long-term care facilities and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for one of three sampled residents (Resident 2) by falling to monitor Resident 2 for the adverse effects (undesired or harmful effects) of levofloxacin (medication used to treat bacterial infections) on 5/10/2026, and 5/11/2026, from 3 pm to 7 a.m.These failures had the potential for antibiotic resistance (do not respond to a drug) and had the potential for Resident 2 to experience an adverse reaction. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/7/2024, with diagnoses that included unspecified (unconfirmed) nontraumatic subdural hemorrhage (bleeding in the space between the brain and skull without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a safe discharge that included sending the resident to a location that met the resident's needs. This deficient practice resulted in Resident 1 being admitted to General Acute Care Hospital (GACH) 1 on 6/1/2026.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the Resident 1 on 4/18/2026 and readmitted the resident on 4/27/2026 with diagnoses including cerebral infarction (when a blood vessel carrying oxygen and nutrients to the brain becomes blocked, cutting off blood flow. Without that blood supply, the brain tissue in that area gets damaged and dies), dysphagia (difficulty swallowing), gastrostomy (g-tube a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), hemiplegia (paralysis of one entire side of the body) affecting the left nondominant side and…

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

Based on interview and record review, the facility failed to follow the Responsible Party's (RPs- the individual legally and financially accountable for paying medical bills) request to be notified prior to any ancillary services (are diagnostic, therapeutic, or custodial support measures that assist primary care providers in treating residents). On 5/18/2026, the Podiatrist (a physician and surgeon who treats the foot, ankle, and related structures of the leg), trimmed one of three sampled residents (Resident 1) toenails without RP's approval.This failure had violated the RPs right to be informed.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/14/2012, with diagnoses that included unspecified (unconfirmed) Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and unspecified peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the Conservator (a court-appointed individual with the legal authority to make personal, medical, and financial decisions for a resident who is no longer capable of making those decisions themselves) of one of three sampled residents (Resident 1) when Resident 1 died on [DATE].This deficient practice resulted in a violation of Resident 1's rights.Findings: During a review of Resident 1's Order Appointing Probate Conservator, filed on [DATE], the Order Appointing Probate Conservator indicated Resident 1's responsible party (RP) 1 was the Conservator of Resident 1 as of [DATE]. During a review of Resident 1's General Acute Care Hospital (GACH) Hospitalist Progress Note, dated [DATE] timed at 7:29 a.m., the Progress Note indicated, Conservatorship paperwork has been initiated due to impaired decision-making capacity.During a review of Resident 1's admission Record, the admission Record 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 interview and record review, the facility failed to inform the attending physician (MD) and responsible party (Conservator - a court-appointed individual with the legal authority to make personal, medical, and financial decisions for a resident who is no longer capable of making those decisions themselves) of two of three sampled residents (Resident 1 and Resident 2). The facility failed to:1.Inform Resident 1's MD and the Conservator, when Resident 1 was found unresponsive and died on [DATE].2.Inform Resident 2's MD when Resident 2 was in pain and medication was unavailable on [DATE].These deficient practices resulted in violation of Resident 1's rights and the potential for Resident 2 to have unmanaged pain.Findings: a. During a review of Resident 1's Order Appointing Probate Conservator filed on [DATE], the Order Appointing Probate Conservator indicated Resident 1's responsible party (RP) as the Conservator of Resident 1 as of [DATE]. During a review of Resident 1's Order Appointing Probate…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) who complained of pain received medication according to the physician orders. This failure resulted in Resident 2's pain management to be ineffective resulting in Resident 2 being in pain.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/6/2026 with diagnoses including encounter for surgical aftercare following surgery on the circulatory system (cardiovascular system, it uses your heart to pump blood through a network of vessels, delivering oxygen and nutrients to every cell while carrying away waste), presence of aortocoronary bypass graft (CABG- a surgical procedure that creates a detour around blocked or narrowed arteries supplying blood to the heart ), and hypertensive heart disease (any heart problem caused by long-term, unmanaged high blood pressure) with heart failure (a condition where the heart muscle becomes too weak or too stiff to pump blood effectively). During a review of Resident 2 Order…

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

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person's health conditions and current treatments for their care) for one of three sample residents (Resident 1), regarding Resident 1's use of aspirin (a medication used as a blood thinner that prevents blood cells called platelets from sticking together) and Resident 1's behavior of hitting herself. These deficient practices had the potential to negatively affect Resident 1's physical and psychosocial wellbeing.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 12/8/2025 and readmitted the resident on 4/2/2026 with diagnoses that included cerebral ischemia (a critical condition where the brain does not receive enough oxygen-rich blood, often caused by a blocked or narrowed artery, leading to tissue damage or death), muscle weakness, and history of falling. During a review of Resident 1's Order Summary Report (ORS) dated 3/1/2026, the ORS indicated aspirin 81 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 maintain medical records in accordance with accepted professional standards and practices for two of three sampled residents (Resident 1 and Resident 3) when:1. The facility failed to ensure Resident 1's Progress Note, dated 4/2/2026, accurately document Resident 1's condition.2. The facility failed to accurately document Resident 3's physician's recommendation on Resident 3's Situational Background Appearance and Review and Notify (SBAR- a structured communication tool used in healthcare to share important patient information quickly and accurately) Communication Form, dated 4/2/2026.3. The facility failed to accurately document Resident 3's care plan (is a form that summarizes a person's health conditions and current treatments for their care) for a witnessed fall.These deficient practices result in inaccurate documentation in Resident 1 and Resident 3's records.Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform and provide written information to adult residents concerning the right to accept and refuse medical and surgical treatment and the residents' option to formulate an advance directive (a legal document including resident preference on end-of-life treatment decisions) for four of six sampled residents (Residents 14, 10, 17, and 150) when the Social Services Director (SSD) failed to provide written information to residents regarding advance directive formulation. These deficient practices violated the residents' rights to be fully informed of the option to formulate their advanced directives, placing the residents at risk of receiving unwanted or inappropriate treatment. Findings: 1. During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 2/12/2026 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided 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.

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 four of five sampled residents (Residents 142, 264, 86 and 80) reviewed for physical restraints by failing to ensure: 1. Resident 42's use of restraint, bed placed against the wall, had a physician's order, informed consent, restraint assessment, and a care plan on its use. 2. Resident 264's use of restraint, bed placed against the wall, had a current physician's order, informed consent, and a specific restraint assessment for bed placed against the wall. 3. Resident 86's use of restraint, bed placed against the wall, had a physician's order, informed consent, restraint assessment, and a care plan on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for one of five sampled residents (Resident 175) reviewed under unnecessary medications care area when: 1. The facility failed to develop a care plan for the use of Lorazepam (a medication that is used to treat anxiety) and monitor its adverse effects (unexpected and harmful reactions caused by a medication taken at normal doses) for Resident 175. This deficient practice had the potential to result in Resident 175's risk for adverse effects, medication dependence, and withdrawal reactions going unmonitored and to delay staff awareness of these issues. 2. The facility failed to develop a care plan addressing self-administration of hot/cold gel pack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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' environment was free of accident hazards for five (5) of 5 sampled residents (Resident 163, 159, 231, 239, and 255) reviewed for accidents by failing to ensure: 1. Resident 163 did not have any medications or biologicals left at the resident's bedside. 2. Resident 159's bed was kept at the lowest position. 3. Resident 231's call light button did not have frayed/exposed wires on them. 4. Resident 239 did not have a table placed on top of the floor mat (a thick, soft pad placed on the floor beside a resident's bed to cushion them if they fall). 5. Resident 255 did not have a table placed on top of the floor mat. These deficient practices increased the risk of accidents such as falls with injuries, poisoning, and electrocution on residents. Findings: 1. During a review of Resident 163's admission Record (AR), the AR indicated the facility admitted the resident on 8/4/2020, and readmitted the resident on 5/16/2022, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents with a urinary catheter (also known as Foley catheter - a hollow tube inserted into the bladder to drain or collect urine) and residents who were incontinent of bladder received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for three of four sampled residents (Resident 168, 3, and 60) reviewed for urinary catheter or UTI care area by, failing to: 1. Ensure Resident 168's urinal bottle (a portable, handheld container designed to collect urine when a person cannot get to the bathroom) was labeled with the name of the resident and the date it was provided. 2. Ensure Resident 3's urinary catheter had a leg strap (a portable, handheld container designed to collect urine when a person cannot get to the bathroom) or stat lock (a specialized, adhesive device used in hospitals to securely hold a catheter tube in place on a patient's skin) on them. 3. Follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of four sampled residents (Residents 22, 235, 5, and 212) reviewed for respiratory care by failing to ensure: 1. Resident 22's suction canister (a rigid or semi-rigid medical container used to collect fluids, blood, and mucus removed from a resident's body during surgery or respiratory care) was labeled with the date and time it was provided. 2. Resident 235's oxygen (O2) via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. 3. Resident 5's physician's order for oxygen therapy and care plan was complete, and included parameters for oxygen titration with a specific target saturation range (instructions how to adjust a resident's oxygen levels safely) and pulse oximetry (measuring how much oxygen is in blood) monitoring. 4. Resident 212 received two liters 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 safely use bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) for three of four sampled residents (Resident 11, 22 and 163) by failing to ensure: 1. Resident 11's half (1/2) bed rails (a 1/2 (half-length) bed rail is a safety barrier that covers only the top portion of a bed, typically near the user's torso) had a physician's order and a comprehensive person-centered care plan for its use. 2. Resident 22's and 163's 1/2 bed rails had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), bedrail assessment, and a care plan on its use. These deficient practices 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, around, between, or through the rails. 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 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 are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for three of three sampled residents (Residents 142, 80, and 1) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet the nutritional needs for 38 out of 237 residents who received fortified diet (foods with nutrients added to them) when on 4/20/2026 during lunch service, [NAME] 2 did not follow the menu and used a teaspoon instead of a tablespoon to add melted margarine on the potatoes and vegetables. This deficient practice had the potential to result in an inadequate number of calories and/or protein the residents need which may lead to weight loss. Findings: During a review of the facility's menu spreadsheet (a list containing types and amount of foods of what each diet type would receive) titled Spring Cycle Menu, dated 4/20/2026, Week four (4) Monday, the menu spreadsheet indicated that for the residents on regular diet, the facility would include the following food items on the tray: - Baked hamburger three (3) ounces (oz - a unit of measurement) - [NAME] sauce one (1) oz - Diced fried potatoes 1/2 cup (c. - a household measurement) - Capri blend vegetables 1/2 c - Wheat roll, 1 - Margarine 1 teaspoon (tsp - a…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure eight (8) meal trays were stacked and still wet in the drying area section next to the dishwashing area and two (2) clear food storage bins were stacked and still wet in the dried food storage bins area. 2. Failing to discard four (4) sprouted onions, and 4 onions with brown and dark gray discoloration inside a brown box. 3. Failing to discard one (1) dented can of fruit cocktail. 4. Failing to ensure 4 plastic bags of hotdog buns and 2 plastic bags of hamburger buns were labeled with an open date. 5. Failing to indicate an open date for 1 container of soy milk, 1 container of almond milk, and 1 container of liquid non-dairy creamer. 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 (a disease caused by consuming food or drinks that are contaminated by germs 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for three of four sampled residents (Residents 168, 22, 28) reviewed for antibiotic use by failing to ensure: 1. Resident 168's Augmentin (a powerful, prescription-only antibiotic used to treat a wide range of bacterial infections) had a monitoring for adverse effects (a harmful, unwanted, or unexpected reaction caused by a medication, medical treatment, or procedure) of its use. 2a. Resident 22's Hiprex Oral Tablet (acts as a urinary antiseptic) for urinary tract infection (UTI - an infection in the bladder/urinary tract) prevention had an end date and had monitoring for adverse effects of its use. 2b. Resident 22's Cefuroxime Axetil Oral Tablet (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 maintain the electrical and resident care equipment in safe operating condition for four of six sampled residents (Residents 49, 136, 3, and 41) reviewed under the environmental task by failing to ensure there were no frayed wires on Resident 49,136, and 3's bed remote control and the call light (a button or pull-cord used in nursing homes that allows a resident to instantly alert staff when they need assistance) was properly functioning for Resident 41. These deficient practices had the potential for Residents 49, 136, and 3 to sustain accidents such as electrical shock and physical discomfort and to place Resident 41 at risk for unmet needs and delayed responses to emergencies. Findings: 1. During a review of Resident 49's admission Record (AR), the AR indicated the facility admitted the resident on 9/30/2025, with diagnoses including difficulty in walking, muscle weakness, and spondylopathy (is a broad, umbrella medical term for any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat residents with dignity and respect for two of two sampled residents (Residents 3 and 287), by failing: 1. To ensure Resident 3 did not sit on his stool (feces) on the resident's incontinence brief while eating his lunch on 4/20/2026, observed during lunch time dining observation. The resident already verbalized to Certified Nursing Assistant (CNA) 6 that he cannot eat with a stool in his bottom. This deficient practice violated Resident 3's dignity and respect by failing to provide a sanitary environment while eating. 2. To ensure Resident 287's privacy curtains were closed by (LVN) 4 while administering medications via gastrostomy tube ([G-tube] - a small tube surgically placed directly into the stomach through the skin of the belly to deliver food, liquids, and medications). This failure had the potential to cause emotional distress and affect Resident 287's self-esteem and cause a loss of dignity and decline in psychosocial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 homelike environment for one of one sampled resident (Resident 2) by not maintaining functional closet drawers. This deficient practice violated Resident 2's rights to a safe, clean, sanitary, and homelike environment. Findings: During a review of Resident 2's admission Records (the front page of the chart that contains a summary of basic information about the resident), the admission Records indicated that the facility admitted Resident 2 on 2/21/2025, and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a temporary, reversible brain dysfunction caused by chemical imbalances in the body), type two Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 3/2/2026, the MDS indicated that the resident`s cognitive skills (brain'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 ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of five sampled residents (Resident 175) reviewed for unnecessary medications by failing to ensure lorazepam (an anti-anxiety medication) was monitored for specific, measurable behavioral manifestations and adverse effects (negative outcomes or effects that result from a particular action or event). This deficient practice had the potential to result in the administration of unnecessary psychotropic medication and placed Resident 175 at increased for adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, or slurred speech. Findings: During a review of Resident 175's admission Record (AR), the AR indicated that the facility admitted the resident on 9/3/2024 with diagnoses including dementia (a progressive state of…

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

Based on interview and record review, the facility failed to report an unwitnessed fall with an injury of unknown origin to the State Survey Agency (SA) immediately but no later than two (2) hours of allegation for one (1) of three (3) sampled residents (Resident 23). This failure had the potential to lead to delayed investigation and intervention of possible abuse or neglect, placing the resident at risk of ongoing harm. Findings: During a review of Resident 23's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 23 on 12/14/2023 with diagnoses including displaced comminuted fracture of shaft of left fibula (a serious break in the smaller bone of your lower left leg), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 3/23/2026, the MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the nursing staff failed to revise a care plan to reflect a change in the physician's order for oxygen therapy for one (1) of one (1) sampled residents (Resident 212). This deficient practice has the potential to result in inconsistent care and staff not following the most current physician orders. Findings: During a review of Resident 212's admission Records (AR), the AR indicated Resident 212 was admitted on [DATE] to the facility with diagnosis including chronic obstructive pulmonary disease, unspecified (COPD- a chronic lung disease causing difficulty in breathing); dysphagia, oropharyngeal phase (starts in the mouth and cannot swallow properly at the beginning, so food or drink does not go down smoothly); muscle weakness (generalized)(weakness in many muscles throughout the body). During a review of Resident 212's History and Physical (H&P), dated 12/12/2025, the H&P indicated Resident 212 has the capacity to understand and make decisions. During a review…

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

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 of care to two of three sampled residents (Residents 142 and 80) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760. Findings: 1. During a review of Resident 142's admission Record (AR), the AR indicated the facility admitted the resident on 1/5/2024, with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 53) had received proper treatment after the Ophthalmology appointment. This deficient practice had the potential to result in Resident 53's vision to deteriorate and possibly cause an infection. Findings: During a review of Resident 53's admission Record (AR), the AR indicated that the facility admitted the resident on 05/11/2022, and readmitted on [DATE], with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty walking, and depression (loss of interest in life). During a review of Resident 53's History and Physical (H&P), dated 8/15/2025, the H&P indicated that Resident 53 has fluctuating capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool), dated 3/01/2026, the MDS indicated that Resident 53 has moderate cognitive impairment.…

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

Based on interview and record review, the facility failed to provide services to one of three sampled residents (Resident 93) reviewed under position, mobility care area who had limited range of motion (ROM - full movement potential of a joint) by failing to: 1. Notify Resident 93's physician when Resident 93 had constant refusals for right hand and right elbow splints. 2. Assess Resident 93 after constant refusals with the Restorative Nurse Assistant (RNA) application of right hand and right elbow splints. These deficient practices had the potential to have decline in Resident 93's ROM and mobility due to delayed treatments and a potential for delayed identification of ROM and mobility decline. Findings: During a review of Resident 93's admission Record (AR), the AR indicated that the facility originally admitted the resident on 8/3/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 recognize, evaluate, and address the needs of residents at risk or already experiencing impaired nutrition and hydration for one of two sampled residents (Resident 3) by failing to perform weight loss assessments (a systematic evaluation conducted by health professionals to measure, track, and interpret changes in an individual's body weight over time) as established by the interdisciplinary team (IDT, a coordinated group of health professionals from different specialties who work together to manage a resident's total care) on the first of the month. The deficient practice had predisposed the resident to unrecognized weight loss without intervention leading to poor nutrition of the resident. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident on 3/29/2024, and readmitted the resident on 12/31/2025, with diagnoses including gastro-esophageal reflux disease (GERD, a chronic, more severe form of acid reflux), 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.

Based on observation, interview, and record review, the facility failed to follow up a resident's request for dentures for one of two sampled residents (Resident 80). Resident 80 was seen by the dentist on 12/12/2025 with treatment recommendations of new dentures/partials, and teeth extractions (removal of a tooth). This deficient practice had the potential to result in the inability to effectively chew foods, weight loss, lack of energy, and loss of muscle mass for Resident 80. Findings: During a review of Resident 80's admission Record (AR), the AR indicated that the facility admitted the resident on 8/3/2021, and readmitted the resident on 8/16/2023, with diagnoses including morbid obesity (means that a person's mental abilities-such as thinking, memory, attention, and language-are working well and have not experienced significant decline or impairment), type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and disease of spleen (a fist-sized, fist-shaped organ located in the upper left side of your abdomen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and maintain an infection control program for one (1) of 1 sampled residents (Resident 153), during a random observation, by failing to ensure Resident 153 did not touch and pour a cup of water from the water pitcher on top of the Medication Cart (Med Cart) 1 used for medication pass in the presence of multiple staff sitting at Station 2 desk. This deficient practice had the potential to spread infections and illnesses among other residents and staff. Findings: During a review of Resident 153's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility originally admitted Resident 153 on 10/31/2024 with diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract), bacteremia (presence of bacteria in the blood caused by a variety of bacterial organisms), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 153's History and Physical (H&P), dated 2/25/2026,…

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

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document General Acute Care Hospital's (GACH) Case Manager (CM) inquiry on Resident 1's discharge back to the facility and reason why the facility did not accept Resident 1 back on 3/5/2026.This failure had the potential to result in confusion in care and the medical records containing incomplete documentation.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/5/2025, with diagnoses that included unspecified (unconfirmed) parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), aphasia (a disorder that makes it difficult to speak), and generalized muscle weakness.During a 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…

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

Based on observation, interview, and record review, the facility failed to ensure two of seven emergency exit doors (Exit Door 1 and Exit Door 2) were free from any obstructions. This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress (designated emergency exit door) access in the event of an emergency.Findings: During an observation on 2/2/2026 at 9:46 a.m., observed Exit Door 2 (the emergency exit door located at Station 5's hallway between the dayroom and the Director of Staff Development (DSD) classroom) was blocked by a signage board that indicated emergency exit only. There were no facility staff at the Station 5 hallways. During a concurrent observation and interview on 2/2/2026 at 9:51 a.m. with Licensed Vocational Nurse (LVN) 1, observed Exit Door 1 (the emergency exit door located at Station 2's hallway between resident room A and resident room B) was blocked by a wheelchair and a floor cleaner machine. LVN 1 stated the hallway leading to the emergency exit door should be clear from any equipment. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from chemical restraint (use of medication to manage a patient's behavior or restrict their freedom of movement, primarily to control agitation [a feeling of irritability, mental distress or severe restlessness] or aggression [any behavior, word, or action that is intended to harm another person, animal, or object]) by:Failing to monitor Resident 1 for the side effect (secondary, usually unwanted, effects of a medication or treatment that occur alongside the intended therapeutic result) of orthostatic blood pressure (a sudden drop in blood pressure occurring within three minutes of standing, that causes symptoms like dizziness, lightheadedness, blurred vision, or fainting) changes on 1/18/2026, and 1/25/2026, while on quetiapine (medication used to treat various mental health conditions) use.Failing to obtain a new Informed Consent (voluntary agreement to accept treatment and/or procedures…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was medicated for pain as per physician's order. On 1/21/2026, 1/25/2026, 1/26/2026, and 1/29/2026, nurses administered hydrocodone (medication used to treat pain) 5/325 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) to Resident 1 despite a physician order to administer oxycodone (medication used to treat pain) for pain level between seven to ten (zero- no pain and ten- worst pain).These failures had the potential to result in Resident 1's uncontrolled pain.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/19/2025, with diagnoses that included orthopedic aftercare (medical care and precautions a person needs to take after a bone or joints procedure to ensure proper healing), unspecified (unconfirmed) chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and acute (sudden in onset) and chronic (a health condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of three sampled residents (Residents 1 and 2) by:Failing to develop a care plan on Resident 1's noncompliance with oxygen use.Failing to implement care plan on Resident 2's risk for fall to keep bed in low position. These failures had the potential for delays in the delivery of necessary care and services to Resident 1 causing hypoxia (low levels of oxygen in your body tissues) and could result in Resident 2's fall and injury.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/19/2025, with diagnoses that included orthopedic aftercare (medical care and precautions a person needs to take after a bone or joints procedure to ensure proper healing), unspecified (unconfirmed) COPD, and acute (sudden in…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was assessed as high risk (a person is significantly more likely to fall due to factors like weak muscles, poor balance, dizziness from medication, or vision problems) for fall, was asleep on a bed in high position.This deficient practice had the potential to place Resident 2's at risk of fall and injury.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/8/2024, with diagnoses that included left shoulder primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), morbid obesity (a serious, chronic disease involving an excessive accumulation of body fat that severely impairs health and limits mobility) and right knee pain.During a review of Resident 2'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 6/10/2025, the…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) were provided with respiratory care consistent with professional standards of practice by:Failing to ensure oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was connected to Resident 1.Failing to follow a physician order for oxygen administration of two liters per minute via nasal cannula.These failures can negatively impact on Resident 1's health and well-being and can potentially result in excessive oxygen, suppressing (the act of stopping) Resident 1's ability to breathe. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/19/2025, with diagnoses that included orthopedic aftercare (medical care and precautions a person needs to take after a bone or joints procedure to ensure proper healing), unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document the conversation of Family Member 1 (FM 1) with Social Service Assistant 1 (SSA 1) about Resident 1's medication.This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/19/2025, with diagnoses that included orthopedic aftercare (medical care and precautions a person needs to take after a bone or joints procedure to ensure proper healing), unspecified (unconfirmed) psychosis ((a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and history of fall.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a resident's medical history, performing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) by failing to ensure oxygen tubing was not touching the floor. This failure had the potential for Resident 1 to get infection.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/19/2025, with diagnoses that included orthopedic aftercare (medical care and precautions a person needs to take after a bone or joints procedure to ensure proper healing), unspecified (unconfirmed) COPD, and acute (sudden in onset) and chronic (a health condition or disease that persists for an extended period, typically lasting three months to one year or longer) respiratory failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood) with hypoxia (a medical emergency where tissues and organs do not receive enough oxygen to function properly, potentially causing rapid damage to the brain and heart).During a review of Resident 1's History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have an on-going, effective pest control management program (a program that monitors, identifies, controls, and prevents pest infestations in the facility). This deficient practice had the potential to spread infections and illnesses among residents. Findings:a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 12/6/2022 with diagnoses including diabetes mellitus type two (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 4/7/2025, the H&P indicated Resident 2 had fluctuating capacity 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 interview and record review, the facility failed to ensure the medical records for one of five sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, vision, balance, mobility, medications) form. This deficient practice had the potential for inaccurate medical interventions for Resident 1. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/14/2025 with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of hip, pressure ulcer of sacral region stage four (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 1's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 failed to document Resident 1's apixaban (an anticoagulant-medication used to prevent and treat blood clots) administration accurately when the medication was documented as administered instead of not administered on 12/15/2025 at 9 a.m. This deficient practice had the potential for facility staff to not know if the medication was administered or not.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 12/14/2025 with diagnoses including sepsis (a life-threatening blood infection), end stage renal disease (ESRD - irreversible kidney failure), and diabetes mellitus type II (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Order Summary Report (OSR), dated…

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

Based on interview and record review, the facility failed to review and revise a comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1) by failing to ensure Residents 1's care plan was revised to reflect Resident 1's skin problems. This deficient practice had the potential to delay provision of person-centered care for Residents 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/2/2025, with diagnoses including diabetes mellitus type two (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), and combined systolic and diastolic heart failure (a condition where the heart's ability to both pump blood and fill with blood is impaired). During a 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 failed to ensure resident safety for three of six sampled residents (Resident 2, Resident 3, and Resident 4) when the ceiling of the residents' room was leaking with rainwater. The facility did not move the residents from the room with leaking rainwater.This deficient practice had the potential for Residents 2, 3, and 4 to be at risk of sustaining injury related to ceiling leaking with rainwater.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/25/2024 with diagnoses including hypertension (the force of your blood pushing against your artery walls is consistently too high) and anemia (a condition where your blood doesn't have healthy red blood cells).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 2's thought process was intact and required supervision assistance from staff to complete activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, clean, homelike environment for two of four sampled residents (Residents 7 and 8) by:1. Failing to ensure Resident 7's room was free of leaking ceiling (from rainwater).2. Failing to ensure Resident 8's room had a comfortable room temperature.These failures had the potential for unsafe and unclean environment with the potential to place Residents 7 and 8 at risk for physical discomfort.Findings:a. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 11/12/2025, with diagnoses that included left tibia (shin bone. It's the second longest bone in your body, and it is an important part of your ability to stand and move) displaced fracture (the pieces of your bone moved so much that a gap formed around the fracture when your bone broke), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and unspecified…

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

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 7) by failing to develop a person-centered care plan to address Resident 7's safety secondary to refusal of room change while Resident 7's room had a leaking ceiling from rainwater.This failure had the potential for delays in the delivery of necessary care and services to Resident 7 and placed Resident 7's safety at risk.Findings:During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 11/12/2025, with diagnoses that included left tibia (shin bone. It's the second longest bone in your body, and it's an important part of your ability to stand and move) displaced fracture (the pieces of your bone moved so much that a gap formed around the fracture when your bone broke), diabetes mellitus (DM- a disorder characterized by difficulty in blood…

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

Based on observation, interview, and record review, the facility failed to provide dignity for one of nine sample resident (Resident 7) by failing to ensure that the staff (Licensed Vocational Nurse 5) address Resident 7 by name and not being called honey and to ensure four staff ( three Certified Nursing Assistants and 1 Occupational Therapist) were talking in English all the time in the hallways. These deficient practices had the potential to affect residents' sense of self-worth and self-esteem. A. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 9/3/2025 with diagnoses of hypertension (high blood pressure) and difficulty of walking. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 9/9/2025, the MDS indicated Resident 7 had intact thought process and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During an observation on 9/4/2025 at 10 a.m. outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nasal spray (delivers a fine mist of medicine directly into your nose) was not left at a resident's bedside table and the resident was assessed for self-administration of medication for one of three sampled residents (Resident 5). This deficient practice had the potential to place the other residents at risk to misuse the medication.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 8/22/2025 with diagnoses including diabetes mellitus (a chronic condition where the body has trouble regulating blood sugar (glucose) levels) and hypertension (high blood pressure).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 8/28/2025, the MDS indicated Resident 5's thought process was intact and required supervision 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer an antibiotic as ordered by the physician for one of three sample residents (Resident 1). This deficient practice had the potential for Resident 1's health condition to be untreated that can lead to physical harm. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 2/12/2025 and readmitted on [DATE] with diagnoses including an encounter for attention to gastrostomy (a surgically created opening into the stomach) and chronic obstructive pulmonary disease (a permanent lung condition that makes it progressively harder to breathe because airways and air sacs in the lungs are damaged and narrowed). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/21/2025, the MDS indicated Resident 1 was severely impaired with thought process and required dependent assistance from staff to complete activities of daily living (ADLs -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nine sample resident's (Resident 2) call light was working properly.This deficient practice had the potential to place Resident 2 at risk for an accident like a fall due to not being able to call for help/assistance.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/26/2025 with a diagnosis of hypertension (high blood pressure) and history of falling.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 9/1/2025, the MDS indicated Resident 2 had intact thought process and required moderate 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 9/3/2025 at 11:40 a.m. with Resident 2 inside Resident 2's room, Resident 2 stated that her call light was not working since she got admitted and was using her roommate's call light for Resident 2 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a written authorization or approval from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development of OSHPD) prior to the use of portable air-conditioning (AC- a machine that forces cool air into a building) unit. HCAI is the state agency that reviews and approves plans for construction, repairs, renovations, and remodeling made in healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility.This deficient practice placed residents at risk for any safety issues related to the unauthorized use of the portable AC unit. Findings: During an observation on 9/4/2025, at 10:18 a.m., observed room [ROOM NUMBER] with a portable air conditioner (AC) unit actively operating. Observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of four residents (Resident 2) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem.This deficient practice had the potential to violate the rights of Resident 1.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/14/2012 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's…

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

Based on interview and record review, the facility failed to develop and implement a person-centered Care Plan (CP - a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs) for one of three sampled residents (Resident 5) by failing to implement the Medication Regimen Review (a pharmacist's [a healthcare professional who specializes in the preparation and management of medications] systematic check of a resident's entire medication list to identify potential issues such as dangerous side effects or inappropriate doses) per Resident 5's CP. This failure had the potential to delay care for Resident 5 and negatively affect Resident 1's well-being. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lock of blood flow), psychosis (a severe mental condition in which thought, and emotions are so…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was reviewed and revised by an interdisciplinary team (IDT-group of professionals from different disciplines who work together to provide coordinated care for residents) for one of three sampled residents (Residents 5) by failing to: 1. Ensure IDT meeting was held to review Resident 5's CP after Resident 5 sustained a fall on 6/24/2025 and 6/25/2025. 2. Ensure Resident 5's CP was revised after Resident 5 sustained a fall on 7/26/2025 and 7/27/2025. These practices had the potential to delay provision of person-centered care for Resident 5, placing Resident 5 at an increased risk for recurrent falls. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 6/21/2025, with diagnoses including dementia (a progressive 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) received appropriate care and services to prevent complications of enteral feeding for one of four sampled residents (Resident 2) when Certified Nursing Assistant (CNA) 1 failed to notify nursing staff to turn off Resident 2's enteral feeding pump (a device that delivers nutrient fluids into a resident's stomach, at a controlled rate) on 8/10/2025. This deficient practice placed Resident 2 at risk for aspiration (accidental inhalation of foreign materials, such as food or liquid, into the lungs). Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/14/2012 and readmitted on [DATE] with diagnoses including type two diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound…

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

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medication as prescribed by the physician when the resident did not receive his prescribed as needed (PRN) albuterol (a medicine used to help people with asthma [a lung condition that makes it hard to breathe] and other lung problems breathe better). This deficient practice had the potential for Resident 1 to be negatively affected. Findings:During a review of Resident 1's admission Record (AD), the AD indicated the facility admitted Resident 1 on 8/5/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke where blood flow to a part of the brain is blocked, causing brain cells to die from lack of oxygen and nutrients), and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/6/2025, the MDS indicated Resident 1 cognitive skill (the…

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

Based on interview and record review, the facility failed to ensure the medical records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented for one of three sampled residents (Resident 5) by: 1. Failing to document a summary of observation and evaluation of Resident 5's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form. 2. Failing to document the physician notification on Resident 5's COC form. 3. Failing to ensure accurate documentation on Resident 5's skin evaluation on the COC form. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 5. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lack of blood flow), psychosis (a severe mental condition in…

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

Based on interview and record review, the facility failed to report an allegation of an employee-to-resident abuse within two hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement (police) as per its policies on abuse for one of three sampled residents (Resident 1).This failure had the potential to place Resident 1 at risk for further abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/11/2023, with diagnoses including Parkinson Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, affecting the arm, leg, hand, and or face) following cerebral infarction…

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

Based on interview and record review, the facility failed to provide an ongoing activity program that is resident-centered for one of three sampled residents (Resident 2).This failure had the potential to affect the Resident 2's sense of self-worth and psychosocial (the interaction between an individual's mental and emotional state [psychological] and their social environment) well-being.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/14/2012, with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).During a review of Resident 2's Care Plan, dated 8/27/2024, about Resident 2's risk for social isolation (a state of reduced social interaction and contact with others, often leading…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to obtain a physician order for oxygen (air we breathe and is used by our bodies to produce energy) use before oxygen administration.This failure had the potential to place Resident 1 at risk of receiving more oxygen than required and could negatively impact Resident 1's well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 8/11/2023, with diagnoses including Parkinson Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), difficulty in walking and shortness of breath.During a 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 6/24/2025, the H&P indicated 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 implement its infection control measures for one of three sampled residents (Resident 3) 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 Certified Nursing Assistant 3 (CNA 3) wore protective gown while proving care.This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminants from one surface to another) of infection among residents and staff.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/5/2025, with diagnoses including unspecified (unconfirmed) organism sepsis (a life-threatening blood infection), urinary tract infection (UTI- an infection in the bladder/urinary tract), and stage three pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) of the buttocks.During a review of Resident 3's History…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed:1. To supervise the student nurse while providing direct care to one out of three sample residents (Resident 1) during the student's clinical hours.This deficient practice resulted in Resident 1 assisted fall on 6/29/2025 when Student Nurse (SN) 1 assisted Resident 1 on the floor without the facilities knowledge.2. To document and assess Resident 1 after receiving a report from Clinical Instructor Registered Nurse (CIRN) 1 that Resident 1 was assisted in the floor by SN 1. Findings:Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2025 with a diagnosis of end stage renal failure (when the kidneys are so damaged that they can no longer filter waste from the blood effectively) and hypertension (high blood pressure).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 1 was intact with thought process and…

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

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medication as prescribed.This deficient practice had the potential for Resident 1 to be negatively affected.Findings:During a review of Resident 1's admission Record (AD), the AD indicated the facility admitted Resident 1 on 6/11/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and essential (primary) hypertension (HTN-high blood pressure).During a review of Resident 1 Physician Orders, dated 6/13/2025 the Physician Orders indicated Miralax (an over-the-counter medication used to relieve occasional constipation) oral powder 17 grams (g- a unit of measurement) give 1 scoop by mouth one time a day for bowel management mix well with optimal amounts of fluid until dissolved. Hold for loose stool.During a review of Resident 1's Bowel Continence for 6/2025, the Bowel Continence indicated the…

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

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 4) by failing to:1. Ensure Resident 4's oxygen tubing and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.2. Ensure Resident 4's oxygen humidifier bottle had water in it while in use.3. Ensure Resident 4 had an oxygen supplies bag for the oxygen tubing to be kept inside when not in use.4. Ensure Resident 4 had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 4 was provided with oxygen. These deficient practices had the potential for Resident 4 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections. These deficient practices had the potential to create confusion in the delivery of care and services to Resident 4.Findings: During a review of Resident 4's admission Record (undated), the…

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

Based on interview and record review, the facility failed to ensure the medical records of one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure Licensed Vocational Nurse (LVN) 4 documented Resident 1's Change in Condition (CIC) monitoring indicating the correct date.2. Ensure Certified Nursing Assistants (CNAs) documented Residents 1's percentage (% - per one hundred) of food eaten every meal (breakfast, lunch, and dinner).3. Ensure CNAs accurately documented Resident 1's bladder (a hallow organ that stores urine in the body) continence. These deficient practices resulted in inaccurate information on Residents 1's medical records and had the potential for delayed and inaccurate medical interventions.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/14/2021, with diagnoses including Guillain-Barre syndrome (a condition in which the body's immune system attacks the…

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

Based on observation, interview, and record review, the facility failed to ensure the residents received services with reasonable accommodation of the resident needs for one of four sampled residents (Residents 4). Resident 4, who was at risk for falls, did not have the call light (an alerting device for residents to call for assistance) within the resident's reach.This deficient practice had the potential for not meeting Residents 4's needs for assistance.Findings: During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted Resident 4 on 6/24/2011 with diagnoses including multiple sclerosis (a chronic disease where the body's immune system attacks the protective covering of nerve fibers in the brain and spinal cord), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 4's Care Plan on injury and falls, initiated on 3/1/2020, the 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 ensure resident's pain was managed as indicated in the facility's Pain Assessment and Management policy for one of four sampled residents (Resident 2) by failing to ensure Resident 2's pain medication, ibuprofen (medication used to treat moderate pain) 400 milligrams (mg - unit of measurement), scheduled every six hours as needed, was administered according to the physician order. This deficient practice had the potential for Resident 2's unnecessary pain experienced during daily activities and had the potential to lead to a decline in Resident 2's quality of life.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/22/2024 with diagnoses including osteoarthritis (condition that causes the joints to become very painful and stiff) left hip, anemia (condition in which the body does not get enough oxygen-rich blood), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences to two of four sampled residents (Resident 3 and 4) by failing to ensure: 1. The call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for Resident 3. 2. The call light was functional for Resident 4. These failures had the potential to result in the inability of Residents 3 and 4 to call for facility staff assistance and delay in the provision of necessary care and services that could negatively affect the residents' well-being. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), repeated falls, and diabetes mellitus (a disorder characterized by difficulty in blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 1), by failing to administer medications and treatments as ordered by the physician. These deficient practices had the potential to place Resident 1 at risk for unrelieved shortness of breath, respiratory complications, and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), CHF ( a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in buildup of fluid in the lungs), and anxiety 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.

Based on interview and record review, the facility failed to ensure a resident's open area on the right buttocks was assessed comprehensively to include the size and healing progress of wound for one of three sampled residents (Resident 2). This deficient practice could result in Resident 2 not receiving proper treatment. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Huntington disease (nerve cells in the brain gradually break down and die) and anemia (blood is not carrying enough oxygen to your body's tissues). During a review of Resident 2's History and Physical Report, dated 1/24/2025, the report indicated that Resident 2 was severely impaired with thought process. During a record review of Change of Condition (COC) Evaluation, dated 4/15/2025, the COC Evaluation indicated the COC started in the afternoon of 4/15/2025 regarding Resident 2's skin wound or ulcer. The COC Evaluation indicated Resident 2 had an open area on the right buttock with no secretions, foul…

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

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) was using pressure-reducing mattress every shift to prevent wound development or promote wound healing. This deficient practice had the potential for Resident 2 to develop or worsen wound if the pressure-reducing mattress was not used. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Huntington disease (nerve cells in the brain gradually break down and die) and anemia (blood is not carrying enough oxygen to your body's tissues). During a review of Resident 2's History and Physical Report, dated 1/24/2025, the report indicated that Resident 2 was severely impaired with thought process. During a record review of Change of Condition (COC) Evaluation, dated 4/15/2025, the COC Evaluation indicated the COC started in the afternoon of 4/15/2025 regarding Resident 2's skin wound or ulcer. The COC Evaluation indicated Resident 2 had an open area on the right buttock 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 interviews and record review, the facility failed to properly manage pain for one of three sampled residents (Resident 1) who was assessed at a higher pain score and pain medication was not administered for treatment. This deficient practice had the potential to ineffectively manage Resident 1's pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/26/2025 with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing) and hypertension (high blood pressure - the force of your blood pushing against your artery walls is consistently too high) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/1/2025, the MDS indicated Resident 1 was severely impaired with thought process and required moderate assistance from staff to complete activities of daily living (ADLs -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 order pain medication and follow up with the physician to sign the narcotic (type of drug that can dull pain) authorization for one of three sample residents (Resident 1). These deficient practices increased the risk that Resident 1 could have with delayed medication treatment leading to untreated pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/26/2025 with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing) and hypertension (high blood pressure - the force of your blood pushing against your artery walls is consistently too high) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/1/2025, the MDS indicated Resident 1 was severely impaired with thought process and required moderate assistance from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Resident 1 and 2) by failing to ensure the physician's order was followed. 1. Failed to ensure Licensed Vocational Nurse 3 (LVN 3) administered acetaminophen (medication used to treat pain and fever) to Resident 1 on 3/6/2025, with a pain level of four despite physician order to use acetaminophen for pain level between one to three. 2. Failed to ensure clobetasol cream (medication used to treat itching) was administered to Resident 1 as per physician order. 3. Failed to ensure LVN 4 administered amlodipine (medication used to treat high blood pressure) to Resident 2 on 3/5/2025, with a blood pressure of 109/70 millimeters of mercury (mmHg - a unit of pressure measurement) despite a physician's order to hold amlodipine for systolic blood pressure (sbp-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a safe, clean, homelike environment for two of three sampled residents (Residents 2 and 3). This failure had the potential for unsafe and unclean resident's (Residents 2 and 3) environment with the potential for the spread of infection and place the residents at risk for physical discomfort. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/9/2024, the H&P indicated Resident 2 had the capacity 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 develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure a care plan was developed on Resident 1's refusal of his ordered medications. This failure had the potential for complications related to Resident 1 not receiving his ordered medications. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/3/2024, with diagnoses that included chronic congestive heart failure (CHF- condition where the heart muscle is weakened and cannot pump blood effectively, leading to fluid buildup in the body), pressure induced deep tissue damage (a type of soft tissue injury that affects the underlying layers of skin, muscle, and other tissues) of sacral region (above the tailbone) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient'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 that one of the three sampled residents (Resident 2), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This failure had the potential to negatively affect Resident 2' s self-esteem and wellbeing and also placed Resident 2 at risk for infection. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2'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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received care consistent with professional standards of practice for one of three sampled residents (Resident 2) by failing to ensure Resident 2's blood pressure was monitored every hour as per physician's order after Resident 2 had a change in condition on 4/1/2025 at 8:58 p.m. This failure had the potential for a delay in care in services and unidentified change in condition. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/9/2024, the H&P indicated…

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

Based on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure ulcers (PU-a localized injury to the skin and or underlying tissue usually over a bony prominences as a result of pressure or pressure in combination with shear) for one of three sampled residents (Resident 2) by failing to provide treatment to Resident 2 on 3/2025. This failure had placed Resident 2 at risk for development of pressure ulcers. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and muscle weakness. During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing 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 maintain accurate clinical records in accordance with accepted professional standards and practices for one of nine sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 added documentation entries in Resident 1 ' s medical record to show that Resident 1 was doing a little bit better. Resident 1 had a change of condition (COC – a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m. when Resident 1 had a low blood pressure (BP – measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg – unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR – the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). LVN 1 added…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medication as prescribed. This deficient practice had the potential for Resident 1 to be negatively affected. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), gastrostomy (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent (helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Procedures (P&P) titled, Grievances/Complaints, Filing, for one of three residents (Resident 1) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem. This deficient practice had the potential to violate the rights of Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and dementia (a progressive state of decline in mental abilities). During a…

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

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for two of three sampled residents (Resident 1 and Resident 4) by: 1. Failing to ensure Resident 1 had a communication board due to hard of hearing according to Resident 1's care plan intervention. 2. Failing to ensure Resident 4 had a care plan regarding Resident 4's diet and food preferences. 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: 1. During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 12/14/2023, with diagnoses including Alzheimer's Disease (brain disorder that gradually destroys memory and thinking skills). During a review of Resident 1's History & Physical (H&P), dated 12/20/2023, the H&P indicated Resident 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.

Based on interview and record review, the facility failed to provide wound care treatment to one of three sampled residents (Resident 4). This deficient practice could lead to worsening and infection of Resident 4's wound. Findings: During a review of Resident 4's Record of Admission, the Record of admission indicated the facility admitted the resident on 1/29/2025, with diagnoses including phantom limb syndrome (feeling of pain in a limb that's been amputated) with pain. During a review of Resident 4's History & Physical (H&P), dated 1/24/2025, the H&P indicated that the resident had fluctuating capacity to understand and make decisions. The H& P indicated Resident 4 had bilateral (both) knee amputation (a surgical procedure where the knee joint is removed, separating the lower leg from the upper leg at the knee). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2025, the MDS indicated that resident's cognition (refers to the mental processes involved in acquiring knowledge and understanding through thinking, experience, and the senses)…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) by not having Resident 1 wear boots per physician's order. This deficient practice had the potential for Resident 1 to develop pressure ulcers/injuries. Findings: During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 12/14/2023, with diagnoses including Alzheimer's Disease (brain disorder that gradually destroys memory and thinking skills) During a review of Resident 1's History & Physical (H&P), dated 12/20/2023, the H&P indicated Resident 1 did not have capacity to make decisions. During a review of Resident 1's Order Summary Report, dated 12/5/2024, the report indicated Resident 1 to wear heel protector boots in place for prevention (of pressure ulcer), may remove (the boots) to provide care and assess skin integrity everyday shift for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse (use of oral, written, or gestured communication, or sounds which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) for one of three sampled residents (Resident 1). This had the potential to negatively affect Resident 1's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/8/2024 with the following diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (feeling of anxiousness that affects daily life). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an incident of a verbal abuse (use of oral, written, or gestured communication, or sounds which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from further abuse. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/8/2024 with the following diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (feeling of anxiousness that affects daily life). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated the resident had the ability to make self understood and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) had the right to be free from physical abuse (willful infliction of injury resulting physical harm, pain, or mental anguish) on 2/16/2025 at 4:30 p.m. when Resident 1 pulled and hit Resident 2 on the back. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Residents 2 ' s severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was provided care and services to maintain good grooming and personal hygiene. Resident 3 was not provided a scheduled shower on 1/29/2025 and 2/22/2025. This deficient practice resulted on Resident 3 ' s feeling dirty and had the potential to result in a negative impact on Resident 3 ' s self-esteem and self-worth. Findings: During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 9/4/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and paraplegia (inability to voluntarily move the lower parts of the body). During a record review or Resident 3 ' s Care Plan on Activities of Daily Living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), initiated on 9/4/2024,…

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

Based on observation, interview, and record review, the facility failed to ensure confidential personal information for one of four sampled residents (Resident 1) was protected. The clinical records of Resident 1 were left unattended on the nurse station 3 computer. This deficient practice had the potential to violate Resident 1's rights for privacy and confidentiality of personal and medical records. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 10/22/2024 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), systemic lupus erythematosus (a long-lasting autoimmune disease where the body's immune system attacks its own healthy tissues causing inflammation and potentially damage organs), and osteoporosis (a disease that cause bones to become brittle and more likely to break). During a concurrent observation and interview on 2/4/2025 at 3:10 p.m. with the Director of Staff Development (DSD), observed Resident 1's medical records on the…

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

Based on observation, interview, and record review, the facility failed to implement their policy and procedure on safeguarding of all prescribed medications for one of four sampled residents (Resident 4) by failing to ensure Resident 4's prescribed medication was stored in the medication cart of the nursing station where Resident 4 was located. This deficient practice had the potential for non-authorized access to Resident 4's medications. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities). During a record review of Resident 4's Physician Orders, the Physician Orders did not indicate that Resident 4 had an order for melatonin (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 follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of three residents (Resident 2) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem. This deficient practice had the potential to violate the rights of Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/6/2024 with diagnoses including respiratory disorders (conditions that affect the lungs and other parts of the respiratory system), muscle weakness (generalized), and adult failure to thrive (a syndrome that describes a decline in physical and mental health in adults). During a review of Resident 2's Order Summary Report, dated 9/7/2024, the report indicated the following: - Change indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drain bag every week and as needed (PRN) if damaged,…

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

Based on interview and record review the facility failed to ensure one of three residents (Resident 4), who was at risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) received the care and services to prevent UTI. This deficient practice had the potential for Resident 4 to develop a UTI. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 1/22/2021 and readmitted the resident on 12/26/2023 with diagnoses including neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles that control the bladder do not work together properly.), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure. During a review of Resident 4's care plan, created on 11/13/2023, for indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) size 16 with 10 millimeters (ml - unit of measurement), the care plan indicated interventions including to observe for signs of…

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

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 4) when on 1/26/2025 Licensed Vocational Nurse 1 (LVN 1) inaccurately documented on the Treatment Administration Record (TAR- a report detailing the treatment administered to a patient by a healthcare professional across all types of healthcare facilities) that Resident 4's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was changed. This deficient practice had the potential for Resident 4 to develop a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 1/22/2021 and readmitted the resident on 12/26/2023 with diagnoses including neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles that control the bladder do not work together properly.), type 2 diabetes…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure of meeting the staff posting requirements. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility. Findings: During an observation and concurrent interview on 1/22/2025 at 11:55 a.m. with the Director of Nursing (DON), observed the projected Direct Care Service Hours Per Patient Day (DHPPD refers to the actual hours of work performed per patient day by a direct caregiver), dated 1/21/2025 and the actual DHPPD, dated 1/16/2025, were posted at the facility lobby. The DON stated the posted projected and actual DHPPD were not current. The DON stated the DHPPD were posted on all nurse stations. Observed the projected DHPPD, dated 1/21/2025, was posted at nurse station 1. There was no posted actual DHPPD at nurse station 1. During an observation and concurrent interview on 1/22/2025 at 11:57 a.m. with the Director of Nursing (DON), observed the projected DHPPD, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 3) were free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to: 1. Ensure Resident 3's brimonidine tartrate ophthalmic solution 0.2 percent (a medication used to lower pressure inside the eyes of people with glaucoma) and netarsudil dimesylate ophthalmic solution 0.02 percent (a medication used to treat glaucoma) were administered at the scheduled time on multiple dates. 2. Ensure Resident 1's gabapentin (a medication used to treat nerve pain and seizures) 600 milligrams (mg - unit of measurement) was administered at the scheduled time on multiple dates. These deficient practices placed Resident 3 at risk for inadequate glaucoma management which can cause vision loss. These deficient practices placed Resident 1 at risk for experiencing unnecessary pain. Findings: During a record review of Resident 3's admission Record, the…

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

Based on observation, interview, and record review, the facility failed to provide safe and comfortable environment for residents, staff, and visitors, as indicated in the facility's policies and procedures by failing to maintain required water temperature range of 105 degrees Fahrenheit (°F - unit of measurement) to 120°F in six of six resident shower rooms (station 1 shower 1B room, station 2 shower 2A and 2B rooms, station 3 shower 4A room, station 4 shower 4 room, and station 5 shower 5 room) and five of five nurse station hand sinks (station 1, station 2, station 3, station 4, and station 5). These deficient practices had the potential for residents, staff, and visitors to be exposed to uncomfortable and unsafe water temperatures. Findings: During a concurrent observation and interview on 1/22/2025 at 9:47 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 ran water in nurse station 1 hand sink for three minutes. A temperature probe was used to take the water temperature and LVN 1 stated the water temperature measured at 71.6°F. During a concurrent observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to provide a call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) to five of nine sampled residents (Resident 249, 159, 48, 49, and 129) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings: a. During a review of Resident 249's admission Record, the admission Record indicated the facility admitted the resident on 11/3/2024, with diagnoses including pathological fracture (a broken bone caused by diseases, rather than an injury) of the right ankle, other symptoms and signs involving the musculoskeletal system (the body's system of bones, muscle, tendons, ligaments, and cartilage that gives the body structure, movement, and stability), and muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. During a review of Resident 193's admission Record, the admission Record indicated the facility originally admitted the resident on 11/7/2023, and readmitted the resident in the facility on 7/28/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, loss of blow to a part of the brain) affecting right dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, and generalized weakness. During a review of Resident 193's History and Physical (H&P) dated 7/28/2024, the H&P indicated Resident 193 had fluctuating capacity to understand and make decisions. During a review of Resident 193's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 193…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 10 sampled residents (Resident 249, 109, and 481) during initial sampling of residents by failing to develop and implement a care plan on: 1. Resident 249's use of Trazadone (a drug used to treat depression [a mental health condition that involves a persistent feeling of sadness and a loss of interest in activities]) and Buspirone (a medication that treats anxiety). 2. Resident 109's use of Zoloft (also known as sertraline, medication that can help treat depression and other mental health conditions). 3. Resident 481's use of indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). 4. Resident 481's use of restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) bed placed against the wall. These deficient practices had the potential for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66. 2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice: 1. For one (1) out of 1 sampled resident (Resident 55) investigated during a random observation when Resident 55's intravenous fluid (IVF) did not indicate the date and time it was started and the licensed nurse's initials on the label. This deficient practice had the potential to place Resident 452 at risk for developing complications such as inflammation of the vein and infection. 2. For 1 of 1 sampled resident (Resident 111) investigated under peripheral intravenous catheter (PIVC, a thin, flexible tube that is inserted into a vein through the skin to administer fluids, medications, or blood products) by failing to: a. Clarify with the primary physician if the midline catheter (a long, thin, flexible tube inserted into a vein in the upper arm) was…

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

Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (SR, adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of nine sampled residents (Resident 39) reviewed under the Restraints care area by failing to: 1. Attempt to use appropriate alternatives prior to installing bilateral lower (at the leg area) SRs. 2. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from bilateral lower SRs use. 3. Review the risk and benefits of bilateral lower SRs with the resident or resident representative and obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). These deficient practices had the potential to result in psychosocial harm, physical harm from entrapment and death of residents. Findings: During a…

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

Based on observation interview, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of one sampled resident (Resident 37) and one of three medication carts (Station 1 Cart B) investigated under the Medication Storage and Labeling task by: 1. Failing to administer Resident 37's Jardiance (hypoglycemic medication-lowers blood sugar levels) and metformin (hypoglycemic medication) medications as ordered by the physician. This deficient practice placed Resident 37 at risk for causing complications and delay in the necessary care and services the resident needs. 2. Failing to ensure licensed nurses completed the incoming and outgoing Floor Narcotic (opioid [a class of drug to reduce moderate to severe pain]) Release (a form signed by the incoming and outgoing licensed nurse after reconciling narcotic medications) on 1/14/2025 for Station 1 Cart B. This deficient practice had the potential to result in increase opportunity for…

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

Based on interview and record review, the facility failed to unsure psychotropic drugs (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) were given to treat a specific condition as diagnosed and documented in the clinical record to one of 5 sampled residents (Resident 213) investigated under unnecessary medications by failing to act upon the pharmacy consultant's request from the physician to indicate the rationale for contraindication for gradual dose reduction (GDR, stepwise tapering of a dose) of Buspar (a medication that treats anxiety) and Zoloft (an antidepressant ). This deficient practice had the potential for residents receiving unnecessary medication and adverse reactions (undesirable effect). Findings: During a review of Resident 213's admission Record, the admission Record indicated the facility admitted the resident on 4/16/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a serious mental illness that causes 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 residents were free of any significant medication errors to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66. 2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins…

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

Based on observation, interview, and record review, the facility failed to: 1. Remove Resident 271's discontinued insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) lispro (fast-acting type of insulin) from the medication cart in one of three inspected medication carts (Station 1 Cart B). 2. Dispose Resident 10's hydrocodone-acetaminophen (medication used to relieve severe pain) when the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place) slot #17 was found with a non-intact seal and covered with tape in one of three inspected medication carts (Station 1 Cart B). 3. Dispose Resident 37's hydrocodone-acetaminophen when the bubble pack slot #15 was found with a non-intact seal and covered with tape in one of three inspected medication carts (Station 1 Cart B). 4. Maintain residents' medication bubble packs in an orderly manner when Resident 37's Jardiance scheduled during the 11 p.m. to 7 a.m. shift was observed in the 7 a.m. to 3 p.m. shift's medication…

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

Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a. Unable to verbalize the process of three (3) compartment sink dishwashing and quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets. b. Unable to verbalize which type of dishwashing machine they were using and the process of testing the chlorine solution of the dishwashing machine. 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 (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 271 of 279 medically compromised residents who received food and ice from the kitchen. Findings: a. During a concurrent demonstration and interview on 1/15/2024 at 2:44 p.m. with Dietary Aide 1 (DA 1) and Dietary Supervisor (DS), DA 1 stated they used Quat sanitizer in the three-compartment sink to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 108 of 109 residents on soft mechanical diet (diet consisting of soft, and chopped foods), seven of 46 residents on fortified diet (addition of food to increase calories and proteins in the diet), and three of 14 residents on large portions (doubling portion size of foods to increase calories and protein in the diet) diet when: 1. Residents on soft mechanical diet did not receive toasted garlic bread without hard crust. 2. Residents on fortified diet did not receive additional cheese on their pasta. 3. Residents on large portion diets did not receive eight (8) ounces ([oz], a unit of measurement) of milk as indicated on the menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get). These failures had the potential to result in difficulty in swallowing, chewing, decreased in food and nutrient intake resulting to unintended weight loss and choking…

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

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance for lunch when staff served mushy and overcooked broccoli, carrots, and peas. This failure had a potential to result in 137 of 279 residents, including Resident 188, facility residents on regular texture (no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of Resident 188's admission Record, the admission Record indicated the facility admitted Resident 188 on 10/24/2023 with diagnoses including acute and chronic respiratory failure (define), type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin) and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). During a review of Resident 188's Minimum Data Set (MDS- a resident assessment tool), dated 12/10/2024, the MDS indicated Resident 188 made self understood and can…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when: 1. Puree pasta was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding-like consistency)/International Dysphagia (difficulty swallowing) Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4). 2. Residents on soft mechanical diet (diet consisted of soft, chopped foods) received toasted garlic bread with hard crust. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 18 of 18 residents on puree diet and 108 of 109 residents on soft mechanical diet, resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: 1. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receive and consume foods in the appropriate nutritive content as prescribed by a physician for regular fortified diet (addition of food to increase calories and proteins in the diet) when staff did not add cheese for seven of 46 sampled residents (Resident 135, Resident 213, Resident 104, Resident 96, Resident 129, Resident 145, and Resident 84) on fortified diet during lunch on 1/14/2025. This deficient practice had the potential to cause weight loss for residents on fortified diets. Cross reference F803 Findings: 1. During a review of the facility's cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray: a. Italian Lasagna 3x3 1/3 inches = 1 square b. Seasoned broccoli ½ cup ([c], household measurement) c. Parsley garnish- yes d. Garlic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Kitchen equipment and areas were not cleaned and sanitized. a. There was an ice, dirt buildup and dirt debris in the chest freezer. Walk-in freezer roof had ice buildup. b. Walk-in refrigerator floors had dirt buildup and food debris. c. Reach-in refrigerator vents had dust buildup and shelves had dirt and food debris. d. Dry storage room floor had dirt and food debris. e. Ice machine internal parts had reddish dirt and mineral buildup. The ice machine filter was dirty to touch. f. Mixer guard, agitator shaft had dried up food and splatters. g. Residents' refrigerator had dirt buildup. 2. Kitchen equipment and utensils were not smooth, had scratches and cracks. a. Seven (7) of 7 racks had rust, dirt, chips, and cracks in the walk-in refrigerator. b. Can opener blade have had chips (a small piece of something removed while opening cans). c. [NAME] chopping board had brown liquid splatters stored in the clean area. 3.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (broad, overarching term that applies to anything that is leftover after it is used) properly when the dumpster (large trash container designed to be emptied into a truck) surroundings had liquid and food juices spills on the ground since Monday, 1/13/2025. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 266 of 274 facility residents. Findings: During a concurrent observation and interview on 1/15/2025 at 11:28 a.m. with the Dietary Supervisor (DS), the dumper surrounding had liquid spills on the ground. The DS stated there were a lot of juices and liquid spills from the trash on the ground and needed to be cleaned everyday as it could attract pests. The DS stated they prevent pests in the facility due to infection control. During a concurrent observation and interview on 1/15/2025 at 11:36 a.m. with the Maintenance Supervisor (MS) near the dumpster area, the MS stated the trash pickup came late last Monday, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 for five of six sampled residents (Residents 73, 47, 129, 72, and 225) by failing to ensure: 1. The oxygen tubing was labeled with the date it was last changed for one of two sampled residents (Resident 73). 2. The urinal bottle (a container for collecting urine that is used by people who are unable to use a bathroom toilet) was labeled with the name and room number of the resident for one of one sampled resident (Resident 47). 3. Failing to ensure Residents 129's and 72's oxygen tubing were labeled with the date they were last changed. 4. Failing to ensure Resident 225's urine bottle was labeled with the resident's room number. 5. Licensed Vocational Nurse 8 (LVN 8) disinfected (cleanse of bacteria that may cause disease) the…

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

Based on observation, interview, and record review, the facility failed to ensure medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for one of three sampled residents (Resident 179) reviewed under the General-Skin Conditions care area by failing to perform a medication self-administration assessment when staff had knowledge that the resident kept topical medication at the bed side for self-administration. This deficient practice violated the residents' right to self-administer medications and had the potential for the resident to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication. Cross-reference F689 Findings: During a review of Resident 179's admission Record, the admission Record indicated the facility admitted the resident on 8/28/2023 with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and acquired absence of left toes.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comfortable and homelike environment to one of two sampled residents (Resident 109) investigated under physical environment by failing to ensure the hot water temperature in the bathroom sink was within acceptable levels per the facility's policy and procedure. This deficient practice violated the resident's rights to a safe, clean, sanitary, and homelike environment. Findings: During a review of Resident 109's admission Record, the admission Record indicated the facility admitted the resident on 7/17/2024, with diagnoses including muscle weakness, depression (a mental health condition that involves persistent feelings of sadness, loss of interest, and difficulty with daily life), and history of falling. During a review of Resident 109's Minimum Data Set (MDS - a resident assessment tool), dated 10/23/2024, the MDS indicated the Resident 109 had the ability to make self-understood and understand others and had mild cognitive impairment (a condition that causes memory or thinking difficulties 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 provide treatment and services to maintain or improve a resident's ability to carry out activities of daily living (ADL - activities such as bathing, dressing, grooming, oral care, mobility, elimination, dining, and communication) for one of one sampled resident (Resident 115) when Resident 115 was not provided nail trimming and cleaning to his fingernails. This deficient practice had the potential in Resident 115 having dirty fingernails, which could lead to scratching himself and cause skin tears or bleeding. Findings: During a review of Resident 115's admission Record, the admission Record indicated the facility originally admitted the resident on 2/1/2022 and readmitted the resident on 1/4/2025 with diagnoses including coronavirus disease (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms), chronic pulmonary edema (a long-term condition that occurs when fluid builds up in the lungs), and other cirrhosis of the liver (chronic disease that occurs when healthy liver…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received care consistent with professional standards of practice to prevent pressure injury (the breakdown of skin integrity due to pressure) for one (1) out of two (2) sampled residents (Resident 66) investigated under pressure injury when Resident 66's low air loss mattress (LALM - a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) was not turned on and was set according to resident's Body Mass Index (BMI - a tool used to estimate the amount of body fat by using the height and weight measurements). This deficient practice had the potential for the resident's pressure injury to worsen. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 9/27/2024, and readmitted the resident on 12/18/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for eight of 12 sampled residents (Residents 213, 220, 471, 482, 159, 193, 58, 19) investigated under accidents by failing to ensure: 1. Resident 213's fall mat (a cushioned mat that reduces the risk of injury from a fall) did not have a furniture or equipment on top of them. This deficient practice increases the risk of injury when the resident slips, trips, and falls by hitting the hard surface of the equipment or furniture that is on top of the fall mat. 2. Resident 220's Fluocinonide External Ointment (is used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) were not left at the bedside. 3. Resident 471's metronidazole (an antibiotic), valacyclovir (an antiviral drug that has been used to manage and treat various herpes infections), glipizide (stimulates the release of insulin from the pancreas, directing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, an infection in the bladder/urinary tract) for one of two sampled residents (Resident 481) being investigated under urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) by failing to keep the urinary catheter tubing 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 urine until it can be excreted]). Findings: During a review of Resident 481's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2024, and readmitted the resident on 1/13/2025, with diagnoses including cellulitis (a bacterial infection that affects the skin and underlying tissue), benign prostatic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral 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) of 1 sampled resident (Resident 66) investigated under the tube feeding care area when the EF bottle did not indicate in the label the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the nurse. This deficient practice had the potential to result in altered nutritional status such as dehydration and malnutrition and complications associated with enteral feeding such as gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on [DATE], 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.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1's increase in blood pressure (BP- pressure of circulating blood against the walls of blood vessels). Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/22/2024 with diagnoses that included stress hip fracture (a small, hairline crack in the bone of the hip, typically caused by repetitive stress from activities like running or jumping, rather than a single traumatic event), left hip osteoarthritis (a chronic disease that causes the breakdown of cartilage [a strong, flexible connective tissue that protects your joints and bones] and bone in joints, leading to pain, stiffness, and swelling) and essential hypertension (HTN- high…

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

Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 4) by failing to: 1. Ensure Resident 4, who was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities), had EBP signage outside the resident's door. 2. Ensure personal protective equipments (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) were available to use for Resident 4's care. 3. Ensure Licensed Vocational Nurse 1's (LVN 1) PPE was worn before entering the EBP room. LVN 1 did not wear gloves before touching Resident 4's oxygen nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose]). 4. Ensure unused PPE supplies were kept clean. Resident 4 had a box of opened unused gloves on the resident's bed. LVN 1 took a pair of gloves from the box and used the gloves to put the nasal cannula on…

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

Based on observation, interview, and record review, the facility failed to ensure care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) for one of four sampled residents (Resident 4) by failing to: 1. Follow the Physician's Order to place Resident 4 on a Low Air Loss Mattress (LALM, a mattress composed of inflatable air cushions and used to relieve pressure). 2. Follow the manufacturer's instructions to set the firmness of the LALM based on Resident 4's weight. These deficient practices placed the residents at risk for the development and worsening of PUs. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 4 was provided with oxygen. This deficient practice had the potential to create confusion in the delivery of care and services to Resident 4. Findings: During an observation and concurrent interview on 1/6/2025 at 12:30 p.m. with Licensed Vocational Nurse 1 (LVN 1), observed Resident 4's O2 nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose]) was on top of the resident's bed and was not connected to the resident's nostrils. LVN 1 stated Resident 4 should have the O2 per nasal cannula at four liters per minute (Lpm - unit of measurement). During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (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 implement policy and procedure on safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for one of four sampled residents (Resident 1) by failing to ensure Resident 1's prescribed controlled medications were stored in the medication cart of the nursing station where Resident 1 was located. This deficient practice had the potential for non-authorized access to the resident's medications. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/6/2024 with diagnoses including sepsis (the body's extreme response to an infection), adult failure to thrive (a state of gradual decline in a person's overall health making it difficult to maintain daily functions), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/13/2024, 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 the following: 1) Failed to supervise and identify one of six sampled residents (Resident 1's) whereabouts inside and outside of the facility and failed to follow Resident 1's Care Plans (a summary of a person's health condition and current treatment interventions associated with care needs). Resident 1 was found on the floor of the facility's parking lot unattended to and without staff supervision. These deficient practices increased the risks for injuries, pain, and or psychosocial despair to Resident 1 who was dependent on staff for care. 2. Failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurate to reflect the correct fall risk score of one of five sampled residents (Resident 3). This deficient practice had the potential to negatively affect Resident 3's plan of care and delivery of necessary care and services. Findings: 1. A review of Resident 1's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the physician order of one of five residents (Resident 3) matched the Physician Order for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life). This deficient practice had the potential for Resident 3's wishes regarding their health care to be violated. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on [DATE] and readmitted the resident on [DATE] with diagnoses that included chronic pain syndrome (a long-term pain condition that persists for more than three months, or longer than the usual recovery time), benign neoplasm (a noncancerous abnormal mass of cells that does not spread to other parts of the body) of pituitary gland (a pea-sized gland located at the base of the brain that produces hormones that control many bodily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, comfortable, and homelike environment for one of five sampled residents (Resident 1) when Resident 1's toilet was observed on 12/19/2024 at 11:29 a.m. overflowing into Resident 1's room. This deficient practice resulted in Resident 1 being unable to use the toilet and placed Resident 1 at risk for fall. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/6/2024 with diagnoses that included displaced subtrochanteric fracture of right femur (a break in the upper part of the thigh bone, or femur, that occurs within 5 centimeters of the lesser trochanter [a small, bony projection on the femur that serves as an attachment site for muscles]), muscle weakness (general), and history of falling. During a review of Resident 1's Fall Risk Observation Assessment, dated 12/6/2024, the assessment indicated Resident 1 had a fall risk score of 18 (a score of 16 to 42 indicated a high risk for fall). During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) for one of five sampled residents (Resident 5), when on 12/14/2024, Resident 4 called Resident 5 a derogatory word. This deficient practice resulted in Resident 5 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 4's admission Record, the admission Record indicated Resident 4 was…

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

Based on interview and record review, the facility failed to implement its abuse prevention policy for one of four sampled residents (Resident 2) by failing to ensure an allegation of sexual abuse (any sexual activity that occurs without consent [permission]) was reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA). This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for Resident 2 to experience further abuse. Findings: During a review of Resident 2's Record of Admission, the Record of admission indicated the facility admitted the resident on 6/8/2024, with diagnoses including urinary tract infection (bacterial infection that can occur in any part of the urinary tract, which includes the bladder, kidneys, ureters, and urethra). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/2024, indicated that resident's cognition (the mental process of acquiring knowledge and understanding through the senses, experience, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse within two hours to the State Survey Agency (SSA) as per its policy on abuse for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to place Resident 1 and Resident 2 at risk for further abuse. Findings: a. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/17/2024, with diagnoses that included cellulitis (a skin infection that causes swelling and redness), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). The admission Record indicated Resident 1 was discharged on 11/2/2024. During a record review of Resident 1's History and Physical (H&P), dated 10/19/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for three of five sampled residents (Resident 9, Resident 10, and Resident 11) by failing to ensure licensed nurses documented the level of care provided to Resident 9, Resident 10, and Resident 11 after the residents were exposed to invasive group A streptococcal disease (iGAS - a severe and sometimes life-threatening infection). This deficient practice resulted in inaccurate information on Resident 9, Resident 10, and Resident 11's clinical records and had the potential for delayed and inaccurate medical interventions. Findings: During a record review of the facility-provided Prospective Surveillance for Group A Streptococcus (GAS - a type of bacteria commonly found in the throat and on the skin), dated 11/6/2024, the Prospective Surveillance for GAS indicated Resident 9, Resident 10, and Resident 11 were assessed for sore throat, increased cough, increased wound drainage, and 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 observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 2) by failing to ensure Resident 2's room was comfortable and free from malodor. Resident 1's wound had a malodor (bad odor). This deficient practice had the potential for Resident 2 to be uncomfortable and loss of appetite. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 8/3/2021 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), asthma (a disease that affects the lungs), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/22/2024, the MDS indicated the resident's cognitive (problems with a person's ability 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 follow infection control procedures for one of three sampled residents (Resident 1) by failing to ensure Resident 1, who had open wounds, was not exposed to the presence of fruit flies. This deficient practice placed Resident 1 at risk for exposure and contracting infections. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 10/7/2024 with diagnoses including Malignant neoplasm (an abnormal growth of cells that can spread to other parts of the body and considered dangerous) of the skin, depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/13/2024, the MDS indicated the resident's cognitive (problems with a person's ability to think,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely follow its policy and procedure titled, Change in a Resident's Condition of Status, which indicated the facility will notify the resident's attending physician (MD) when there was a significant change (a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) in the resident's condition for one of three sampled residents (Resident 1). Resident 1 had a Change of Condition (COC- a major decline in a resident's status) that started on 7/25/2024 when Resident 1's intake was less than 50 % for three (3) consecutive meals. This deficient practice resulted in a delay of care in Resident 1's nutritional status. Resident 1 lost 20.6 pounds (lbs - a unit of measurement) in a month. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses that included hemiplegia (inability to move the arm, leg, and trunk on the same side of the body) and hemiparesis…

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

Based on interview and record review, the facility failed to administer dextrose (sugar) five (5) percent (%) in water (D5W - a solution of 5% sugar [dextrose]) mixed in water, given when patients need fluids and a small amount of sugar to replenish their body) as prescribed for intravenous (IV - given directly into the blood stream) hydration for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to develop dehydration (a condition that occurs when the body loses more fluids than it takes in). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses that included hemiplegia (inability to move the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, depriving brain cells of oxygen and nutrients) affecting left non-dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the…

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

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when: 1. The facility failed to accurately document Resident 1's intake (the amount that you eat, drink, or breathe in). 2. The facility failed to accurately document Resident 1's behavior for poor oral intake. These deficient practices resulted in Resident 1 losing 20.6 pounds (lbs.- a unit of measurement) in a month. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses that included hemiplegia (inability to move the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, depriving brain cells of oxygen and nutrients) affecting left non-dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when Licensed Vocational Nurse 2 (LVN 2) did not don (put on) a gown while providing gastrostomy (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) care for one of seven sampled residents (Resident 5). 2. Implement Enhanced Barrier Precautions when Certified Nurse Assistant 6 (CNA 6) and CNA 7…

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

Based on interview and record review, the facility failed to ensure the physician was notified timely for one of three sampled residents (Resident 4) when Resident 4 eloped from the facility on 11/9/2024. This deficient practice resulted in delay of obtaining appropriate instructions from the physician for proper management. Findings: During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 10/25/2024, with diagnoses that included other chronic osteomyelitis (a bone infection that lasts longer than six months), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and unspecified psychosis (a collection of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what's real and what's not). During a record review of Resident 4 ' s History and Physical (H&P), dated 10/26/2024, the H&P indicated Resident 4 had no capacity to understand and…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan on wandering (to walk around slowly in a relaxed way or without any clear purpose or direction) and elopement (leaves a healthcare facility without supervision or detection), for one of five sampled residents (Resident 4) when resident eloped from the facility on 11/9/2024. This deficient practice can potentially place Resident 1 at risk for injury. Findings: During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 10/25/2024, with diagnoses that included other chronic osteomyelitis (a bone infection that lasts longer than six months), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and unspecified psychosis (a collection of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what's real and what's not). During a record review of…

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

Based on interview and record review, the facility failed to ensure that one of the three sampled residents (Resident 3), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This deficient practice had the potential to negatively affect Resident 3's self-esteem and wellbeing and placed Resident 3 at risk of infection. Findings: During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 8/2/2024, with diagnoses that included cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), unspecified (unconfirmed) sepsis (the body's extreme response to an infection that can lead to tissue damage, organ failure, or death if not treated right away) and unspecified pneumonia (lung infection). During a record review of Resident 3 ' s History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 3 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who was a high risk for fall, had history of dementia (a progressive state of decline in mental abilities) and had wandering behavior (to walk around slowly in a relaxed way or without any clear purpose or direction) was provided adequate supervision to prevent an elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 4). This deficient practice potentially placed Resident 4 at risk for injury. Findings: During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 10/25/2024, with diagnoses that included other chronic osteomyelitis (a bone infection that lasts longer than six months), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) dementia and unspecified psychosis (a collection of symptoms that cause 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 failed to maintain accurate and complete medical record for two of three sampled residents (Resident 3 and Resident 4). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care. Findings: a. During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 8/2/2024, with diagnoses that included cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), unspecified (unconfirmed) sepsis (the body's extreme response to an infection that can lead to tissue damage, organ failure, or death if not treated right away) and unspecified pneumonia (lung infection). During a record review of Resident 3 ' s History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a record review of Resident 3 ' s…

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

Based on interview and record review, the facility failed to ensure that one of the three sampled residents (Resident 2), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene as indicated in Resident 2 ' s care plan. This deficient practice had the potential to negatively affect Resident 2's self-esteem and wellbeing and placed Resident 2 at risk of infection. Findings: During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 3/19/2024, with diagnoses that included other seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and dysphagia (difficulty in swallowing). During a record review of Resident 2 ' 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.

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 the 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 3/19/2024, with diagnoses that included other seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and dysphagia (difficulty in swallowing). During a record review of Resident 2 ' s History and Physical (H&P), dated 3/20/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a record review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/25/2024, the MDS…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to follow the physician ' s order. This deficient practice placed Resident 1 at risk of developing dangerous low blood pressure levels and medication error. Findings During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/23/2018, with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (condition in which not enough oxygen passes the lungs into your blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertensive (HTN-high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs). During a record review of Resident 1 ' s History and 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 follow its policy and procedure titled, Change in a Resident ' s Condition or Status, which indicated the facility to promptly notify the resident ' s attending physician (MD) and the resident representative of a change in the resident ' s medical and or mental condition and or status for one of five sampled residents (Resident 2). This deficient practice had a potential to delay the care of Resident 2. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach), dysphagia (swallowing difficulties), and gastro-esophageal reflux (GERD- is a common condition in which the stomach contents move up into the esophagus). A review Resident 2 ' s Physician Orders, dated 8/2/2024, indicated the following orders: - elevate head of bed 30 to 40 degrees at all times during feeding and…

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

Based on interview and record review, the facility failed to follow its policy and procedure when on 9/30/2024 at 10 p.m. a Certified Nursing Assistant 6 (CNA 6) turned off the enteral feeding pump (a device that delivers nutrient fluids into a patient's stomach, at a controlled rate) for one of five sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for complications. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach), dysphagia (swallowing difficulties), and gastro-esophageal reflux (GERD- is a common condition in which the stomach contents move up into the esophagus). A review Resident 2 ' s Physician Orders, dated 8/2/2024, indicated the following orders: - elevate head of bed 30 to 40 degrees at all times during feeding and for at least 30 to 40 minutes after feeding stopped every shift. -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of seven sampled residents (Resident 2, Resident 3, and Resident 9) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: a. Ensure Resident 3's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set at the appropriate setting per facility policy. b. Ensure treatment was provided to Resident 9 as per physician's order. c. Ensure staff use a single draw sheet on Resident 2's LALM as indicated in the facility's policy. These deficient practices placed Resident 2, 3, and 9 at risk for the development and worsening of pressure ulcers. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of five sampled residents (Resident 3, 9, and 10) by: 1. Failing to hold (not administer) Resident 3 ' s hydralazine (medication used to manage elevated blood pressure) for systolic blood pressure (SBP – measures the pressure the blood exerting against the artery walls when the heart beats) less than 110. At 5 p.m., on 8/12/2024, 8/13/2024, and 8/30/2024, Licensed Vocational Nurse 13 (LVN 13) administered hydralazine to Resident 3 when the resident ' s SBP levels were less than 110. 2. Failing to hold Resident 3 ' s diltiazem (medication used to manage elevated blood pressure) for SBP less than 110. On 8/12/2024 at 2 p.m. LVN 15 administered diltiazem, and at 9 p.m., LVN 13 administered diltiazem when Resident 3 ' s SBP levels were less than 110. 3. Failing to hold Resident 9 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for two of 14 sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure Licensed Vocational Nurse 8 (LVN 8) and the Social Service Assistant (SSA) documented Resident 1 ' s condition in the resident ' s clinical records before and after the resident's discharge from the facility. 2. Ensure LVN 13 documented Resident 3 ' s Change of Condition (COC) timely in the resident ' s clinical record. Resident 3 had a COC on 9/16/2024 and the COC form was created on 9/17/2024. 3. Ensure facility staff documented the level of care provided to Resident 3 based on the resident ' s level of care assessment. These deficient practices resulted in inaccurate information on Resident 1 and Resident 3 ' s clinical record and had the potential for delayed and inaccurate medical interventions for Resident 3. Findings: 1. During a review of Resident 1 ' s admission Record, the admission Record…

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

Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 3) was provided dignity when Resident 3 ' s gown was pulled up to her chest, exposing the resident in view of other residents and staff. This deficient practice had the potential to negatively affect the resident ' s psychosocial wellbeing and loss of dignity. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (a progressive state of decline in mental abilities) and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident ' s cognitive skills was severely impaired. The Functional Limitation in Range of Motion section of the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within reach for one of three sampled residents (Resident 14). 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 call for assistance. Findings: During a record review of Resident 14 ' s admission Record, the admission Record indicated the facility admitted Resident 14 on 11/9/2020, with diagnoses that included displaced intertrochanteric fracture (type of broken hip) of left femur (thigh bone), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and acute respiratory failure (condition in which not enough oxygen passes the lungs into your blood).…

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

Based on interview and record review, the facility failed to notify the resident and the resident's responsible party (RP) of the result of the investigation and resolution of the grievance and failed to document the result of the grievance in the complaint and grievance form for one of three sampled residents (Resident 3). This deficient practice had the potential to violate residents' rights to have grievances addressed. Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/14/2012, with diagnoses that included encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 3's History and Physical (H&P) dated 8/5/2024, the H&P indicated 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 develop and implement a comprehensive, person-centered care plan (contains relevant information about a resident ' s health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for one of 14 sampled residents (Resident 1) by failing to develop a care plan addressing Resident 1 ' s discharge plans. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident ' s discharge goals and needs. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses including diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (persistent and excessive worry that interferes with daily activities).…

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

Based on interview and record review, the facility failed to provide an ongoing activity program that is resident centered for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the resident's sense of self-worth and psychosocial well-being. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia, and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3 ' s Minimum Data Set (MDS -a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident ' s cognitive skills was severely impaired. The Functional Limitation in Range of Motion section of the MDS indicated Resident 3 had impairment on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and the lower extremities (hip, knee, ankle,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of practice for one of four sampled residents (Resident 3) by failing to: a. Ensure Resident 3 was assessed and monitored after the resident had a change of condition (COC) on 9/16/2024. b. Ensure Resident 3 ' s Attending Physician 1 (MD 1) and resident representative (FM 1) were notified about the resident's COC timely. These deficient practices had the potential to result in inaccurate assessment that can lead to the resident not receiving timely medical interventions. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia, and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 are receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate treatment and services for one of three sampled residents (Resident 3) by: 1. Failing to ensure the physician was notified timely when Resident 3 ' s gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) malfunctioned (fail to operate). 2. Failing to ensure GT residual (the amount of liquid drained from a stomach following administration of enteral feed) was checked and documented before administration of medications, flushing and formula every shift. This deficient practices had the potential to result in Resident 3 not receiving the volume of tube feeding formula ordered and placed Resident 3 at risk for unplanned, progressive weight loss and or fluid overload. Findings: a. During a record review of Resident 3 ' s admission Record, the…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), who was receiving Lovenox (an anticoagulant that helps prevent the formation of blood clots) was monitored for the side effects of bleeding. This deficient practice had the potential to place Resident 9 at increased risk for side effects including bleeding and bruising. Findings: During a record review of Resident 9 ' s admission Record, the admission Record indicated the facility admitted Resident 9 on 1/2/2024, with diagnoses that included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), history of fall, and essential hypertension (persistently raised blood pressure with no secondary cause identified). During a record review of Resident 9 ' s History and Physical (H&P) dated 1/21/2024, the H&P indicated Resident 9 had fluctuating capacity to understand and made decisions. During a record review of Resident 9 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control procedures for two of six sampled residents (Resident 3 and Resident 11) by: a. Failing to ensure Certified Nursing Assistant 7 (CNA 7) wore gloves while performing oral care (cleaning of the teeth, oral cavity [mouth], and dentures). Resident 3 was on enhanced barrier precaution (EBP – an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities). b. Failing to ensure Resident 11 ' s oxygen tubing was not touching the floor. These deficient practices had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) of the resident ' s care equipment and placed the residents at risk for infection. Findings: a. During a record review of Resident 3 ' s admission Record, the 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 observation, interview, and record review the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement and modify interventions to prevent accidents for one of three sampled residents (Resident 1) by failing to ensure Resident 1, who had repeated falls, was appropriately assessed by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) after each fall incident. This deficient practice placed the resident at increased risk for falls resulting in injuries. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 8/6/2024 and readmitted the resident on 8/19/2024, with diagnoses including traumatic amputation (surgical procedure to remove a part of the body) between elbow and wrist left arm and pneumothorax (occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse). During a review of…

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

Based on interview and record review, the facility failed to fully inform the Responsible Party (RP- a person delegated to make medical decisions for the resident in the event they are unable to do so) for one of four sampled residents (Resident 1) when heparin (an anticoagulant medication; substance that is used to prevent and treat blood clots in blood vessels and the heart) a new medication to Resident 1 was prescribed on 6/25/2024. This deficient practice violated Resident 1's right to be informed of and participate in the resident's treatment. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including hypertensive hear disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, cardiomegaly (an enlarged heart seen on any imaging test, including a chest radiography [X-ray- is the imaging of body structures, or parts of the body]), chronic embolism (an obstruction or blockage in a blood vessel) and…

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

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of any significant medication error when: 1. Licensed Vocational Nurse 4 (LVN 4) failed to administer diltiazem (a calcium channel blocker [type of drug that keeps calcium from entering the muscle cells of the heart and blood vessels] that treats high blood pressure and angina [chest pain]) and hydralazine (medication that relaxes the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its workload) to Resident 1 as prescribed. This deficient practice had the potential for Resident 1's blood pressure to go down. 2. Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 3 (LVN 3) failed to administer heparin (an anticoagulant medication; substance that is used to prevent and treat blood clots in blood vessels and the heart) to Resident 1, as prescribed. This deficient practice had the potential for Resident 1 to develop lipohypertrophy (a lump of fatty tissue under your skin caused by repeated injections in the same…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records are complete, accurately documented, readily accessible, and systematically organized for two of nine sampled residents (Resident 1 and Resident 2) by failing to document the resident ' s condition upon leaving the facility and the time the residents were transferred to the General Acute Care Hospital (GACH) emergency room (ER). This deficient practice had the potential for delayed medical interventions for Resident 1 and Resident 2. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/21/2023, with diagnoses including fibromyalgia (a chronic widespread pain throughout the body or in multiple areas), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and essential hypertension (high blood pressure that is not due to another medical condition). A review of Resident 1 ' s History and Physical (H&P), dated 10/29/2023,…

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

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life by failing to ensure only a female Certified Nursing Assistant will be assigned to the resident. On 5/1/2024 Resident 1 was assisted by a male CNA, Certified Nursing Assistant 1 (CNA 1) with perineal care (washing the genital and rectal areas of the body). This deficient practice had the potential to affect the residents ' self-worth and self-esteem. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/30/2023 with diagnoses that included abnormalities of gait and mobility, lack of coordination, and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 4/6/2024 indicated Resident 1 cognition was intact and able 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 interview and record review, the facility failed to implement its Abuse Prevention and Prohibition Policy and Procedures by failing to conduct pre-employment screening prior to hiring of employees for four out of five sampled staff (CNA 1, 3, 4, and 5). This deficient practice had the potential to place the residents at risk for abuse. Findings: During a concurrent interview and record review on 5/6/2024 at 1:41p.m. with the Assistant Director of Staff Development (ASDS), reviewed Certified Nursing Assistant 1, 3, and 5 ' s (CNA 1, 3, and 5) employee file. The ASDS stated CNA 1 ' s employee file indicated CNA 1 was hired on 1/10/2024 and CNA 1's pre-employment background was completed on 1/14/2024. The ASDS stated CNA 1 was assigned to take care of three residents on 1/13/2024, prior to completion of pre-employment screening. The ADSD stated CNA 3 ' s employee file indicated CNA 3 was hired on 2/7/2024 and CNA 3 ' s pre-employment screening was completed on 2/12/2024. The ADSD stated CNA 3 was assigned to take care of three residents on 2/10/2024, prior to completion of…

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

Based on interview and record review the facility failed to ensure a Certified Nursing Assistant has a current certification for one of five Certified Nursing Assistant reviewed for certifications (CNA 4). CNA 4 was hired on 4/7/2024. This deficient practice placed the residents at risk for receiving care from CNAs who are not competent and proficient. Findings: During a concurrent interview and record review on 5/6/2024 at 1:41 p.m. with the Assistant Director of Staff Development (ADSD), CNA 4 ' s employee file was reviewed. The ADSD stated there is no proof of a CNA certificate in the employee file. The ADSD stated CNA 4 had been working in the facility since 4/7/2024. The ADSD stated she is unable to verify CNA 4's certificate on the State website. During an interview on 5/6/2024 at 2:59 p.m. with the ADSD, the ADSD stated CNA 4 had proof of passing to work as a CNA but it was given to the previous Director of Staff Development (DSD) but the facility was unable to provide documentation. During an interview on 5/6/2024 at 3:31 p.m. with the Assistant Administrator (AA), the AA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident centered care plan addressing oxygen use for one of three sampled residents (Resident 2). This deficient practice had the potential to result in inappropriate care and treatment. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with medical history including hemiplegia (a condition that causes paralysis or weakness on one side of the body), and hemiparesis (muscle weakness on one side of the body), hyperlipidemia ( elevated cholesterol), pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin), hyperlipidemia (elevated cholesterol), dementia (memory loss), sepsis (a life-threatening complications of an infection), calculus of kidney (a small, hard deposit that forms in the kidney). A review of Resident 2 ' s Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 4/7/2024, indicated the…

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

Based on interview and record review, the facility failed to: 1. Limit the use of PRN (as needed) Alprazolam (a medication used to treat the inability to sleep) to 14 days in one of five sampled residents (Resident 1). 2. Define and monitor for specific target behaviors tied to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in one of three sampled residents (Resident 1). These deficient practices increased the risk that Resident 1 may have experienced adverse effects of psychotropic medication therapy leading to an overall negative impact on their physical, mental, and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record, indicated the facility admitted the resident on 6/16/2023 with medical history including type 2 diabetes (body ' s inability to process sugar), dysphagia (inability to swallow), obesity, depression (mood disorder characterized by sadness), hyperlipidemia (elevated cholesterol), hypertension (hypertension), generalized anxiety disorder (excessive worry), acute…

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

Based on interview and record review, the facility failed to create a comprehensive person-centered care plan for one of three sampled residents (Resident 1) by failing to address Resident 1's refusal for Restorative Nursing Assistant (RNA- provide residents routine restorative nursing care and assist residents with exercises to improve or maintain mobility and independence) Program. This deficient practice 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 6/23/2015 with diagnoses that included Multiple Sclerosis (MS-a long-lasting [chronic] disease of the central nervous system thought to be an autoimmune disorder [ a condition in which the body attacks itself by mistake] that affects people differently. Some people with MS may have only mild symptoms but others may lose their ability to see clearly, write, speak, or walk when communication between the brain and other parts of the body becomes disrupted), unspecified (unconfirmed) rheumatoid arthritis (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 ensure seven of 18 sampled residents (Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17) received the necessary care and preferred services, such as warm showers and bed bath, to attain and maintain the residents' highest practicable physical, mental, and psychosocial well-being. The facility failed to: a. Ensure continuous hot running water were available for Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17. b. Ensure that the water used for Resident 17 who had cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment, was at comfortable temperature level. These deficient practices resulted in Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17 not able to take a comfortable bed bath or shower. Findings: a. On 3/5/2024 at 8:12 a.m., during a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 18 sampled residents (Resident 8, Resident 9, and Resident 16) were provided bed baths using a safe and comfortable water temperature. The facility staff used the microwave to heat the water for the resident's bed bath. This deficient practice placed the residents at risk for sustaining burns, scalding (injury from hot liquid or steam), and experiencing uncomfortable water temperatures. Cross reference to F675 and F908. Findings: On 3/5/2024 at 8:46 a.m., during a concurrent observation and interview, observed water heater #2 room with two water heater machines and two hot water containers. The Maintenance Supervisor (MS) stated that the second water heater in the room was turned off because it was not safe to use after a smell of combustion was observed. The MS turned on water heater 2 and smoke came out of the water heater machine. Water heater 2 was observed with a black smoke stain on the top front side. The hot water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 boiler (a device providing hot water supply) room equipment were in good working condition and provided safe and comfortable environment for the residents, staff, and visitors, as indicated in the facility's policies and procedures. The facility failed to: 1. Maintain boilers in safe operating conditions in one of three boiler rooms. 2. Maintain required water temperature range of 105 degrees Fahrenheit (°F - unit of measurement) to 120°F in five of five resident shower rooms (station 1 shower 1B room, station 2 shower 2A room, station 3 shower 4A room, station 4 shower 4 whirlpool room, and station 5 shower 5 room) and five of five nurse station hand sinks (station 1, station 2, station 3, station 4, and station 5). These deficient practices resulted in residents not able to shower because of the uncomfortable and unsafe water temperatures. Findings: On 3/5/2024 at 8:12 a.m., during a concurrent observation and interview, water…

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

Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 18) was provided a safe and homelike environment. The facility failed to ensure the ceiling in Resident 18 ' s room was free from water leak and water stains. This deficient practice resulted in Resident 18 not having a homelike comfortable and safe environment. Findings: A review of Resident 18 ' s admission Record indicated the facility admitted the resident on 12/30/2023 with diagnoses including lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that is usually drained through the body ' s lymphatic system), type 2 diabetes mellitus (occurs when the blood sugar is too high), and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 18 ' s History and Physical, dated 12/30/2023, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 18 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 1/5/2024, indicated the…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) was provided transportation to the facility timely after a medical appointment. On 2/14/2024 at 6 a.m., Resident 4 was transported to Outpatient Rehab Center 1 (ORC 1) for an appointment at 8:40 a.m. Resident 4 did not return to Skilled Nursing Facility 1 (SNF 1) on 2/14/2024. Resident 4 was found in a parking lot near ORC 1 and transferred to General Acute Care Hospital 1 (GACH 1) on 2/16/2024. This deficient practice placed Resident 4 at risk for accidents and injuries. Findings: A review of Resident 4's admission Record indicated the facility admitted the resident on 12/12/2023 and readmitted the resident on 1/8/2024 with diagnoses that included paraplegia (paralysis that affects your legs, but not your arms), muscle weakness, and chronic pain syndrome (pain that lasts for over three months). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/18/2023, indicated the resident was able to understand and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3), was provided necessary treatment and services to prevent formation of and promote healing of pressure sore by failing to implement the facility's policy on Braden Skin Risk Assessment Tool (a standardized, eveidence-based assessment tool commonly used in healthcare to assess and document a patient's risk for developing pressure injuries) for Prevention of Pressure Ulcers, by not having an appropriate assessment and that changes in condition are recognized, evaluated, addressed, when a new pressure ulcer developed within the facility. This deficient practice could potentially hinder the healing of Resident 3's pressure ulcers and cause infections. Findings: A review of Resident 3's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included Parkinson's disease (is a progressive 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 one of three sampled residents (Residents 3) received the necessary Restorative Nursing Program [RNP, nursing program that uses restorative nursing aides (RNA are health care professionals who are responsible for providing restorative and rehabilitation care for residents to maintain or regain physical, mental, and emotional well-being. Aides in this capacity are certified nurse assistants (CNAs), with specialized training in restorative care] to help residents improve or maintain one's functional ability and joint mobility by failing to provide RNP services consistently to Resident 3 from 1/2024 to 2/2024 as ordered by the physician and as recommended by the licensed therapist. This deficient practice had the potential to cause a further decline in ROM with worsening contractures (deformity and joint stiffness) to both upper and lower extremities and increased potential for skin injuries including pressure sores (injuries to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when the Registered Dietitian did not conduct a comprehensive (complete) nutritional assessment (a detailed evaluation of the resident's nutritional health) by not talking to the resident or resident's family member and physically assessed a resident during the initial admission and quarterly assessment for one of one sampled resident (Resident 3) who had a weight loss. This failure had a potential to result in inaccurate nutrition assessment, ineffective nutrition intervention, and goals. Findings: A review of Resident 3's admission Record, indicated Resident 3 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including Parkinson Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), unspecified dementia (loss of cognitive functioning, thinking,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control procedures for two of 18 sampled residents (Resident 13 and Resident 16) by failing to: a. Ensure Resident 16's water pitcher was not placed on an area used by other residents. b. Ensure Resident 13's wash basins were not placed on another resident's bathroom sink for hot water. These deficient practices placed Resident 13 and resident 16 at risk for exposure and contracting infections. Findings: a. A review of Resident 16's admission Record indicated the facility admitted the resident on 12/7/2021 with diagnoses including type 2 diabetes mellitus (occurs when the blood sugar is too high) with foot ulcer (wound), hemiplegia (paralysis that affects only one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, and pressure ulcer (damage to the skin and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for two of three sampled residents (Resident 143, 291, and 99) investigated under the dignity investigative care area by: 1. Failing to maintain Resident 143's privacy while addressing their behavior of removing clothes due to itchiness. 2. Failing to ensure Resident 291's shower preference was honored and respected. 3. Failing to ensure Certified Nursing Assistant 4 (CNA 4) asked Resident 99's permission prior to providing care. These deficient practices had the potential to affect the residents' self-worth and self-esteem. Findings: a. A review of Resident 143's admission Record indicated the facility originally admitted the resident on 2/5/2022 and readmitted on [DATE] with diagnoses including bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with injectable lorazepam (a medication used to treat mental illness) in one of six sampled residents investigated during review of unnecessary medications (Resident 14). 2. Obtain informed consent from the resident or their responsible party prior to treatment with Zyprexa (a medication used to treat mental illness) and Celexa (a medication used to treat mental illness) in one of six sampled residents investigated during review of unnecessary medications (Resident 232.) The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications (medications that affect brain activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer the resident or their resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission for three (Resident 4, 194, and 222) out of four sampled residents investigated during review of advance directive care area. This deficient practice violated the resident and/or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: a. A review of Resident 4's admission Record indicated the facility admitted the resident on 10/21/2023 with diagnoses including fibromlyagia (a chronic [long-lasting] disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping) and…

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

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraint (refers to means of purposely limiting or obstructing the freedom of a person's bodily movement) for one of one sampled resident (Resident 222) investigated during review of physical restraints care area by failing to assess the need for a restraint and by failing to obtain an order from the physician when: 1. Resident 222's right side bed was pushed against the wall to prevent the resident from getting out of bed. 2. A booster pillow was placed on the left side of Resident 222's bed to prevent the resident from getting out of bed. 3. A tab alarm (features a pull-string that attaches magnetically to the alarm with garment clip to the resident) was applied to Resident 222 to notify staff the resident was getting out of bed. These deficient practices placed Residents 222 at risk for affecting their self-worth for being restricted with movement and had the potential to violate the resident's right to be free from any restraints that are imposed for reasons 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: 1. Failed to develop a care plan on the use of anticoagulants (a blood thinner that treats and helps prevent blood clots) for two of four sampled residents (Resident 39 and Resident 194) investigated during review of anticoagulant care area by failing to develop a care plan for Resident 39's use of Eliquis (an anticoagulant medication) and by failing to develop a care plan for Resident 194's use of Xarelto (an anticoagulant medication). This deficient practice had the potential for failure to deliver necessary care and services and subjecting residents to adverse effects (a harmful or abnormal result) of significant medications. 2. Failed to develop a care plan on the use of antipsychotic (Seroquel, medication-used to treat disordered thinking associated with severe mental illness) for one out of six sampled residents (Resident 23) investigated during review of unnecessary medications. This deficient practice had the potential to result in inconsistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to four out of four sampled residents (Residents 73, 97, 1, and 6) investigated for insulin use. 2. Failing to rotate subcutaneous administration sites of heparin (is used to prevent formation of blood clots in the vessels) to one out of four sampled residents (Resident 97) investigated for anticoagulant use. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Findings: 1. a. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide needed care and services that are resident centered for two of two sampled residents reviewed under non-pressure skin conditions (Resident 105 and 134) and (Resident 196 Care Area/Universe) when: 1. The facility failed to follow up with Resident 105 regarding the effectiveness of his rash treatments. 2. The facility failed to provide treatment for Resident 134's surgical wound as ordered by the physician. These deficient practices had the potential for Resident 105 and 134's skin conditions to worsen or delay healing. Cross-reference F745 Findings: 1. A review of Resident 105's admission Record indicated the facility originally admitted Resident 105 on 8/4/2020 and readmitted the resident on 5/16/2022 with diagnoses including polyneuropathy (when multiple nerves become damaged) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily…

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

Based on observation, interview, and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice by failing to: 1. Flush the peripherally inserted central catheter (PICC, a long, thin tube that is inserted through a vein in the arm and passed through the larger veins in the heart) line/central line (a tube that doctors placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or do medical tests quickly) with 10 milliliters (ml, a unit of volume) of normal saline (NS, a mixture of sodium chloride [salt] and water) prior to administration of intravenous (IV, within a vein) antibiotics to one of one sampled residents (Resident 446) investigated under infection control task. This deficient practice had the potential to impair the patency of the PICC/Central line causing occlusion (blockage). 2. Indicate the date when the IV tubing was last changed for one of one resident (Resident 452) with intravenous (IV) catheter (a thin plastic tube inserted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective pain management by failing to identify the resident's pain level after administration of pain medication for one of one sampled resident (Resident 203), who was investigated under the care area of pain management. Resident 203 had no pain level assessments after pain medications were given on: 1/1/2024 at 9:45 a.m.; 1/1/2024 at 2 p.m.; 1/1/2024 at 6 p.m.; 1/3/2024 at 9 a.m.; 1/3/2024 at 5:36 p.m.; 1/4/2024 at 2 p.m.; 1/5/2024 at 2 p.m.; 1/8/2024 at 8:45 a.m.; 1/9/2024 at 3:15 p.m.; 1/10/2024 at 11:30 a.m.; 1/10/2024 at 8:47 p.m.; 1/11/2024 at 9:30 a.m.; 1/11/2024 at 8:10 p.m.; 1/12/2024 at 1 a.m.; 1/14/2024 at 12:15 p.m.; 1/15/2024 at 11 a.m.; 1/16/2024 at 1:20 a.m.; 1/19/2024 at 5:30 a.m.; 1/19/2024 at 11 a.m.; 1/21/2024 at 1 p.m.; and 1/22/2024 at 12:11 p.m. This deficient practice had the potential to result in lack of detection of unrelieved pain, placing Resident 203 to unnecessarily suffer with pain. Findings: A review of Resident 203's admission Record 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 provide necessary medically related social services to maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents investigated during review of non-pressure skin conditions care area (Resident 105) and one of six sampled residents reviewed under the abuse investigative care area (Resident 203) when: 1. The facility failed to follow up with Resident 105's dermatology (branch of medicine dealing with the skin) consult for itching. 2. The facility failed to identify and assess Resident 203's need for mental and emotional support after a resident-to-resident altercation between Resident 203 and Resident 23 on 1/13/2024. These deficient practices resulted in a delay in provision of care for Resident 105 and had the potential to result in distress and frustration and for not meeting the needs of Resident 203. Cross-reference F600, F610, and F684. Findings: 1. A review of Resident 105'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.

2. A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including generalized edema, dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 203's Order Summary Report, dated 12/28/2023, indicated a physician's order for Hydrocodone (contains codeine)/Acetaminophen tablet (Norco) 10-325 milligram (mg- a unit of measure) give one (1) tablet by mouth every 4 hours as needed for moderate to severe pain, ordered 12/28/2023. A review of Resident 203's Medication Administration Record (MAR - medications administered to the residents), indicated an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the consultant pharmacist identified and reported the medication irregularities of failing to monitor for adverse effects and target behaviors related to psychotropic (medications that affect brain activities associated with mental processes and behavior) medication therapy in one of five sampled residents (Resident 14). 2. Facility failed to ensure a Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) request was completed upon admission for one of five sampled residents (Resident 232.) The deficient practices of failing to ensure the consultant pharmacist identifies medication irregularities related to the failure to monitor psychotropic medications for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and efficacy and failing to conduct a MRR upon admission increased the risk that Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. A review of Resident 194's admission Record indicated the facility admitted the resident on 8/18/2023, and readmitted the resident on 10/13/2023, with diagnoses including traumatic brain injury (a form of acquired brain injury caused by sudden trauma), syncope (a loss of consciousness for a short period of time), and history of falling. A review of Resident 194's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/28/2023, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class anticoagulant medication (a substance that is used to prevent and treat blood clots in the blood vessels and the heart). A review of Resident 194's Order Summary Report indicated the following orders: - Anticoagulant Medication- Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a new order for PRN (as needed) injectable lorazepam (a medication used to treat mental illness) was limited to a 14-day duration in one of six sampled residents investigated during review of unnecessary medications (Resident 14.) 2. Identify and define specific, measurable target behaviors related to the use of Zyprexa (a medication used to treat mental illness) in one of six sampled residents investigated during review of unnecessary medications (Resident 232.) The deficient practice of failing to limit PRN orders for lorazepam to a 14-day duration or identify specific, measurable target behaviors related to the use of Zyprexa increased the risk that Residents 14 and 232 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. 3. Monitor…

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

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 by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to four out of four sampled residents (Residents 73, 97, 1, and 6) investigated for insulin use. 2. Failing to rotate subcutaneous administration sites of heparin (is used to prevent formation of blood clots in the vessels) to one out of four sampled residents (Resident 97) investigated for anticoagulant use. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference to F658. Findings: 1. a. 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: 1. Ensure two unopened vials of latanoprost (a medication used to treat eye conditions) eye drops were stored in the refrigerator according to the manufacturer's requirements affecting Residents 165 and 341 in two of five inspected medication carts (Station 2 Cart B and Station 5 Medication Cart.) 2. Ensure lorazepam oral solution (a medication used to treat mental illness) and injectable lorazepam solution (a medication used to treat mental illness) were stored in the refrigerator per the manufacturer's requirements affecting residents 143 and 211 in one of five inspected medication carts (Station 3 Cart A.) 3. Ensure six unopened vials of insulin (a medication used to treat high blood sugar) were stored in the refrigerator per the manufacturer's requirements affecting residents 71, 169, 176, 197, and 207 in one of five inspected medication carts (Station 5 Medication Cart.) The deficient practices of failing to store or label…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. There was no air gap (the unobstructed vertical space designed to prevent any backflow of contaminated water into the [NAME] supply) between the ice machine drainage pipe and the floor drain. 2. There was no thermometer kept inside the walk-in freezer. 3. The paper towel dispenser next to the hand washing station was empty and not replaced immediately after the previous roll was emptied. These deficient practices had the potential to result in harmful bacterial growth and foodborne illnesses (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food). Findings: 1. During a concurrent observation and interview with the Dietary Supervisor (DS), on 1/22/2024, at 8:03 a.m., inside the kitchen next to the ice machine, the drainpipe leading outside the ice machine was situated going through an open grate 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.

b. A review of Resident 129's admission Record indicated the facility admitted the resident on 12/7/2021 and readmitted the resident on 11/4/2022 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as stroke - refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left dominant side, dysphagia (difficulty swallowing), and encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 129's History and Physical (H&P) dated 11/8/2023, indicated that the resident had the capacity to understand and make decisions. A review of Resident 129 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 11/11/2023, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and oral hygiene; and maximal to total assistance from 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's MDS, dated [DATE], indicated the resident's cognitive skills (ability to understand and make decisions) were intact. The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 203's Order Summary Report, dated 12/28/2023, indicated the resident had a physician's order for oxygen at two liters per minute via nasal cannula continuously every shift for shortness of breath (SOB). A review of Resident 203's care plan, titled Oxygen: resident requires the use of oxygen, dated 12/28/2023, indicated an intervention to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the initial care conference meeting was held with the resident or their representative for two of three sampled residents investigated during review of the residents' interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents) care plan meeting (Resident 91 and Resident 200). This deficient practice had the potential to violate Resident 91 and Resident 200's right to be an active participants in their care and had the potential for delay in the provision of necessary care and services. Findings: 1. A review of Resident 91's admission Record indicated the facility admitted the resident on 11/8/2023 and readmitted the resident on 12/27/2023 with diagnoses including end stage renal disease (final stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own) epilepsy (a condition 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for two out of five sampled residents (Resident 182 and Resident 233) investigated during review of environment facility task. These deficient practices 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. A review of Resident 182's admission Record indicated the facility admitted the resident on 6/29/2023, with diagnoses including dysarthria (a motor speech disorder that makes it difficult to form and pronounce words), anarthria (a complete loss of speech), and subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain). A review of Resident 182's History and Physical (H&P), dated 6/30/2023, indicated the resident had the capacity to understand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of six sampled residents (Resident 23 and Resident 203). On 1/13/2024 at 11:30 a.m., in the hallway, Resident 203 threw a fruit cup and spat at Resident 23's face. Then, Resident 23 punched Resident 203 in the face followed by Resident 203 hitting Resident 23 back in the face. This deficient practice resulted in Resident 203 and Resident 23 subjected to physical abuse while under the care of the facility. This deficient practice also caused Resident 203 to report right eye pain and received pain medication. Findings: A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation regarding allegations of abuse involving two of six residents (Residents 23 and Resident 203) investigated under the care area of abuse by failing to interview Licensed Vocational Nurse 5 (LVN 5) who witnessed the incident. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact. The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 send a copy of the notification of a resident's transfer/discharge to the office of the long-term care ombudsman (resident advocate) for one of three sampled residents investigated during review of closed records (Resident 240). The facility did not have documented evidence a copy of Resident 240's Notices of Transfer/Discharge, dated 12/4/2023 and 12/5/2023 was sent to the long-term care ombudsman office. This deficient practice had the potential for Resident 240 to have an unsafe discharge. Cross-reference to F-Tag F661, F625, and F641 Findings: A review of Resident 240's admission Record indicated the facility admitted Resident 240 on 10/7/2023 with diagnoses including, but not limited to, Wernicke's encephalopathy (a type of brain injury). A review of Resident 240's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 240 was discharged to a short-term general hospital on [DATE]. 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 a bed-hold notice to a resident upon transfer to the general acute care hospital (GACH) for one of three sampled investigated during review of closed records (Resident 240). This deficient practice had the potential for Resident 240 to not know if they had a place to return to after hospitalization. Cross-reference F-Tag 661, F623, and F64. Findings: A review of Resident 240's admission Record indicated the facility admitted Resident 240 on 10/7/2023 with diagnoses including, but not limited to, Wernicke's encephalopathy (a type of brain injury). A review of Resident 240's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 240 was discharged to a short-term general hospital on [DATE], had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect everyday life), and required setup or clean up assistance 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 interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of nine sampled residents (Resident 452) investigated under care planning care area. This deficient practice had the potential for Resident 452 not to receive the appropriate care and treatment specific to his needs. Findings: A review of Resident 452's admission Record indicated the facility admitted the resident on 1/19/2024 with diagnoses including sepsis (a condition that happens when an infection triggers a chain reaction throughout your body), epilepsy (a condition that happens as a result of abnormal electrical brain activity, also known as a seizure), and generalized muscle weakness. A review of Resident 452's History and Physical (H&P) dated 1/21/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 452 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 1/25/2024, indicated the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 indicate and include the interdisciplinary team (IDT - professional disciplines that work together to provide the greatest benefit to the resident) members involved with a resident's plan of care for one of three sampled resident reviewed under care planning (Resident 6) when Resident 6's IDT notes, dated 3/2/2023, did not indicate whether the physician, registered nurse (RN), certified nursing assistant (CNA), and a member of the food and nutrition staff were present during Resident 6's care plan meeting and did not indicate who was present during the IDT meeting conducted on 9/12/2023. This deficient practice had the potential for the facility to be unaware of which disciplines were involved with the resident's plan of care and what their contributions were to the resident's plan of care. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 5/24/2021 with diagnoses including, but not limited to, chronic respiratory failure (condition that occurs when the lungs cannot get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 on a timely basis the resident's discharge plan by failing to follow-up the discharge planning process with the resident and the resident's representative for one of two sampled residents (Resident 107) investigated under the discharge care area. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. Findings: A review of Resident 107's admission Record indicated the facility admitted the resident on 6/19/2023 with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (commonly known as stroke, caused by a blockage in a blood vessel in the brain, leading to brain damage) affecting left non-dominant side and encounter for attention to gastrostomy (a type of artificial opening to the stomach that requires special care). A review of Resident 107's History and Physical, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to ensure Certified Nursing Assistants maintain current CPR certification two of two Certified Nursing Assistants (CNA 4 and CNA 11) investigated during review of personnel files. These deficient practices had the potential of delayed provisions of emergency care for residents who wishes to have full treatment in a life-threatening situation. Findings: a. A review of Certified Nursing Assistant 4 (CNA 4) employee file on [DATE] at 3:30 p.m. indicated a CPR certificate dated [DATE] that is valid for two (2) years. During a concurrent interview and record review on [DATE] at 4:00 p.m., CNA 4's CPR card was reviewed with the Director of Staff Development (DSD). The DSD verified that the CPR card for CNA 4 was expired. The DSD stated the facility do not require the…

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

Based on observation, interview, and record review the facility failed to ensure one of three sampled resident (Resident 200) has reading glasses as recommended by the optometrist (health care provider who specializes in eyecare) on 10/20/2023. This deficient practice resulted in Resident 200 not being able to read her books she enjoys. Findings: A review of Resident 200's admission Record (Face Sheet), dated 1/25/2024, indicated the facility admitted Resident 200 on 9/19/2023, with diagnoses including chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a common form of diabetes in which the body cannot properly store or use glucose [sugar], the main body's source of energy), and anemia (a condition in which the blood does not have enough red blood cells that carries oxygen from the lungs to other parts of the body). The Face Sheet indicated Resident 200 was self-responsible. A review of Resident 200's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/26/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of three sampled residents (Residents 73 and 194) being investigated under pressure ulcer care area, by failing to consistently perform weekly skin assessment to Residents 73 and 194 who had pressure ulcers at stage 4 (the sores extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) on the coccyx (the small bone at the end of the spine, also called tailbone). This deficient practice had the potential for development and worsening of pressure ulcers/injuries to the residents. Findings: 1. A review of Resident 73's admission Record indicated the facility admitted the resident on 8/3/2021 and readmitted the resident on 2/9/2022, with diagnoses including pressure…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria, 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 two sampled residents (Resident 73) being investigated under catheter care area, by failing to replace worn out Statlock (a device to secure the catheter to prevent tugging and pulling) in order 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. This deficient practice had the potential for the resident 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 urine until it is can be excreted]) due to tugging and pulling of the urinary catheter causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to discard a feeding formula bottle of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 calories (a unit of energy), dated 1/16/2024 (observed on 1/22/2024), via gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) feeding and an undated irrigation syringe (used to administer medication and irrigate the feeding tube) to one out of one sampled resident (Resident 182) being investigated under tube feeding. The deficient practice had the potential for residents to experience gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: A review of Resident 182's admission Record indicated the facility admitted the resident on 6/29/2023, with diagnoses including nontraumatic subarachnoid hemorrhage (a bleeding in the space that surrounds…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed staff failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and failed to document the assessment in the Pre (before)- and Post (after)-Dialysis Communication Form for one of one sampled resident (Resident 63) investigated during review of dialysis care area. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment. Findings: A review of Resident 63's admission Record indicated the facility admitted the resident on 11/22/2023 with diagnoses including dependence on renal dialysis and acute kidney failure (also known as acute kidney injury, condition in which the kidneys suddenly cannot filter waste from the blood). A review of Resident 63's History and Physical, dated 11/22/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly provide dental services for two out of three sampled residents (Residents 97 and 39) reviewed under the dental investigative care area by failing to schedule an oral x-ray (use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on a film or digital media) per the dentist's treatment recommendation for Resident 97 and Resident 39. This deficient practice had the potential to result in discomfort and the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass of the residents. Findings: 1. A review of Resident 97's admission Record indicated the facility admitted the resident on 4/12/2023, with diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar is too high), and moderate protein-calorie malnutrition (a nutritional status in which reduced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. A review of Resident 70's admission Record indicated the facility admitted Resident 70 on 8/11/2023 with diagnoses including, but not limited to, hyperlipidemia (high cholesterol) and need for assistance with personal care. A review of Resident 70's H&P, dated 8/11/2023, indicated Resident 70 had fluctuating capacity to understand and make decisions. A review of Resident 70's MDS, dated [DATE], indicated Resident 70 had intact cognition and required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, partial or moderate assistance with toileting hygiene, showering or bathing himself, upper and lower body dressing, and substantial or maximal assistance with putting on or taking off footwear and personal hygiene. A review of Resident 70's Order Summary Report, dated 9/20/2023, indicated Resident 70 was ordered a fortified no added salt diet with mechanical soft chopped meat texture and thin liquids consistency. During a concurrent observation and interview, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards by failing to: 1. Accurately document a pertinent individualized care plan for one out of six residents sampled being investigated under abuse (Resident 203) to indicate that abuse occurred between Resident 203 and Resident 23. This deficient practice resulted in Resident 203's medical records being inaccurate and had the potential to result in confusion regarding whether actual abuse took place between Resident 203 and Resident 23. 2. Document the name of the person who pronounced the resident expired (died) at the facility and by the physician failing to create a discharge summary indicating the resident's cause of death to one of three sampled residents (Resident 239) selected for closed record review. This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Resident 239's death. Findings: 1. A review of Resident 203's…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM, designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was in good repair at all times for one of five sampled residents (Resident 128) investigated under the Environment facility task. This deficient practice had the potential to place the resident at risk for pressure ulcers (also called pressure injuries and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) due to inadequate pressure redistribution. Findings: A review of Resident 128's admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2023 with diagnoses including morbid (severe) obesity (excessive fat accumulation that presents a risk to health) due to excess calories and chronic peripheral venous insufficiency (failure of the veins to adequately circulate the blood). A review of Resident 128's History and Physical, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) for two of six residents (Resident 1 and Resident 4) by failing to: 1. Ensure the air pressure redistribution mattress (APM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) for Resident 1 was turned on and functioning. 2. Ensure there were appropriate number of linens between Resident 1 and the mattress per manufacturer ' s recommendation. 3. Ensure there was a physician order for the APM setting for Resident 1 and Resident 4. 4. Ensure the indwelling catheter (a tube that was inserted into the bladder, allowing urine to drain freely) ports were not pressed on Resident 1 ' s skin. 5. Ensure Resident 1 was turned and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) for three of five sampled residents (Resident 8, 9, 1and 1) by: 1. Failing to ensure Resident 8 was not administered neutral protamine [NAME] (NPH- intermediate acting [works throughout the day and night to provide you with low levels of insulin all the time]) with regular (short acting-starts to work quickly) when the resident ' s blood sugar was below 150 milligrams per deciliter (area of measurement) as ordered by the physician. 2. Failing to ensure Resident 9 was not administered amlodipine (medication used to treat high blood pressure) and hydrochlorothiazide (also known as water pill, medication used to reduce the amount of water in the body by increasing the flow of urine) when the resident ' s systolic blood pressure (sbp- pressure in the arteries when the heart beats) was less than 110…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 7) receive treatment and care in accordance with professional standards of practice by failing to check for Resident 7's identification and physician's order prior to transporting Resident 7 to a medical appointment intended for Resident 11 on 12/20/2023. Resident 11 was discharged to General Acute Care Hospital 1 (GACH) on 12/15/2023. As a result Resident 7 was brought by a transportation service arranged by the facility to a medical appointment intended for Resident 11. This deficient practice had the potential to create confusion in the delivery of care and services to Resident 7. Findings: A review of Resident 11 ' s admission Record indicated the facility admitted the resident on 9/21/2023 with diagnoses that included unspecified (unconfirmed) hydronephrosis (is a condition that occurs when a kidney swells and can't get rid of urine [pee] like it should), calculus of kidney (kidney stones-are hard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to maintain accurate and complete medical record for one of five sampled residents (Resident 7) by failing to ensure the facility documented information of Resident 7's transport to a medical appointment intended for Resident 11. This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care. Findings: A review of Resident 7 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 12/18/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood) and spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots). A review of Resident 7 ' s Minimum Data Set (MDS - a standardized…

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

Based on interview and record review, the facility failed to employ a qualified social service on a full-time basis that met the qualifications as indicated in the facility ' s job description for Social Service Director (SSD). This deficient practice had a potential for the residents residing in the facility not being assisted with obtaining medically related necessary care to attain their highest practicable well-being. Findings: During an interview on 1/5/2024 at 2:05 p.m., with the Administrator (ADM), the ADM stated the facility hired Social Service Director 1 (SSD 1) three months ago. The ADM stated they checked SSD 1 ' s records and was deemed qualified for the position. The ADM stated SSD 1 had worked in multiple skilled nursing facilities as Social Services Director. A review of SSD 1 ' s Employee Maintenance File dated 8/31/2023 indicated SSD 1 was hired full time for the position of Co- Director of Social Services. A review of SSD 1 ' s Job Description and Performance Standards undated indicated SSD 1 signed for the title Social Service Director (Designee-a person who has…

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

Based on observation, interview and record review, the facility failed to ensure two of five sampled staff (admission Assistant 1 [AA 1] and Payroll Staff [PS 1]) wore surgical mask (a respiratory protective device that provides barrier protection against large particles droplets) during an outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy) of Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) in the facility. This deficient practice has the potential to result in the spread of COVID-19 to all staff and residents. Findings: During an observation on 1/3/2024 at 9:10 a.m., observed Activity Assistant 1 (AA 1) sitting in the front office and observed Payroll Staff 1 (PS 1) standing by the copier machine inside the same office without a surgical mask. During a concurrent observation and interview on 1/3/2024 at 9:11 a.m., with the Director of Nursing (DON) in the lobby, observed AA 1 and PS 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 follow infection control procedures for two of seven sampled residents (Resident 6 and Resident 7) by failing to ensure Licensed Vocational Nurse 2 (LVN 2): 1. Performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after gloves use while administering medications to Resident 7. 2. Performed hand hygiene before and after touching Resident 6 and Resident 7 and the resident ' s surroundings without wearing gloves. 3. Disinfected the glucometer (a medical device for determining the approximate concentration of blood sugar) before it was returned in the medication cart drawer. These deficient practices placed Resident 6 and Resident 7 at risk for exposure and contracting infections. Findings: A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 9/19/2023 with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the allegation of resident-to-resident abuse to the State Survey Agency (SSA) for two of seven sampled residents (Resident 1 and Resident 2). On 11/16/2023 at 9:30 a.m., Resident 2 reported an allegation of abuse by Resident 1 to Charge Nurse 1 (CN 1). On 11/16/2023 at 6:10 p.m., the Abuse Coordinator reported the allegation to the SSA, 8 hours and 40 minutes after the allegation of abuse was made. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/18/2023 with diagnoses including traumatic brain injury (an injury that affects how the brain works), traumatic subdural hemorrhage (a condition where blood collects between the skull and the surface of the brain), and osteoarthritis (a degenerative joint disease in which the tissues of the joint breaks down over time) 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 interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of seven sampled residents (Resident 1). The facility failed to develop and implement individualized care plans and interventions addressing Resident 1 ' s aggressive behavior. This deficient practice had placed Resident 1 for not receiving the necessary services and assistance that can result in injury to other residents, visitors, and facility staff. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/18/2023 with diagnoses including traumatic brain injury (an injury that affects how the brain works), traumatic subdural hemorrhage (a condition where blood collects between the skull and the surface of the brain), and osteoarthritis (a degenerative joint disease in which the tissues of the joint breaks down over time) of the left knee. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/24/2023, indicated the…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure on meeting the staff posting requirements. The facility also failed to provide the Direct Care Service Hours Per Patient Day (DHPPD refers to the actual hours of work performed per patient day by a direct caregiver) for one of seven sampled residents (Resident 3) after the resident ' s verbal request. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility. Findings: On 11/28/2023 at 9:08 a.m., during an observation, the DHPPD dated 8/26/2023 was posted at the facility lobby. On 11/28/2023 at 9:11 a.m., during a concurrent observation and interview, observed that there was no DHPPD posted at nurse station 1. Observed the DHPPD dated 8/26/2023 was posted at the nurse station 2, 3, 4, and 5. The Assistant Director of Nursing (ADON) stated that an updated DHPPD should be posted in the facility lobby and at the nurse stations 1, 2, 3, 4, and 5. The ADON stated the Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow menu for residents when: - Ninety (90) out of two hundred forty-seven (247) residents on soft mechanical chopped meats diet got of big pieces of chicken that measured one and a half inches (1 ½) to two (2) inches in size. - Ten (10) out of 247 residents on regular diet got 2 oz of chicken with rosemary sauce instead of 3 oz and 1 oz of boiled potatoes instead of 4 oz. These deficient practices had the potential to decreased nutritional value for carbohydrate, and protein content not consistent to the physician ' s diet order. Furthermore, soft mechanical chopped diet receiving 1 ½ to 2 of meat may result to difficulty eating, swallowing, and choking (blocked airway causing difficulty in breathing) which decreased food intake resulting to weight loss. Findings: During an interview with Resident 3 on 10/31/2023 at 10:23 AM, Resident 1 stated the menu was not accurate with what was written and what was served for type of food and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. In addition, food portions were not correct. This deficient practice placed two hundred one (201) of two hundred forty-seven (247) facility residents at risk of unplanned weight loss, a consequence of poor food intake. Findings: During an interview with Resident 1 on 10/31/2023 at 10:38 AM, Resident 1 stated the menu was not followed regularly, portion sizes were usually not followed when trays were served, and food lacked taste and seasoning. Resident 1 stated the menu sounds delicious in paper but it is not edible. Resident 1 stated, the kitchen served huge servings of starch like rice and pasta and fish was covered with large portions of breading. Vegetables such as green beans do not have any seasonings, zesty spinach was not zesty, and the tuna tasted like cardboard. Deli meats that they used in sandwiches were thin slices of meat and even the gasoline station sandwiches…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services for one of 15 sampled residents (Resident 15) who was unable to carry out activities of daily living received the necessary services to maintain good grooming when Resident 15 was observed with long curled nails. This deficient practice had the potential for Resident 15 to have discomfort. Findings: A review of Resident 15 ' s admission Record indicated the facility admitted the resident on 9/18/2023 with diagnoses that included anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), legal blindness, and functional quadriplegia (complete immobility due to frailty or severe physical disability). A review of Resident 15 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 9/24/2023 indicated Resident 15 had the ability to understand and be understood. The MDS indicated Resident 15 was totally dependent on staff for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate nutritional and hydration care and services to residents when: 1. The facility failed to provide physician ordered high calorie (Kcal, a unit of energy used to express the nutritional value of foods), high protein (a type of nutrient a person needed for growth and development of muscles) nutritional supplement (product used to add kcal and protein in the diet) of preference. 2. The facility failed to prepare foods by methods that conserved flavor and appearance for Resident 1 causing varied oral intake (PO intake). These deficient practiced caused 14.4% severe unplanned weight loss in six (6) months of one (1) of three (3) sampled residents (Resident 1). Findings: A review of Resident 1 ' s admission Record, dated 10/31/2023, indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including malignant neoplasm of upper lobe, right bronchus or lung (a type of 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 interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 1) was free from significant medication error by failing to ensured licensed staff did not administer oxycodone (a pain-relief medicine used to treat severe pain) with Gabapentin (medication used to treat epilepsy [a disorder of the brain characterized by repeated seizures] also taken for nerve pain) to Resident 15. This deficient practice placed Resident 15 at risk for respiratory depression, coma, and death. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/28/2021 and readmitted the resident on 12/27/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), emphysema (a chronic obstructive pulmonary disease that causes coughing and breathing difficulties), and chronic pain syndrome (CPS- when people have symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives). A review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) by: 1. Facility failed to ensure Registered Nurse 1 (RN 1) documented head to toe body assessment after Resident 3 grabbed the back collar and pushed Resident 2 while seated on a wheelchair away from Resident 3 ' s door on 10/25/2023. 2. Facility failed to ensure RN 1 documented administration of amlodipine (medication used to treat high blood pressure) accurately and per physician ' s order for Resident 1 on 10/2023 Medication Administration Record (MAR-record of medications received by the resident). 3. Facility failed to ensure RN 1 documented administration of Lipitor (medication used to lower cholesterol and triglyceride [fat] levels in the blood) on Resident 3 ' s 10/2023 MAR. These deficient practices resulted to inaccurate information entered into residents ' medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse inflicted by Resident 3. On 10/25/2023 at 3:05 p.m., Resident 3 grabbed the back collar of Resident 2 ' s shirt and pushed her away from Resident 3 ' s door. This deficient practice resulted to Resident 2 being subjected to physical abuse while under the care of the facility. Findings: 1. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 6/27/2023 with diagnoses that included complete atrioventricular block (an abnormal heart rhythm that happens when the electrical impulses that control your heartbeat are delayed or blocked), encephalopathy (damage or disease that affects the brain leaving you confused and not acting like you usually do) and altered mental status (an abnormal state of alertness or awareness). A review of Resident 2 ' s History and Physical (H&P), dated 6/30/2023, indicated the resident had fluctuating capacity 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 interview and record review, the facility failed to ensure that licensed nurses followed the physician's order for one of three sampled residents (Resident 1) by: 1. Failing to ensure resident was given propranolol (medication used to treat high blood pressure) despite physician ' s order to hold medication if systolic blood pressure (sbp- pressure in the arteries when the heart beats) was below 110 millimeters of mercury (mmHg- unit of measurement) as indicated in residents 10/2023 Medication Administration Record (MAR- record of medications received by the resident). 2. Failing to ensure resident was given amlodipine (medication used to treat high blood pressure) despite physician ' s order to hold medication if sbp was below 110 as indicated in residents 10/2023 MAR. These deficient practices can potentially lower Resident 1's blood pressure. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/10/2018 with diagnoses that included cerebral infarction (when the blood supply to part of the brain is interrupted or reduced,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform the resident ' s responsible party when the resident had laboratory results with out of range values for one of six sampled residents (Resident 1). 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 admitted the resident on 3/14/2012 ,with diagnoses including encounter for attention to gastrostomy (a feeding tube surgically inserted on the abdomen directly to stomach to provide nutritional needs), type ll diabetes mellitus (characterized by having high amounts of sugar in the blood), and Alzheimer ' s disease (brain disorder that worsens over time causing memory loss and mental decline). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 9/12/2023, indicated Resident 1 was severely impaired with thought process and decision-making tasks. The MDS indicated Resident 1 required total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly notify the resident's physician of laboratory results that fall outside of clincal reference ranges for one of six sampled residents (Resident 1). This deficient practice had the potential for a delay in treatment and delivery of care and services for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admited the resident on 3/14/2012 with diagnoses including encounter for attention to gastrostomy (a feeding tube surgically inserted on the abdomen directly to stomach to provide nutritional needs), type ll diabetes mellitus (characterized by having high amounts of sugar in the blood), and Alzheimer ' s disease (brain disorder that worsens over time causing memory loss and mental decline). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 9/12/2023, indicated Resident 1 was severely impaired with thought process and decision-making tasks. The MDS indicated Resident 1 required total dependence from staff for transfers (moving…

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

Based on interview and record review, the facility failed to notify residents, resident ' s representatives, and families of suspected or confirmed COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) cases in the facility along with mitigating actions in a timely manner. This deficient practice resulted in residents, their representatives, and their families not receiving notifications regarding the status and impact of COVID-19 in the facility. Findings: During an interview on 10/30/2023 at 4:15 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated that on 10/15/2023, Registered Nurse 3 (RN 3) tested positive for COVID-19. The IPN stated that it is the Social Services staff responsibility to notify residents and resident representatives (RP) via telephone or email regarding COVID-19 cases in the facility. During an interview on 10/30/2023 at 4:21 p.m., with the Social Services (SS) staff, the SS staff stated that she is unable to provide documentation of the notification to all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an odor free and sanitary environment for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2022 with diagnoses that included diabetes mellitus (uncontrolled elevated blood sugar), encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), methicillin resistant staphylococcus aureus (MRSA- a type of bacteria that is resistant to several antibiotics [medication used to treat infection]), and respiratory failure (condition in which not enough oxygen passes the lungs into the blood). A review of Resident 1's History and Physical, dated 5/18/23, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and…

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

Based on observation, interview, and record review, the facility failed to ensure prompt attempts were made to resolve the grievance (an official statement of a complaint over something believed to be wrong or unfair) for one of three sampled residents (Resident 1). This deficient practice violated Resident 1's right to have his grievance addressed. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2022 with diagnoses that included diabetes mellitus (uncontrolled elevated blood sugar), encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), methicillin resistant staphylococcus aureus (MRSA- a type of bacteria that is resistant to several antibiotics [medication used to treat infection]), and respiratory failure (condition in which not enough oxygen passes the lungs into the blood). A review of Resident 1's History and Physical, dated 5/18/23, indicated the resident had capacity to understand and make decisions. 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.

Based on interview and record review the facility failed to ensure the resident 's safety for one out of three sampled residents (Resident 1) by failing to provide transportation to a medical appointment. The facility staff transported Resident 1 via wheel chair to the local General Acute Care Hospital (GACH 1). This deficient practice placed the resident at risk for injuries resulting from an accident. A review of Resident 1 ' s admission Records indicated the facility admitted the resident on 9/1/2023 with diagnosis that included sepsis (the body's extreme response to an infection) unspecified organism, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with other diabetic kidney complications, and acquired absence of left leg below knee. A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 9/7/2023 had the ability to understand and be understood. The MDS indicated Resident 1 required extensive assistance with bed mobility, toilet use and personal hygiene and was…

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

Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program by: 1. Failing to ensure a resident's oxygen tubing (used for oxygen delivery) was not touching the floor for one of eight (Resident 5) sampled residents. 2. Failing to ensure the Screener (SC) screened visitors for signs and symptoms of Coronavirus Disease 2019 (COVID-19, a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) prior to entering the facility. 3. Failing to ensure ice scoopers in Station 3 and Station 4 were kept in a closed container. These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents and increase the risk of spreading COVID-19 to residents and staff. Findings: 1. A review of Resident 5 ' s admission Record indicated the facility admitted Resident 5 on 7/19/2023, with diagnoses including sepsis (a body ' s extreme reaction 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.