Lincoln Meadows Care Center

Based on observation, interview, and record review, the facility did not follow and maintain an effective infection prevention and control program for one out of 19 sampled residents (Resident 5) when a visiting hospice staff did not wear the required personal protective equipment (PPE) during high-contact care for Resident 5, who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] by targeted gown and glove use).This failure increased the risk of cross contamination and exposed Resident 5 to germs and infection.Findings:A review of Resident 5's clinical record indicated that Resident 5 was admitted in December 2025 and had diagnoses including hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to disrupted blood flow) affecting the left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 call light system was functioning properly for 2 residents (Resident 1 and Resident 2) residing in room [ROOM NUMBER]. This failure had the potential to result in residents' needs not being met and prevent residents' communication for assistance when needed. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses which included displaced comminuted fracture of left patella (kneecap was broken into multiple pieces and pieces were not properly aligned). During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), the MDS indicated Resident 1 had moderate cognitive impairment. During a review of Resident 2 ' s AR, the AR indicated Resident 2 was admitted on [DATE] with diagnoses which included surgical aftercare following surgery on the digestive system. During a review of Resident 2 ' s MDS, the MDS 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, interviews, and record review, the facility failed to ensure the planned menu was followed for the therapeutic diets (modified diets from regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during lunch on 3/12/25 when: 1. 19 Residents (Resident (3, 4, 5, 7, 22, 29, 33, 35, 47, 52, 56, 63, 66, 68, 75, 79, 82, 291, and 341) with regular portion with regular texture diets got 6 ounces (oz.) (3/4 cup) of pasta instead of 4 oz. (1/2 cup) 2. 11 residents (Resident 19, 23, 24, 30, 32, 36, 44, 57, 60, 72, and 85) with CCHO (Consistent Carbohydrate) diet (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) and CCHO Renal (kidney) diet (a diet to manage chronic kidney disease and diabetic disease) got one serving of dessert (lemon snow bar) and 6 oz. of pasta instead of half (1/2) serving of dessert and 4 oz. of pasta 3. Four residents (Resident 9, 34, 76, and 340) with small portion with diets received one serving of dessert,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 food was prepared, stored, served, or distributed in accordance with professional standards of food serve in a safety manner when: 1. Various sizes of metal pans were found having issues stored in the clean and ready-to-use storage areas: - Stacked wet - Were not clean with food particles 2. The storage areas for storing the clean and ready-to-use metal pans were not clean 3. The blade of the can opener was not well maintained 4. Dietary Aide (DA) 1 was not able to verbalize the process of manual dishwashing by 2-compartment sink 5. DA 2 was not able to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas 6. DA 2 was not able to verbalize and demonstrate the correct procedure to prepare and test the sanitizer solution for the red bucket (red color-coded bucket is used as a standard of practice to contain sanitizer solution) 7. DA 3 did not have the hair restraint fully cover the hair 8. There were issues found for the resident's refrigerator: - Residents' food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 timely assistance with incontinence (a condition where a person experiences involuntary loss of urine or stool) care for four of 25 sampled residents (Resident 23, Resident 339, Resident 340, and Resident 60). This failure resulted in residents not attaining their highest practicable physical, psychosocial, and emotional well-being. Findings: During a review of Resident 23's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 23 was admitted [DATE] with diagnoses including fracture (a break or crack) of left femur (thigh bone). Resident 23's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/20/25, indicated Resident 23 had moderate cognitive impairment. Resident 23's self-care functional ability indicated, needed maximum assistance for toileting hygiene (helper does all the effort). The MDS indicated, he is always…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 Dietary Aide (DA) 1 and DA 2 had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. DA 1 was unable to verbalize the correct process of manual dishwashing with 2-compartment sink (cross refer to F812, #4); 2. DA 2 was unable to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas (cross refer to F812, #5), and 3. DA 2 was unable to verbalize and demonstrate the correct procedure for testing and proper temperature when preparing the sanitizer solution for the red bucket (red color-coded bucket is used as a standard of practice to contain sanitizer solution) (cross refer to F812, #6). These failures had the potential to place 88 out of 92 highly susceptible residents who consumed food from the facility at risk for food borne illness. Findings: 1. During an interview with DA 1 regarding the process of manual dishwashing by the 2-compartment sink on 3/11/25 at 8:57 a.m., DA 1 stated he would switch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 proper infection control practices were implemented when: 1. Oxygen tubing was on the floor for Resident 18, Resident 12 and Resident 36. 2. Resident 10's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was dragging on the floor while on the wheelchair. 3. Tube feeding formula was left uncapped and open to air while disconnected from Resident 45. These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses. Findings: 1. During a review of Resident 18's admission Record (AR), the AR indicated, Resident 18 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with acute exacerbation (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory failure with hypoxia (when lungs suddenly can't get enough oxygen into the blood) and asthma (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.

Based on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for one of 25 sampled residents (Resident 63), when the call light was not within reach. This failure had the potential to result in Resident 63 not attaining their highest practicable physical, psychosocial, and emotional well-being. Findings: During a review of Resident 63's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 63 was admitted to the facility in September 2023 with multiple diagnosis of muscle weakness, difficulty walking, and history of falling. During a review of Resident 63's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/12/24, the MDS indicated Resident 25 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on…

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

Based on observation, interview and record review, the facility failed to ensure one out of 25 sampled residents (Resident 58) received appropriate pain management services consistent with professional standards of practice and facility's policy and procedure (P&P) when Resident 58's pain was not managed during wound care treatment. This failure had the potential for Resident 58 not achieve relief from pain and not attain her highest practicable well-being. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted to the facility March 2024 with multiple diagnoses which included sacral pressure ulcer stage 3 (full-thickness loss of skin, dead and black tissue may be visible) and chronic pain. During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/5/25, the MDS indicated Resident 58's wound was documented as pressure ulcer Stage 4 (Full-thickness skin and tissue loss with exposed 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.

Based on observation, interview, and record review, the facility failed to follow proper infection control practices for one resident (Resident 1) out of four sampled residents when staff did not use proper personal protective equipment (PPE, specialized clothing or equipment worn for protection against infectious material) when they performed wound care on Resident 1. This failure had the potential to increase the spread of infection. Findings: Resident 1 was admitted to the facility in June of 2024 with diagnoses that included: chronic osteomyelitis (an infection of bone) to left radius and ulna (bones in the forearm) and bacteremia (presence of bacteria in the blood). During a review of Resident 1's Order Details (OD), dated 7/24, the OD indicated, Enhanced Barrier Precautions [EBP, extra precautions taken during high contact patient care] for: ADL's [activities of daily living], Hygiene, Toileting, Linen Change, Wound Care, Transferring/Repositioning. During a concurrent observation and interview on 10/1/24 at 10 a.m., with Licensed Nurse 1 (LN 1), LN 1 performed wound care 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 report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Survey Agency and local law enforcement, and the facility failed to report the results of all investigations to the State Survey Agency within five working days of the incident for one of four sampled residents (Resident 1). This failure had the potential to result in a delayed investigation. Findings: Resident 1 was admitted to the facility in September 2024 with medical diagnoses which included hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (when blood flow to the brain is blocked or reduced) affecting left dominant side and exhibiting facial weakness.A Brief Interview for Mental Status (BIMS, a cognitive screening tool used to assess a person's mental status) score showed 14 out of 15 (cognition intact). During a review of Resident 1's Grievance/Concern Form, dated 9/6/24, 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 1's) right was exercised timely when the resident's representative (RR) was not notified of Resident 1's change in condition and/or the resident's emergency transfer to a hospital. This failure resulted in RR feeling astounded and upset when the hospital contacted her regarding Resident 1's care. Findings: Review of Resident 1's clinical record, admission Record, indicated the resident was admitted to the facility with diagnoses that included memory problem with agitation and aphasia (loss of ability to understand or express speech). In the resident's admission Record, Resident 1's spouse was listed as the Emergency Contact #1 and also as his Responsible Party. In a telephone interview on 7/1/24 at 3:50 p.m., the RR stated that the facility did not notify her of her husband (Resident 1's) change in condition nor his hospital transfer to the emergency department on 6/12/24. The RR stated the hospital called her the following day and only then she knew her husband was in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide respiratory care services according to professional standards of quality for three of 23 sampled residents (Resident 39, Resident 240 and Resident 5), when: 1. Resident 39's and Resident 240's administered oxygen was not consistent with physician's order and care plan; and 2. Resident 5 was not provided with an incentive spirometer (a medical device used to help improve lung function) as ordered by the physician. These failures decreased the facility's potential to safely follow the physician's orders when providing respiratory services and increased the residents' risk of developing lung problems. Findings: 1. A review of Resident 39's admission Record, indicated Resident 39 was readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary (lung) disease (COPD, lung disease that blocks airflow and makes it difficult to breathe) and acute respiratory failure (when the lungs cannot get enough 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 observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents 6, 189 and 190) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications. Findings: Resident 6 had a physician's order for tramadol (a medication to treat pain) 50 milligrams (mg, a unit of measurement), 1 tablet orally every 12 hours as needed for moderate to severe pain, dated 5/19/23. The CDR indicated 1 tablet was signed out on 2/9/24 and 2/28/24. The February 2024 MAR did not indicate their respective…

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

Based on observation, interview, and record review, the facility had a 10.42% error rate when five medication errors out of 48 opportunities were observed during a medication pass for two out of five residents (Residents 5 and 189). This failure resulted in medications not given in accordance with the prescriber's orders, manufacturer specifications and potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 3/25/24 at 8:04 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed administering medications to Resident 5, including a Trelegy Ellipta (a medication to treat asthma) 200/62.5/25 microgram (mcg, a unit of measurement) inhaler. Resident 5 inhaled 1 puff from the inhaler then sipped and swallowed his orange juice. A review of the manufacturer's specifications for the use of Trelegy Ellipta dated 12/2022 indicated, Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water. During an interview on 3/25/24 at 11 a.m. with LN 1, LN 1 stated she normally instructed residents to rinse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 special eating utensil for one of 23 sampled residents (Resident 28), when Resident 28 was not provided with a rocker knife (a knife that can make it easier to cut food for one-handed individuals due to weakness or paralysis) during meals. This failure decreased the facility's potential to provide adaptive utensils designed to meet the clients' nutritional needs. Findings: A review of Resident 28's admission Record, indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including left side hemiplegia (paralysis of one side of body), muscle weakness, and lack of coordination. A review of Resident 28's Minimum Data Set (MDS; an assessment tool), dated 12/30/23, indicated Brief Interview of Mental Status (BIMS) score was eight of 15 with some memory problems. MDS further indicated Resident 28 needed setup or clean-up assistance when eating. During an observation on 3/25/24 at 12:29 p.m. in the facility's dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 store food in a sanitary manner for a census of 90 when: 1. Dietary staff did not use hair nets and/or beard guards while in the kitchen; 2. Several food items were opened and not dated with their open date and expired food items were in the reach-in refrigerator and dry storage; and, 3. Expired left-over roast beef with used by date 3/26/24 was available to use on 3/27/24. These failures had the potential to result in foodborne illness. Findings: 1. During a concurrent observation and interview on 3/25/24 at 7:45 a.m., the Dietary Aid (DA) was in the kitchen and was not wearing a hairnet. Later, the Kitchen Dietary Manager (KDM) entered the kitchen and was not wearing a hair net and beard guard. KDM confirmed hair net and beard guards are required while in the kitchen. Review of the facility's policy titled, Dress Code, dated 2023, indicated, Hair net for hair . beard and mustaches (any facial hair) must wear beard restraint. 2. During an observation in the reach-in refrigerator and dry storage on 3/25/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 practices when: 1. Dietary [NAME] 1 (DC1) did not perform proper hand hygiene practice while in the kitchen for a census of 90; and, 2. Licensed Nurse 5 (LN 5) did not change gloves and perform hand hygiene during wound care for one of 23 sampled residents (Resident 140). These failures had the potential to spread infection in the facility. Findings: 1. During a concurrent observation in the kitchen and interview on 3/25/24 at 8 a.m., the DC1 entered the kitchen and performed hands washing and then pat drying using her clothes. Then DC1 washed her hands again without using hand soap, scrubbing hands less than 20 seconds. DC1 confirmed she should have washed hands with soap and water and dried with towels. During an interview on 3/27/24 at 3:14 p.m. with Food Service Efficiency Consultant (FSEC), FSEC confirmed staff must perform hand washing before providing food services. 2. According to the admission Record, Resident 140 was admitted to the facility in 2024 with diagnoses including…

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

Based on observation, interview, and record review, the facility failed to ensure self-administered medications kept at bedside for one of 23 sampled residents (Resident 189) were reviewed and approved by the physician. This failure had the potential for unsafe medication use, exposure to unwanted side effects and duplication of therapy. Findings: During an observation on 3/25/24 at 9:07 a.m. with Licensed Nurse 4 (LN 4), LN 4 was observed administering medications to Resident 189. To the left of Resident 189's bed was an albuterol (a medication to treat asthma) inhaler, without a pharmacy label, on a bedside table. Resident 189 stated she had been using the inhaler to help her breathe, but it was not providing her relief. She stated she had brought the inhaler with her to the facility from the hospital. During a concurrent interview and record review on 3/25/24 at 11:24 a.m. with LN 4, Resident 189's physician's orders were reviewed. LN 4 confirmed Resident 189 did not have an order for albuterol or an order that allowed the resident to self-administer medications. LN 4 stated 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 resident's respect and quality of care were maintained for one of 23 sampled residents (Resident 62) when Resident 62 was not able to reach for the call light. This failure had the potential to increase the residents' fear of not able to reach for the call light when needing assistance. Findings: According to the admission Record, Resident 62 was admitted to the facility in 2024 with diagnoses including asthma and left lower limb infection. During a concurrent observation and interview on 3/25/24 at 9:30 a.m. in Resident 62's room, Resident 62 reported she was not able to reach for the call light while in her wheelchair. The call light was located on the other side of Resident 62's bed. During an interview on 3/28/24 at 9:11 a.m., the Director of Nursing (DON) confirmed the call light should have been within reach of the resident. Review of the facility's policy titled, Answering the Call Light, dated 12/2022, indicated, When the resident is in bed or confined to a chair be sure the call light is…

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

Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for one of 23 sampled residents (Resident 37), when Resident 37's room was disorderly and cluttered with personal bags and boxes. This failure decreased the facility's potential to ensure residents' autonomy when using their personal belongings. Findings: A review of Resident 37's admission Record, indicated Resident 37 was readmitted from hospital to the facility on 2/13/24 with diagnoses including urinary tract infection, major depressive disorder, and paraplegia (paralysis of the legs and lower body). A review of Resident 37's Minimum Data Set (MDS; an assessment tool), dated 1/6/24, indicated Brief Interview of Mental Status (BIMS, a cognitive assessment tool) score was 15 of 15 with good memory. MDS further indicated Resident 37 had impairment on bilateral lower extremities, used a wheelchair, and was dependent in transfer to and from bed to a chair or wheelchair. During a concurrent observation and interview on 3/25/24 at 9:59 a.m. with Resident 37 in her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 Minimum Data Set (MDS, an assessment tool used to guide care) was accurate for three of 23 sampled residents (Resident 70, Resident 64 and Resident 88) when: 1. Resident 70's impaired vision was not reflected in his most recent quarterly MDS assessment; 2. Resident 64's MDS indicated she had no feeding tube; and, 3. Resident 88 was discharged to home and MDS indicated hospitalization. These failures had the potential for residents to not receive appropriate care and interventions. Findings: 1. A review of an admission record indicated Resident 70 was admitted to the facility in June 2023 with diagnoses including adjustment disorder with mixed anxiety and depressed mood. During an initial screening on 3/25/24 at 10:43 a.m. inside Resident 70's room, Resident 70 was observed lying in bed squinting while watching television and a pair of eyeglasses was on top of the table. Resident 70 stated the reading glasses were from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and provide the baseline care plan (BCP) and written summary for one of 23 sampled residents (Resident 240) within 48 hours after admission. This failure decreased the facility's potential to address the residents' initial goals and current health needs. Findings: A review of Resident 240's admission Record, indicated Resident 240 was admitted to the facility on [DATE]. A review of Resident 240's Baseline Care Plan Person-Centered Care Planning, indicated BCP was completed on 3/19/24. BCP further indicated a printed summary was not provided to Resident 240 or her representative. During an interview on 3/26/24 at 2:14 p.m. with Director of Nursing (DON), DON confirmed Resident 240's BCP was not completed within 48 hours of admission and stated it should have been done within 48 hours because there was a potential that nurses will not have a quick tool to identify what the resident's specific focus areas are that guide their provision 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 develop a comprehensive person-centered care plan for one of 23 sampled residents (Resident 5), when Resident 5's care plan did not address the use of an incentive spirometer (a hand held device that helps people take slow, deep breaths) and compression stockings as ordered. This failure had the potential for the order to be missed and not implemented. Findings: A review of Resident 5's medical records indicated he was admitted in May 2022 with diagnoses including pulmonary dysfunction due to Chronic Obstructive Pulmonary Disease (COPD, lung disease causing restricted airflow and breathing problems) exacerbation. A review of Resident 5's Order Summary Report, for March 2024, indicated a physician's order, dated 3/17/24, for the use of an incentive spirometer three times a day for 10 days which also placed him on a respiratory program to improve lung function. A review of Resident 5's Order Summary Report, dated 2/22/24, indicated an order for Resident…

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

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of five sampled residents (Resident 189) when nursing staff failed to expel air from a syringe to ensure the full dose of heparin (a medication to treat and prevent blood clots) was administered. This failure resulted in Resident 189 receiving an incorrect dose of heparin and potential for developing blood clots leading to complications of their clinical condition. Findings: During a medication pass observation on 3/25/24 at 9:07 a.m. with Licensed Nurse 4 (LN 4), LN 4 was observed preparing ten medications for Resident 189, including heparin 5000 units/milliliter (u/ml, a unit of measurement). She withdrew medication and pulled the plunger back to the 1 milliliter (ml, a unit of measurement) measurement marker. She held the syringe up and a large bubble was observed in the syringe. The heparin in the syringe was at the 0.88 ml measurement marker with the bubble on top. LN 4 confirmed she had finished preparing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 assist one of 23 sampled residents (Resident 70) with the arrangement of an eye doctor consultation. This failure had the potential for a delayed delivery of care to help improve Resident 70's vision. Findings: A review of an admission record indicated Resident 70 was admitted to the facility in June 2023 with diagnoses including adjustment disorder with mixed anxiety and depressed mood (having emotional or behavioral symptoms within 3 months of a stressful event, including nervousness, worry, feeling sad, tearful, and hopeless). During an initial screening on 3/25/24 at 10:43 a.m. inside Resident 70's room, Resident 70 was observed lying in bed squinting while watching television and a pair of eyeglasses was on top of the table. Resident 70 stated the reading glasses were from the Activities Director and they gave him headaches whenever he used them. Resident 70 added he already told the staff he needed to see an eye doctor but he had not seen one yet. A review of a social services note, dated 8/7/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 a physician treatment order for a stage 4 pressure ulcer (injury to skin and underlying tissue, exposing the tendon or bone) for one of 23 sampled residents (Resident 140) when staff did not follow the treatment order for the left posterior leg as physician prescribed. This failure had the potential for the resident's current pressure ulcers to worsen. Findings: According to the admission Record, Resident 140 was admitted to the facility in 2024 with diagnoses including diabetes (issues regulating blood sugars; can delay wound healing) and stage 4 pressure ulcer. Review of the Order Summary Report, dated 3/28/24, indicated Resident 140 had a treatment order: stage 4 pressure injury (ulcer) to the left posterior leg, to cleanse with normal saline, pat dry, apply collagen, hydroferra blue (a powerful antibacterial wound dressing), triad (a cream to create a sterile coating for wound management) to the margin and silicone border foam dressing with skin prep (a wipe to protect the skin) to adhesive exposed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 the proper checking of a roam signal device (a device that allows sensors on doors to alarm to keep track of wandering residents) for one of 23 sampled residents (Resident 56) when Licensed Nurses (LNs) took Resident 56 near a door to test its transmitter. This failure placed Resident 56 at an increased risk for elopement. Findings: A review of Resident 56's admission record indicated he was admitted in June 2022 with diagnoses including paranoid schizophrenia (mental illness with persistent false beliefs) and Alzheimer's disease (brain disorder that destroys memory, thinking skills, and the ability to carry out simplest task). During an initial screening on 3/25/24 at 11:28 a.m. inside Resident 56's room, observed Resident 56 wearing an alarm device to his left ankle while propelling himself out of the room towards the dining room to eat lunch. A review of an Order Summary Report, dated 12/15/23, indicated Resident 56 was ordered to use a roam signal device for exit seeking behavior. The 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 observation, interview, and record review, the facility failed to implement fluid restriction orders for two of 23 sampled residents (Resident 139 and 77) when Resident 139's and Resident 77's water pitchers were at the bedside while on fluid restriction order. This failure had the potential for Resident 139 and Resident 77 not maintaining acceptable parameters of fluid intake. Findings: According to the admission Record, Resident 139 was admitted to the facility in 2024 with diagnoses including heart failure. Resident 139 was his own responsible party. Review of the Order Summary Report, dated 3/26/24, indicated Resident 139 had a fluid restriction 1500 milliliters (ml, a unit of measurement) daily. During an observation on 3/25/24 at 11:03 a.m. in Resident 139's room, Resident 139 confirmed the water pitcher was at the bedside. During a concurrent observation and interview on 3/26/24 at 8:46 a.m., Certified Nursing Assistant 1 (CNA 1) confirmed the water pitcher was on Resident 139's bedside table. According to the admission Record, Resident 77 was admitted 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.

Based on observation, interview, and record review, the facility failed to ensure the routine care practice and dressing change of the midline catheter (midline-a soft, long, and sterile tube inserted into a large vein in upper arm and used for administering medications into the bloodstream) for one of 23 sampled residents (Resident 76). This failure had the potential to result in serious blood stream infections causing hospitalization, organ failure, or death. Findings: During a concurrent observation and interview on 3/25/24 at 8:50 a.m. with Licensed Nurse (LN) 4, Resident 76 had a midline catheter with dressing dated 3/4/24 at 5 p.m. LN 4 stated the dressing should have been changed. A review of Resident 76's Physician's Orders, dated 3/4/24, indicated to insert a midline catheter for intravenous antibiotics treatment. A review of nurse's notes dated 3/4/24, the nurse's notes indicated, .a midline insertion at left upper arm . Sterile dressing applied. During a concurrent interview and record review on 3/28/2024 at 3:30 p.m. with Director of Nursing (DON), the Resident 76'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 medications were not stored on top of medication carts (med carts) when left unattended. The deficient practice had the potential for diversion or misuse of medications from not being stored securely. Findings: During an observation on 3/26/24 at 9:46 a.m. with Licensed Nurse 7 (LN 7), LN 7 was observed preparing medications at the med cart stationed in the hallway. LN 7 left the med cart in the hallway to attempt to locate a medication that was not inside the med cart. On top of the med cart was a bubble pack (a packaging system from the pharmacy for unit dosing medication) containing six hyoscyamine (a medication to treat excessive oral secretions) 0.125 milligram tablets. During an interview on 3/26/24 at 10:03 a.m. with LN 7, LN 7 confirmed the bubble pack that was left unattended on the med cart contained medication and was not securely stored when she had stepped away. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated April 2023, the P&P…

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

Based on observation, interview, and record review, the facility failed to ensure the competency of Food and Nutrition Services staff when: 1. Dietary [NAME] 1 (DC1) did not correctly know cooling down process; and, 2. DC1 did not know pureed consistency, did not use measurable tools/utensils, and did not use a recipe for pureed beef, vegetable, and starch. These failures to ensure staff competency for food related tasks had the potential to cause contamination of food and provide pureed food to residents with an inappropriate consistency for medical needs resulting in choking for 88 residents who received food from the kitchen out of a census of 90. Findings: 1. During an initial tour observation of the kitchen on 3/25/24 at 7:56 a.m. with Kitchen Dietary Manager (KDM), the KDM confirmed there were two pans of turkeys cooking in the oven for 3/26/24 lunch. Review the Cool Down Log, dated 3/25/24, indicated the turkey cooling down process was completed at 8 a.m. During a concurrent interview and record review of the cooling down log on 3/25/24 at 8 a.m. with DC1 and KDM, both staff…

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

Based on observation, interview, and record review, the facility failed to prepare food in a manner to conserve nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, pureed vegetable, and pureed starch. This failure had the potential to decrease the nutrients in food served and decrease food intake for five residents who received a pureed diet out of a facility census of 90. Findings: Review of the menu served for lunch on 3/27/24 and titled, Spring Cycle Menus indicated residents with a Regular texture diet received BBQ beef roast, sweet potatoes, fresh zucchini and carrots, and cheddar biscuit. Residents that were prescribed a pureed diet received pureed BBQ beef roast, sweet potatoes, fresh zucchini and carrots, and cheddar biscuit. During a concurrent observation and interview on 3/27/24 at 9:18 a.m., Dietary [NAME] 1 (DC1) was pureeing beef, she used two hands to put 2 and a half hand-fulls of beef into the blender. Then she added one pitcher (about 24 oz) of beef broth into the blender to mix and blend. There was no recipe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 resident needs were accommodated for one of three sampled residents (Resident 17), when the call light was not answered. This failure had the potential to result in the resident not attaining his highest practicable physical, psychosocial and emotional well-being. Findings: Resident 1 was admitted to the facility in early 2024 with diagnoses which included paraplegia (paralysis of the legs and lower body), pressure sores of both heels, and muscle weakness. During a review of Resident 1's Admission/readmission Evaluation/Assessment (A/RE/A), dated 1/3/24, the A/RE/A indicated Resident 1 had no memory impairment, had paralysis, and needed assistance with activities of daily living (ADLs). During a review of Resident 1's Nursing Care Plan (NCP), dated 1/10/24, the NCP indicated, ADL/Mobility .Interdisciplinary team .has established a goal for Functional Abilities and Goals based on Prior Level of Functioning .chair/bed-to-chair transfer, eating, lower body dressing, lying to sitting on side of bed .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 demonstrated competency when one of four sampled resident's (Resident 1), urine sample was not able to be processed due to incomplete documentation of the sample collection. This failure resulted in delay in treatment of Resident 1's urinary tract infection. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in May 2023 with multiple diagnoses including fracture of right ulna (forearm bone) and right humerus, (upper arm bone), diabetes (too much sugar in the blood), and retention of urine (bladder does not empty all the way during urination). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 5/13/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated she was cognitively intact. A review of Resident 1's MDS, Bowel and Bladder, dated 5/13/23, indicated Resident 1 had an indwelling foley catheter (tube placed in the bladder…

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