Arbor Rehabilitation & Nursing Center

Based on observation, interview, and record review, the facility failed to ensure infection control measures were used to prevent the spread of germs for a census of 128 when the oxygen nasal cannula (a flexible plastic tube connected to an oxygen source with two prongs that fit in the nostrils used to provide extra oxygen through the nose) was not placed in an antimicrobial bag (a bag that reduces the growth of germs on the nasal cannula) as ordered for Resident 134.This failure had the potential to result in the spread of germs and the need for additional medical interventions (medications and/or treatments).Findings: A review of Resident 134's admission Record indicated that Resident 134 was admitted to the facility in 2019 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a long-term disease that cause airflow blockage, breathing related problems, shortness of breath and cough).During an observation and concurrent interview with Resident 134 in her room on 1/8/26 at 9:12 a.m., Resident 134 pointed to her walker and stated that she asked facility 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 Based on interview, and record review, the facility failed to follow their policy and procedure for the pneumococcal (a serious bacterial infection that can cause respiratory illness) immunization for two out of five sampled residents (for immunization review) when: 1. Resident 31's pneumonia vaccine was not documented; and,2. Resident 86's pneumococcal vaccine was not given after being admitted to the facility.These failures had the potential for Resident 31 and Resident 86 to be at risk to be infected with the pneumococcal virus that could lead to severe illness, hospitalization, and/or death.Findings:a. A review of Resident 31's admission RECORD, indicated Resident 31 was admitted on [DATE].b. A review of Resident 86's admission RECORD, indicated Resident 86 was admitted on [DATE].During a concurrent interview and record review on 1/8/26, at 10:27 AM, with the Infection Preventionist (IP), Resident 31 and Resident 86's electronic health record (EHR) were reviewed. The IP stated Resident 31 received pneumonia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 their surveillance plan (oversight plan to prevent the spread of infection) for scabies (an infection that causes an itchy skin rash when mites [tiny insects] burrow under the skin) prevention and control for one of four sampled residents (Resident 1) when, the Infection Preventionist (IP) did not implement the required six-week contact identification list and failed to train and notify all key healthcare personnels on how to recognize and report signs and symptoms consistent with scabies infestation.These failures had the potential to result in continued transmission of scabies among staff and residents within the facility. Findings:During a review of Resident 1's clinical record titled, admission Record, the record indicated Resident 1 was admitted to the facility in 2020 with a diagnosis which included respiratory failure. A review of Resident 1's clinical record titled, Order Summary, dated 8/26/25 at 11:33 AM, indicated the medical provider ordered permethrin cream (medicine that kills mites) and Ivermectin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 failed to implement a comprehensive care plan (a guide that healthcare workers used to ensure residents receive tailored care to meet individual needs and goals) for one of four sampled residents (Resident 1) when Resident 1 did not have water available within reach.This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions).Findings:During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with a diagnosis of dehydration, acute kidney failure (when the kidneys suddenly stop working well and can't clean waste from your blood, balance fluids, or regulate electrolytes), and essential hypertension (high blood pressure- which can damage kidneys). A record review of Resident 1's clinical record titled, Minimum Data Set (MDS, an assessment tool used to generate a plan of care) . Section GG - functional status, dated 11/5/25, indicated…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 1) hydration requirements were met when Resident 1 did not have water available within reach.This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions) and could have led to illness or kidney injury. Findings:During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with a diagnosis of dehydration, acute kidney failure (when your kidneys suddenly stop working well and can't clean waste from your blood, balance fluids, or regulate electrolytes), and essential hypertension (high blood pressure- which can damage kidneys). A record review of Resident 1's clinical record titled, Minimum Data Set (MDS, an assessment tool used to plan care) . Section GG - functional status, dated 11/5/25, indicated Resident 1 had impairment on one side of upper extremity (shoulder,…

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

Based on observation, interview, and record review, the facility failed to maintain a safe and supervised environment to prevent accidents and hazards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when: 1a. Resident 1 was moved, prior to being assessed, following Resident 1's fall on 3/16/25; b. Resident 1's physician was not notified of Resident 1's blurred vision, on 3/17/25, following a fall on 3/16/25, resulting in a 5-day delay in treatment; 2. Resident 2's clinical documentation was incomplete for a fall on 3/23/25; 3a. Resident 3's clinical documentation was incomplete for a fall on 3/31/25; and, b. Resident 3's care plan interventions to prevent falls were not followed on 5/1/25. These failures resulted in delayed treatment for Resident 1, the potential for Resident 1 to experience further injuries following Resident 1's fall, and had the potential for Resident 1, Resident 2, and Resident 3 to experience falls, negatively affecting their health and well-being. Findings: 1a. During an interview with licensed nurse (LN) 2, on 5/2/25, at 2:20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, management and administration of pain relieving medication, (including a narcotic [a drug that could have induced sleep, stupor, or a state of insensitivity to pain]), was done according to professional standards of practice and the narcotic pain medication did not have pain level parameters in place (pain level parameter are assessed using the numeric pain assessment tool: 0=no pain and 10=the worst pain) associated with the narcotic medication order. These failures resulted in Resident 1 not receiving the appropriate type of pain medication for the assessed pain level. Findings: A review of Resident 1's clinical document titled, admission RECORD, indicated Resident 1 was admitted to the facility with multiple rib fractures on the left side of his ribcage. A review of Resident 1's clinical document titled, Care Plan Report, (contained focus, goals and interventions that addressed Resident 1's pain) dated 3/7/25, indicated, Focus . The resident has acute pain r/t…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 treated with dignity and respect when Resident 1's request to use the bathroom was denied. This failure had the potential to negatively impact Resident 1's psychosocial well-being. Findings: A review of Resident 1's clinical document titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included muscle weakness and multiple fractures of ribs on the left side of the ribcage. A review of Resident 1's clinical document titled, Care Plan Report, (contains goals and interventions for Resident 1), dated 3/6/25, indicated, . Toilet upon rising and before or after meals at bedtime and PRN [as needed] as tolerated . During an interview on 5/6/25, at 8:38 a.m., Certified Nursing Assistant (CNA) 3 stated following Resident 1 ' s fall, on 3/16/25, Resident 1 stated she needed to go to the bathroom. CNA 3 explained she had informed Resident 1 that she was wearing a brief (incontinence brief - disposable undergarment designed to absorb…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 Responsible Party (RP - person responsible for making healthcare and medical decisions) was informed and consented to the use of psychotropic (drugs that affect a person's mind, emotions, and behavior) medications for Resident 1 when, the facility had Resident 1 sign the informed consent for psychotropic medications instead of Resident 1's RP. This failure resulted in Resident 1 receiving the psychotropic medication quetiapine (used to manage symptoms of various mental health condition) for four days. This failure also resulted in the use of the medication escitalopram (used to treat depression) for the entirety of Resident 1's stay at the facility, without having an informed consent in place, potentially negatively affecting Resident 1's psychosocial health and physical well-being. Findings: A review of Resident 1's clinical document titled, admission RECORD (a document that contained Resident 1's demographic information), indicated Resident 1 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 interview and record review, the facility failed to notify Resident 1's Responsible Party (RP - responsible for making medical and healthcare decisions) when Resident 1 fell on 3/16/25. This failure had the potential for Resident 1's necessary and/or preferred medical decisions to be delayed, which could have negatively affected Resident 1's health and well-being. Findings: A review of Resident 1's clinical document titled, admission RECORD (a document that contained Resident 1's demographic information), indicated Resident 1 was admitted to the facility with a diagnoses which included multiple rib fractures on Resident 1's left side of the ribcage. A review of Resident 1's clinical document titled, SBAR [SBAR - Situation, Background, Assessment, and Recommendation - A structured communication tool to relay critical information] Fall Report of Incident . , dated 3/16/25, indicated, . Responsible Party Notified . Self RP . During an interview with licensed nurse (LN) 2, on 5/2/25, at 2:20 p.m., LN 2 confirmed he documented Resident 1 was her own RP, and did notify Resident…

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

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1), was free from unnecessary medications when Resident 1 received the psychotropic (drugs that affect a person's mind, emotions, and behavior) medication quetiapine (used to treat episodes of mania [frenzied, abnormally excited or irritated mood]) or (bipolar disorder - could cause episodes of depression, episodes of mania, and other abnormal moods) without having an accurate diagnosis and indications for use of the medication quetiapine. These failures resulted in Resident 1 receiving the medication quetiapine for four days, potentially negatively affecting Resident 1's health and well-being. Finding: A review of Resident 1's clinical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included depression. A review of Resident 1's clinical document titled, Medication Administration Record, (MAR – a document that contained physician's orders and dates and times of medication administration) dated 3/1/25 through 3/31/25, 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) received care in accordance with professional standards of practice when: 1. Resident 1's blood pressure (BP - the measurement of the pressure in the arteries when the heart contracts and pumps blood through the body) medication (Losartan) was administered without parameters (measurable factors or specific values that are used to assess a resident's health or the effectiveness of a treatment) listed on the order that would have indicated when to not administer the medication, and the order was not clarified with the medical doctor (MD) to not administer the medication if the BP reading or heart rate was too low (a measure of how fast the heart is pumping blood throughout the body); and, 2. Resident 1 had high blood pressure readings on 3/10/25 of 173/56 during the morning shift and 168/60 during the night shift (normal BP reading is 120/80), and the MD was not notified. These failures could have resulted in Resident 1 inappropriately receiving BP medication and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a safe and effective transition of care after discharge from the facility for Resident 1 when Resident 1 was transferred to a room and board facility (where basic living needs are provided such as meals and housing) that was unable to provide for her care needs. This failure caused Resident 1 to be immediately transferred to the local emergency department from the room and board facility and to spend 26 days in the hospital pending appropriate placement. This failure further had the potential to negatively impact Resident 1 ' s health and psychosocial wellbeing. Findings: A review of Resident 1 ' s admission RECORD, indicated she was admitted to the facility in fall of 2022 with diagnoses which included morbid obesity (weight greater than 100 pounds over ideal body weight), repeated falls, and weakness. A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 readmit Resident 1 when she was transferred to a local emergency department after an unsafe discharge to a room and board facility (where basic living needs are provided such as meals and housing) that could not accommodate her care needs. This failure put Resident 1 at risk of psychosocial harm and negative health outcomes. Findings: A review of Resident 1 ' s admission RECORD, indicated she was admitted to the facility in fall of 2022 with diagnoses which included morbid obesity (weight greater than 100 pounds over ideal body weight), repeated falls, and weakness. A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section GG – Functional Abilities, dated 10/5/24, indicated, The code 02. Substantial/maximal assistance- Helper does MORE THAN HALF the effort for the following care areas: Toileting hygiene: The ability to maintain perineal hygiene [wiping or cleaning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility failed to ensure: 1. Expired medical supplies were removed from the medication storage room, and 2. Medication carts were maintained clean and in an orderly manner. These failures had the potential for accidental use of expired supplies and for drug diversion for a census of 124. Findings: 1. During the medication storage room check on [DATE] starting at 2:35 p.m. in the North Station with the Licensed Nurse (LN 4), an expired Mic-Key continuous feed extension set (a feeding tube extension) was stored in the medication room available for use. The expiration date was [DATE]. There were Covid-19/Flu test kits also stored in the bag with the expiration date of [DATE]. LN 4 verified the expiration dates of the medical supplies and stated they should have been discarded. Review of the facility's [DATE] revised policy and procedure, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, stipulated, Facility should ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 professional standards for food service safety when Quat (Quaternary Ammonium, a sanitizer) strips (measure the concentration of sanitizer) currently being used were expired. This failure increased the risk for food borne illness for the residents that consumed facility prepared meals in a total facility census of 124. Findings: During an initial tour observation of the kitchen on 8/19/24 at 8:38 a.m. with the Dietary Manager (DM), DM was asked to check the sanitizer level of the Quat solution used to sanitize surfaces in the kitchen. The bucket was tested at 150 ppm (parts per million, a measurement) and then the DM was asked for the expiration date on the strips. The DM verified the Quat strips expired 5/15/24. During a concurrent interview, the DM was asked his expectations regarding the checking of expiratory dates of the sanitizer strips and said, I expect the date should be checked frequently enough that they are not expired. During an interview on 8/20/24 at 10:43 a.m. with the Registered…

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

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for of census of 124 residents when: 1. Resident 1's nasal cannula (thin, flexible tube with two prongs that fit into the patient's nostrils and is attached to an oxygen source), and tubing were laying on top of the oxygen condenser (a medical device that takes air from the surroundings, extracts oxygen and filters it into purified oxygen); 2. Hand hygiene was not practiced during the meal service; 3. Resident 72's urinary bag touched the floor; 4. PPE (Personal Protective Equipment) was not donned for Resident 38; and 5. Linen cart was not covered, and Laundry Aide's (LA) uniform touched the clean personal clothes of the residents while hanging them. These deficient practices had the potential to spread infection and disease among residents, staff, and visitors. Findings: 1. Resident 116 was 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.

Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 72's) dignity was protected when the urine drainage bag was exposed to public view. This failure resulted in Resident 72 feeling embarrassed. Findings: Review of Resident 72's admission RECORD, indicated the resident was admitted to the facility recently with diagnoses that included prostate gland enlargement that could cause urination difficulty. In a concurrent observation and interview on 8/19/24 at 8:58 a.m. in the resident's room, Resident 72 was in bed with his urine drainage bag hanging at the side of the bed facing toward the hallway. The door of the resident's room was wide open. The urine drainage bag contained yellow urine, was exposed, and visible from the hallway. Infection Preventionist (IP) verified Resident 72's urine drainage bag was exposed and stated it should have been covered with the dignity bag to protect the resident's dignity. In an interview on 8/21/24 at 12:07 p.m. in the Director of Nursing (DON's) room, the DON acknowledged, in the…

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

Based on observation, interview and record review, the facility failed to accommodate resident needs when call lights were inaccessible for three of 26 sampled residents. A. Resident 479 B. Resident 65 C. Resident 1 This failure prevented the residents from getting help as quickly as possible when experiencing pain, discomfort or for any emergency needs. Findings: A. Resident 479 was admitted to the facility in the summer of 2024 with diagnoses which included multiple fractures, repeated falls and need for assistance with personal care. During a review of Resident 479's Progress Notes [PO], dated 8/14/24, the PO indicated, admitted to [name of hospital] hospital for recurrent ground-level falls. It appears .possibly precipitated by orthostatic hypotension and syncope [a sudden drop in blood pressure when standing up from a seated or lying position] .now admitted to SNF for rehabilitation .Plan .Implement fall prevention strategies . During a review of Resident 479's Care Plan titled, At risk for falls and injuries r/t [related to] .Medications .Hx [history of] repeated falls, 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 implement a care plan for one of 26 sampled residents (Resident 120) when the care plan for fall interventions was not carried out. This failure had the increased potential for injury should Resident 120 fall again. Findings: Review of Resident 120's admission RECORD, indicated the resident was admitted to the facility recently with diagnoses that included right side paralysis, generalized muscle weakness and other abnormalities of gait and mobility. Review of Resident 120's medical records, a care plan, created on 7/11/24, indicated the resident was identified at risk for falls and injury related to medications, stroke, and a heart problem. The care plan set goals to minimize and manage risk for falls with interventions including fall mats on sides of bed implemented on 8/5/24. Review of Resident 120's medical records, SBAR [Situation, Background, Assessment, Recommendation, a medical communication framework] fall Report of Incident 8hr - V3, created on 8/3/24, indicated the resident had an actual fall,…

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

Based on observation, interview and record review, the facility failed to meet the professional standards of practice of nursing for one of 26 sampled residents (Resident 20) when a medication was not administered as ordered. This failure had the potential for ineffective medication therapy for Resident 20. Findings: Review of Resident 20's medical record, admission RECORD, indicated the resident was admitted to the facility recently with the diagnoses that included chronic lymphocytic leukemia, a type of cancer of the blood and bone marrow. A medication administration observation was conducted on 8/20/24 at 9:20 a.m. for Resident 20 by Licensed Nurse (LN 2). The medication administration by LN 2 was reconciled with Resident 20's medication orders and noted that the resident had a physician order, dated 4/5/24, for Ferrous Sulfate 325(65 Fe, a mineral) mg (milligram, a unit of measurement) 1 tablet daily that was not administered during the medication administration. In an interview on 8/20/24 at 2:17 p.m., LN 2 verified Resident 20 had the physician order for Ferrous Sulfate 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 nail care was provided for one of 26 sampled residents (Resident 96). This failure had the potential for Resident 96 to sustain injury, neglected personal grooming and infection. Findings: A review of Resident 96's admission Record indicated Resident 96 was admitted in the facility on 9/22/23, with the diagnosis that included Type 2 Diabetes Mellitus (high blood sugar), gout (painful form of arthritis), sepsis (infection), and muscle weakness. A review of Resident 96's Minimum Data Set (MDS-tool used to direct care), Brief Interview for Mental Status (BIMS, evaluates mental impairment] Section C - Cognitive Patterns, dated 6/12/24, showed Resident 96's cognition is intact with a score of 15. Section E - Behavior, dated 6/12/24, indicated, Resident 96 did not have a history of rejecting care. During a concurrent observation and interview on 8/19/24 at 10:10 a.m., with Resident 96 inside his room, Resident 96 was observed with contracted right hand, the skin was dry and peeling, his index, middle and…

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

Based on observation, interview and record review, the facility failed to provide meaningful ongoing activities for one of 26 sampled residents (Resident 120). This failure caused the resident to feel trapped. Findings: Review of Resident 120's admission RECORD, indicated the resident was admitted to the facility recently with diagnoses that included right sided paralysis, heart and lung problems. In an observation on 8/19/24 at 9:36 a.m. in Resident 120's room, the resident was lying in bed with the TV on. The resident stated his right side of the body was paralyzed and wanted to do something to get it stronger, but showers were pretty much the only time he got out of bed. The resident complained he spent his day watching TV because the facility did not get him up and put him in the wheelchair. Resident 120 stated he liked to attend group activities. There were no books, magazines, crossword puzzles or any other activity materials visible in the room. The resident stated, they come out once in a while and went away when asked if the activities provided room visits. The resident…

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

Based on observation, interview and record review, the facility failed to supply medication for one of 26 sampled residents (Resident 20) when ferrous sulfate, an iron supplement, was not available for administration. This failure resulted in Resident 20 not receiving the mineral supplement for five days. Findings: Review of Resident 20's medical record, admission RECORD, indicated the resident was admitted to the facility recently with the diagnoses that included chronic lymphocytic leukemia, a type of cancer of the blood and bone marrow. Review of Resident 20's medical record included a physician order, dated 4/5/24, for ferrous sulfate 325(65 Fe, a mineral) mg (milligram, a unit of measurement) 1 tablet every day. During the medication administration observation on 8/20/24 starting at 9:20 a.m., Licensed Nurse (LN 2) did not administer ferrous sulfate. Review of Resident 20's laboratory reports dated 5/14/24 and 5/18/24, indicated the resident's red blood cell counts were low at 3.81 and 3.83 (normal reference range: 3.93-5.22 millions/microLiter, a unit of measurement)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, clinical record and policy and procedure review, the facility failed to ensure wound care teaching was done in preparation for discharge for 1 of 2 sampled residents (Resident 1) when the wound nurses were not aware of the discharge plan and the discharge paperwork did not include wound care instructions. This failure had the risk potential for deterioration of the wounds upon discharge. Additionally, Resident 1 was reported to have been admitted to the hospital with wound infection. Findings: According to the 'admission Record,' the facility admitted Resident 1 on 9/19/23, with multiple diagnoses which included, diabetes, pneumonia, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors, stiffness or slowing movement), heart failure, muscle weakness among other comorbidities (medical issues). Resident 1's Minimum Data Set (MDS, an assessment tool), dated 9/25/23, indicated he was totally dependent 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, clinical record and the facility's policy and procedure review, the facility failed to ensure one of 2 sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PUs) when risks were not comprehensively identified, and appropriate preventative measures were not implemented in a timely and consistent manner. This failure resulted in Resident 1 sustaining deep tissue injury (DTI, pressure ulcers that appear as purple localized areas of discolored intact skin or blister due to damage of underlying soft tissue from pressure and /or shear) to bilateral heels within 5 days of admission to the facility. Findings: According to the 'admission Record,' the facility admitted Resident 1 on 9/19/23, with multiple diagnoses which included, diabetes, pneumonia, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Parkinson's disease (a disorder of the nervous system that affects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 that met professional standards of practice when one of 3 residents' (Resident 1) oral intake was low, and her fluid intake and output were not monitored to ensure she was not dehydrated. This failure resulted in Resident 1 being sent to the emergency room (ER) and receiving intravenous fluid due to dehydration. Findings: According to Resident 1's 'admission Record,' the facility admitted her recently with multiple diagnoses which included diabetes (inability to process blood sugar), dysphagia (difficulties swallowing food or liquids) anemia (low red blood cell count), nausea and vomiting. Resident 1 scored 14 out of 15 in a Brief Interview for Mental Status (BIMS, test memory and recall) contained in her admission Minimum Data Set (MDS, an assessment tool). Resident 1 was discharged home on 8/18/23. A review of Resident 1's meal intake 'Report' for August 2023 that was printed on 9/13/23, indicated the meal intake between 8/1/23 through 8/17/23 documented in percentages for 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 provide treatments and services in accordance with professional standards of practice for four sampled residents (Resident 62, Resident 71, Resident 78, and Resident 279), when: 1. Resident 78's Lovastatin (a medication to treat high cholesterol level) was not administered as ordered and the physician was not notified; 2. Resident 279's physician's order for Monurol (an antibiotic to treat urinary tract infection (UTI) was not carried out; 3. continuous oxygen (O²) was administered to Resident 71 without a physician order; 4. a controlled drug was not entered on the narcotic log; and, 5. the medication cart was not locked when unattended. These failures resulted in residents not receiving their medications as ordered by the physician and placed them at risk for complications associated with high cholesterol level and untreated UTI, insufficient O² supply or for O² toxicity that could cause lung damage due to excessive supplemental oxygen and had the potential to negatively impact the overall care provided to 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 Based on observation, interview and record review, the facility failed to ensure showers and personal care was provided for 3 of 25 sampled residents (Resident 10, Resident 68, and Resident 230) when: 1. Resident 10 did not receive showers/ bathing, personal hygiene assistance and was not assisted out of bed consistently; 2. Resident 68 did not receive showers/bathing for 26 days, and 3. Resident 230 did not receive showers for 13 days. This failure had the potential to diminish the residents' dignity and psychosocial well-being and had the potential for residents to feel unable to participate in their favorite activities. Findings: 1. According to the admission Record, Resident 10 was admitted to the facility in 2022 with multiple diagnoses which included anxiety, depression, and dementia. A review of the MDS (Minimum Data Set, an assessment tool) dated 3/22/23, indicated Resident 10 required extensive 2-person assistance with bed mobility, personal hygiene, and toileting and was totally dependent on the staff…

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

Based on interviews and record review, the facility failed to provide thorough medication regimen reviews (MRR) for four of 25 sampled residents (Resident 108, Resident 29, Resident 22, and Resident 99) when irregularities for the physician orders were not identified and reported to the attending physician and/or the director of nursing. These failures had the potential for ineffective psychotropic medication therapy. Findings: 1. Resident 108 was admitted to the facility with diagnoses that included mental issues. Review of Resident 108's clinical record included a 12/5/22 physician order for Zyprexa, an antipsychotic medication, Zyprexa 10 mg [milligram] via PEG-Tube [Percutaneous Endoscopic Gastrostomy, a surgically placed feeding tube on stomach to receive nutrition and medication] at bedtime for [mental diagnosis]. However, the physician order for this medication did not specify manifestations why the antipsychotic was given to the resident and what symptoms staff should monitor. In a concurrent interview and record review on 5/17/23 at 11:06 a.m., Licensed Nurse (LN) 2 stated…

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

Based on observation, interview and record review, the facility failed to maintain the kitchen in a sanitary condition when: 1. Kitchen floor was dirty with sticky black debris, and 2. The sanitizing agent concentration used for cleaning, was not in the acceptable effective range. These failures placed the residents at risk for food borne illness and exposure to high concentration of sanitizing agents for census of 130. Findings: 1. During an initial tour of the kitchen on 5/15/23 starting at 9:30 a.m., the floor was observed sticky, with black and brown dirt particles and food debris. In a concurrent observation and interview on 5/15/23 starting at 9:30 a.m., the Dietary Manager (DM) acknowledged and stated Yes, the floor is dirty. A review of the facility's policy and procedure, form 804a, titled, FOOD & DINING SERVICES EQUIPMENT CLEANING PROCEDURES, indicated, . 10. FLOOR Daily, after breakfast & lunch, do #1; After lunch & dinner, complete #'s 1 to 7: 1. Sweep the floor and dispose of dirt particles. Sweep under the equipment. Move the equipment, if it is mobile, in order to…

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

Based on observation, interview and record review, the facility failed to maintain a sanitary and safe laundry room for a census of 130 residents, when both washing machines and water pipes were covered with a thick, gray accumulation of debris, and the area behind the washers had an accumulation of dust, dirt, and debris. In addition, the dryers were found to have a thick layer of lint on the mesh screen inside the dryers' lint traps. These failures placed the residents at risk for infection and had the potential to result in a fire risk. Findings: The laundry inspection was conducted on 5/18/23, at 1:05 p.m., accompanied by Housekeeping Supervisor (HS) and Environmental Service Director (ESD). During a concurrent observation and interview on 5/18/23 at 1:05 p.m., with HS and ESD, a rack with clean residents' clothes, stacks of clean linens, gowns, blankets, and curtains folded and stored on the table were observed uncovered in the clean side of the laundry service area. Two large washing machines were located across where the clean clothes and linens were stored. The tops of both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 documentation review, the facility failed to promote one of 25 sampled residents (Resident 99's) dignity when his long fingernails were not trimmed. This failure resulted in Resident 99 feeling not being respected by staff. Findings: Resident 99 was a long-term resident in the facility with diagnoses that included joint pain and stiffness. In a concurrent observation and interview on 5/15/23 at 10:58 a.m., Resident 99 was lying in bed with both hands on his chest. His fingers were observed to be curled inward. Resident 99 complained that his fingernails had not been trimmed. His fingernails were about half an inch long hanging over the nail beds and had black substances underneath them. The resident voiced that he asked staff multiple times that he wanted his long fingernails to be trimmed but no one clipped them. Resident 99 stated he could not trim his fingernails by himself due to his contracture, so he had to use his teeth to bite them off. The resident stated, I understand they are busy .but it made me feel that I don't get respect, avoiding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comfortable, and homelike environment for 1 of 25 sampled residents (Resident 13), when roaches were observed in the resident's room. This failure negatively impacted the comfort level and quality of life for Resident 13 and had the potential to harbor pests that could carry diseases or adversely affect the health and safety of vulnerable and medically compromised residents. Findings: Resident 13 was admitted to the facility in March 2016, with diagnoses that included cellulitis of left lower limb, contact with and (suspected) exposure to other viral communicable diseases, and aphasia following cerebral infarction (loss of ability to understand or express speech). He was able to communicate with the staff through gestures and writing down what he needed on a pad. During an observation on 5/15/23 at 10:40 a.m., Resident 13 was in his room beside his bed, seated on his wheelchair when he suddenly said, Hey, hey, hey,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 person-centered care plan was revised for one of 25 sampled residents (Resident 29) when the resident had repeated significant weight loss. This failure resulted in Resident 29's changing care needs not being accurately reflected in the care plan and the current care interventions not being readily available to evaluate for their effectiveness and relevance to the resident's significant weight loss. Findings: Resident 29 was admitted to the facility in November 2022 on hospice care for his cognitive abilities and mental decline. Throughout the survey period, 5/15/23 through 5/18/23, Resident 29 was frequently visible in his wheelchair self propelling the hallways. Review of Resident 29's clinical record, Weight and Vitals Summary, indicated the resident had significant weight loss during the six months stay in the facility as follows: 11/3/22: 209 lbs. (admission weight) 2/1/23: 180.8 lbs. (-28.2 lbs. loss (-13.5%) significant weight loss in 3 months) 3/1/23: 177.6 lbs. 4/4/23: 180.8 lbs. 5/4/23:…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure for one of 25 sampled residents (Resident 5) that a humidifier bottle (used to prevent the resident's airways from getting too dry while on concentrated oxygen) was labeled and filled with distilled water. This failure had the potential to cause discomfort and dryness to Resident 5's airway. Findings: Resident 5 was admitted to the facility in September 2019 with diagnoses that included acute and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), and obstructive sleep apnea (temporary cessation of breathing). Resident 5 scored 15 on the BIMS (Brief Interview for Mental Status) which meant there was no cognitive impairment and was her own responsible party for decision making. She was alert and oriented. During a concurrent observation and interview on 5/15/23 at 11:30 a.m., with Resident 5, an oxygen concentrator (provides higher amounts of oxygen needed for oxygen therapy) was set at 3 liters per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 25 sampled residents (Resident 19), who received Lorazepam (anti-anxiety drug) and Sertraline (anti-depressant,), was adequately monitored for specific target behaviors. Additionally, medication adverse effects (unwanted, uncomfortable or dangerous effects) of Lorazepam and Sertraline were not monitored. These failures had the potential to have a negative impact on Resident 19's physical, mental, and psychosocial well-being and placed the resident at risk for experiencing adverse effects related to the use of psychotropic medications, including, but not limited to drowsiness, dizziness, movement disorders, and death. Findings: A review of Resident 19's admission Record indicated the resident was admitted to the facility in 2019 with diagnoses that included depressive disorder and anxiety disorder. A review of Resident 19's order summary report contained a physician's order, dated 9/22/22, to administer Sertraline 50 milligram (mg, unit of measurement) every morning for depression. Resident 19 had multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 urgent dental services were provided in a timely manner for 1 of 25 sampled residents (Resident 21) when her dental bridges were broken, and she requested to see her former dentist. These deficient practices had the potential to result in, difficulty chewing, choking and/or weight loss. Findings: According to Resident 21's 'admission Record,' the facility admitted her over 2 years ago with multiple diagnoses which included diabetes, heart failure and unspecified protein-calorie malnutrition (a nutrition deficiency condition). A review of Resident 21's most recent quarterly Minimum Data Set (MDS, an assessment tool) dated 4/4/23 indicated she scored 15 out of 15 in a Brief Interview For Mental Status (BIMS, tests memory and recall) which indicated she was cognitively intact. The MDS also indicated Resident 21 had broken or loosely fitting full or partial dentures. During a concurrent observation and interview on 5/15/23, shortly after 9:41 a.m., Resident 21 was observed resting in bed fully awake.…

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