Edgewater Skilled Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow manufacturer's storage specifications for one of six sampled resident's (Resident 11) levalbuterol inhalation solution, USP (an inhaled prescription medicine used for the treatment or prevention of breathing difficulties).This failure had the potential to reduce the medication's effectiveness and placing the resident at risk for shortness of breath and difficulty.Findings:During a concurrent interview and record review on [DATE] at 1:38 p.m. with Licensed Vocational Nurse (LVN) 1, at nurses' station 1, medication cart 1 contained an open levalbuterol inhalation solution, USP 0.63 milligram (mg)/3 milliliters (ml) labelled for Resident 11. The medication packaging indicated an open date of [DATE]. LVN 1 stated the label indicated Once the foil pouch is opened, the vials should be used within two weeks. During an interview on [DATE] at 3:40 p.m., with the Director of Nursing (DON), the DON stated, ensuring medications were not expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documented food preferences was followed for one of three sampled residents (Resident 75), when Resident 75 was served food items documented as resident's dislikes. This failure had the potential to contribute to reduced nutritional intake, affecting the resident's overall health and well being.Findings:During a review of Resident 75's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 9/14/2023 and re-admitted on [DATE], with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN- high blood pressure).During a review of Resident 75's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated the resident had intact cognitive function (ability to process information, learn, and reason without impairment).During a review of Resident 75's physician's order dated…

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

Based on interview and record review, the facility failed to provide documented evidence of COVID-19 (a contagious respiratory disease that spreads from person to person through coughing, sneezing, or talking) vaccine screening, education, administration, and/or declination for two of seven sampled staff members: Medical Doctor (MD) 1 and MD 2.This failure had the potential for an increased risk of COVID-19 exposure for facility residents and staff from delayed identification of vaccine status and missed opportunities to prevent the spread of COVID-19 within the facility.Findings:During a concurrent interview and record review on 3/18/2026 at 3:31 p.m., with the Infection Prevention Nurse (IPN), the facility's Employee Health Tracking Log (record that includes vaccination status of all employees) was reviewed. The IPN stated there was no documentation indicating MD 1 and MD 2 were educated and offered the COVID-19 vaccine. The IPN stated they (IPN) did not offer the COVID-19 vaccine to the physicians.During an interview on 3/19/2026 at 3:40 p.m., with the Director of Nursing (DON),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of urinary retention (inability to completely empty the bladder of urine), and was exhibiting signs of urinary retention (groin and abdominal pain), requiring indwelling catheter (flexible soft tube inserted in the body to drain urine) insertion was inserted timely by Licensed Vocational Nurse (LVN) 1 when she could not locate the indwelling catheter supply in the facility. This deficient practice resulted in Resident 1 experiencing further pain and discomfort and placed him at risk for bladder injury and infection. Resident 1 was subsequently transferred to a General Acute Care Hospital (GACH) via 911 for treatment. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including myocardial infarction ([MI] heart attack), type 2 Diabetes Mellitus ([DM] a disorder characterized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to:1. Re-admit one of three sampled residents (Resident 1) to the facility after Resident 1 was evaluated and cleared by the General Acute Care Hospital (GACH) to return to the facility.2. Ensure the facility followed its policy and procedure (P&P), titled Bed Holds which indicated if the resident's hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.This deficient practice resulted in Resident 1 being unable to return to the skilled nursing facility (SNF) that has been considered their home, for about 12 months after being deemed appropriate for transfer to the SNF. As a result, Resident 1 was transferred to another SNF, and both the Resident 1 and Family Member (FM) 1 experienced unnecessarily psychosocial harm, including emotional…

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

Based on interview and record review, the facility failed to provide a completed written Bed Hold notification to one of one sampled resident (Resident 1) upon transfer on 7/15/2025 to the General Acute Care Hospital (GACH). This failure had the potential to result in a resident and/or their representative being unaware of their right to return to the facility within the designated bed-hold period, potentially leading to unnecessary displacement.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/24/2024 with diagnoses including psychotic disorder (severe mental illnesses where people lose touch with reality) with hallucinations ( a sensory experience that feels real but is not based on an external stimulus) and major depressive disorder( a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly impact daily life). During a review of Resident 1's History and Physical Examination (H&P), dated 7/26/2024, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a refund was issued within 30 days to the Responsible Party (RP 1), upon a resident's discharge for one out of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's RP 1 not receiving a refund of $1,752.00. Findings: During a review of Resident 1's admission Record (Face Sheet), the face sheet indicated, Resident 1 was originally admitted on [DATE] and re-admitted on [DATE], with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body), and malignant neoplasm of the prostate (prostate cancer). The Face Sheet further indicated Resident 1 was discharged from the facility on 2/19/2025 at 3:25 p.m. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 12/6/2024, the MDS indicated Resident 1 was usually understood and usually able to understand others. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure prompt attempts were made to resolve the resident council meeting complaints of call lights not being answered, staff being rude, and not receiving care timely or at all for 5 of 11 sampled residents (Resident 1, Resident 2, Resident 4, Resident 7, and Resident 9). This deficient practice had the potential to violate the residents' right to have their concerns addressed. Findings: a. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also known as a stroke, where blood flow to the brain is interrupted causing brain tissue to die) and congested heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/30/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement its Infection Prevention and Control Program for four of 11 sampled residents (Resident ' s 5, 6, 7 and 8) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 performed hand hygiene and used the proper personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments equipment) while providing care to Resident 5 who was on Enhanced Barrier Precautions ([EBP] infection control precautions in addition to the standard to prevent the spread of multidrug-resistant organisms). 2. Ensure CNA 1 did not throw Resident 5 ' s contaminated linen and soiled incontinence (loss of bladder and/or bowel control) brief on the floor. 3. Ensure CNA 2 wore proper PPE on while providing direct care to Resident 5. 4. Ensure CNA 2 discarded contaminated gloves prior to entering Resident 6 ' s room and turning the call light off. 6. Ensure licensed nurses dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 4) when the facility failed to provide timely incontinent (having little or no control over urination or defecation) care (assistance in cleaning up a resident after toileting in a brief [adult diaper]) to Resident 4. Resident 4 was left to sit in a soiled, wet brief for an hour. This deficient practice resulted in Resident 4 feeling uncomfortable, embarrassed , frustrated and neglected by staff. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-disorder characterized by difficulty in blood sugar control and poor wound healing) , muscle weakness and major depressive episode (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 4's Minimum Data Set ([MDS] a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its Infection Prevention and Control Program by failing to: 1. Ensure Certified Nurse Assistant (CNA) 4 ' s N95 (a disposable face mask that cover ' s the user ' s nose and mouth which offers protection from small solid or liquid droplets found in the air) was covering her nose. 2. Ensure CNA 4 washed her hands upon exiting Resident 10 ' s room after providing care to Resident 10. These failures placed residents, staff, and the community at higher risk for cross contamination, transmitting infectious microorganisms, and an increased spread of Influenza A (a contagious an infection of the nose, throat and lungs, which are part of the respiratory system) in the facility and community. Findings: During a review of Resident 10 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 10 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM - a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of three sampled resident ' s (Resident 1) resident representative (RR) 1 immediately after Resident 1 sustained a fall and was transferred to a General Acute Care Hospital (GACH) for evaluation. This failure resulted Resident 1 ' s RR 1 not being notified of Resident 1 ' s fall and transfer to the GACH until five hours and 25 minutes later. The deficient practice resulted in violation of the RR 1 ' s right to be informed of Resident 1 ' s care and services provided. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including acute cerebrovascular insufficiency (a temporary lack of blood flow to the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting left dominant side, abnormalities of gait (a manner of walking on foot) and mobility. During a review of Resident 1 ' s History &…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident, who was initially assessed and determined to be at high risk for falls and had a history of falling at the facility did not fall and continue to fall for one out of four sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed nurses developed a care plan that addressed Resident 1 ' s inability to communicate his needs or use the call light when needing assistance which led to Resident 1 falling on 11/14/2024, 11/28/2024, and on 12/13/2024. 2. Ensure the nursing staff implemented interventions timely when Resident 1 fell on [DATE]. Resident ' s 1 ' s Post Fall Care Plan interventions dated initiated 11/14/2024 included a room change closer to the nursing station which was not initiated until 11/19/2024 (five days after the first fall on 11/14/2024), and also included an order for a Perimeter Low Air Loss Mattress (an air inflated mattress with raised borders on the sides designed to protect the skin and prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document a resident ' s change of condition in the medical record for one of four sampled resident ' s (Resident 1). This deficient practice resulted in inaccurate documentation of the care provided to Resident 1 after he sustained a fall with injury on 11/28/2024. This deficient practice had the potential for non-continuity of Resident 1 ' s care by other health care providers. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the body doesn ' t have enough oxygen in its tissues), stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (low back), aphasia (a disorder that makes it difficult to speak), and cognitive communication deficit (difficulty communicating due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of four residents (Resident 8, 15, and 37) were free of unnecessary medications by failing to: 1.Ensure informed consents for the use of psychotropic medication were obtained for Resident 8 and Resident 15. 2. Ensure informed consents were obtained prior to the use of Trazadone Hydrochloride (HCL: salt used in medication) medication used to treat depression and or anxiety)150 milligram (mg: unit of meaure of mass) and Quetiapine Fumarate (brand name Seroquel) medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought), depression, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) 100mg for Resident 37. 3. Ensure the indication for Quetiapine Fumarate 100mg was clarified prior to administration for Resident 37. Findings: a. During a review of Resident 8's admission Record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS - a resident assessment tool) related to discharge status was accurately documented to reflect that the resident was discharged home for one of three residents (Resident 78). This deficient practice had the potential to negatively affect Resident 78's plan of care and delivery of necessary care and services. Findings: During a review of Resident 78's admission Record, dated 12/12/2024, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including respiratory failure and chronic kidney disease (gradual failing of the kidneys). The face sheet indicated Resident 78 was discharged on 9/13/2024 to a board and care/assisted living/group home. During a review of Resident 78's MDS, the MDS indicated Resident 78 had moderate cognitive (ability to think and reason) impairment and required maximal assistance (helper does more than half the effort) for eating,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 5 and Resident 37) preadmission screening and resident review (PASRR) screening was reassessed to determine the facility's ability to provide care for the special needs of the residents. This deficient practice placed the residents at risk of not receiving necessary care and services. a. During a review of Resident 5's admission Record, the admission Record indicated the facility initially admitted Resident 4 to the facility on 7/29/2024 and readmitted on [DATE] with diagnoses including unspecified dementia (progressive state of decline in mental abilities), mood disturbance (mental health condition that affects your emotional state), anxiety, and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 5's History and Physical (H&P) dated 10/12/2024, the H&P indicated Resident 5 did not have the capacity to…

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

Based on observation, interview, and record review, the facility failed to develop a trauma (a deeply distressing or disturbing event that overwhelms a person's ability to cope, causing significant and lasting negative consequences) informed care plan for one of one residents (Resident 52), who reported difficulty sleeping related to previous trauma. This failure had the potential to compromise Resident 52's emotional well-being and increas the risk of re-traumatization. Findings: During a review of Resident 52's admission Record, the admission Record indicated the facility admitted Resident 52 on 10/10/2023 with diagnoses including major depressive disorder (a mental health condition that can cause severe feelings of sadness, hopelessness, and a loss of interest in activities), and anxiety disorder (a condition that causes excessive and persistent feelings of fear, worry, dread, and uneasiness.) During a review of Resident 52's Minimum Data Set (MDS-a resident assessment tool), dated 10/11/2024, the MDS indicated Resident 52 was cognitively (the ability to think and process…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise care plans when medication regimens were updated for one of three sampled residents (Resident 15). This failure had the potential to result in not accurately addressing Resident 15's psychosocial care. Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility initially admited Resident 8 on 2/22/2020 and readmitted on [DATE] with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 15's History and Physical (H&P) dated 6/4/2023, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a review of Resident 15's order summary report as of 12/12/2024, the order summary report indicated: a. Mirtazapine tablet 7.5 MG, give 1 tablet by mouth at bedtime for poor meal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) received her last dose of antibiotic per physican's order. This deficient practice could have potentially prolonged Resident 2's infection. Findings: During a review of Resident 2's admission record, the admission Record indicated the facility initially admitted Resident 2 on 9/3/2024 and readmitted on [DATE] with diagnoses including atherosclerosis (chronic inflammatory disease of the arteries) of right leg with ulceration (a small open sore or wound generally found in the stomach or on the skin) of thigh, peripheral venous (damaged or blocked veins that affect blood flow) insufficiency, and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 2's Minimum Data Set [(MDS- a resident assessment tool], dated 9/14/2024, the MDS indicated Resident 2's cognitive (the mental action or process of acquiring…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices during indwelling urethral catheter (Foley catheter-a thin tube that is inserted into your bladder through the urethra-the tube you pee through and left there to continuously drain your urine into a collection bag) care for one of one sampled resident (Resident 1) by: a. Failing to perform hand hygiene before and after Foley catheter care. b. Failing to ensure and the resident's urine bag was kept off the floor. This deficient practice had the potential for urinary tract infection (UTI- condition that affect the urinary tract and can cause urine to flow abnormally) recurrence. Findings. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/15/2016, and readmitted him on 2/14/2024 with diagnoses including infection and inflammatory reaction (the body reacting negativly to an inserted foreign object) due to indwelling urethral catheter, calculus of kidney (a solid mass of minerals and salts that forms 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 develop a trauma informed care plan for one of one resident (Resident 52), who reported difficulty sleeping related to previous trauma. This failure has the potential to compromise Resident 52's emotional well-being and increased the risk of re-traumatization. Findings: During a review of Resident 52's admission Record, the admission Record indicated the facility admitted Resident 52 on 10/10/2023 with diagnoses including major depressive disorder (a mental health condition that can cause severe feelings of sadness, hopelessness, and a loss of interest in activities), and anxiety disorder (a condition that causes excessive and persistent feelings of fear, worry, dread, and uneasiness.) During a review of Resident 52's Minimum Data Set (MDS-a resident assessment tool), dated 10/11/2024, the MDS indicated Resident 52 was cognitively (the ability to think and process information) intact, had symptom of feeling down, depressed, or hopeless,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure one of three sampled residents (Resident 36) had the required Insulin Glargine Solution (medication that controls the amount of sugar in the blood) on hand to be administered. This deficient practice resulted in Resident 37 not getting the insulin on time. During a review of Resident 36's admission record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and long-term use of insulin (hormone that regulates blood sugar levels). During a review of Resident 36's History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 36 has the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set [(MDS) a resident screening tool], dated 10/14/2024, the MDS indicated Resident 36's cognitive (the mental…

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

Based on observation, interview, and record review, the facility failed to ensure dietary staff knew the proper techinize of thawing frozen food and testing the concentration of the sanitizer. These deficient practices had the potential to cause food-borne illnesses due to improperly thawed for being served to the residdnts of the facility, and the sanitizer not being at an effective strength. Findings: a.During a concurrent observation and interview on 12/9/2024 at 9:35 a.m., with the Dietary Aid (DA) 2, in the Kitchen, DA 2 checked the sanitizer concentration in a sanitizer bucket using the the wrong testing strip. DA 2 acknowledged that there was no color change on the test strip to indicate the concentration level of the sanitizer solution. b.During a concurrent observation and interview on 12/9/2024 at 9:35 a.m. with the Dietary Supervisor (DS), in the Kitchen, a sealed frozen item was observed running under hot water in a stainer in the sink. The DS acknowledged that the water was hot and stated DA 2 had accidently turned on the hot water, but the proper method required using…

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

Based on observation, interview, and record review, the facility failed to: 1. Store staff personal belongings outside the food storage area. 2. Ensure proper labeling of potatoes and green produce. These deficient practices had the potential to cause food-borne illnesses. Findings: a.During a concurrent observation and interview on 12/9/2024 at 8:22 a.m., with Dietary Aid (DA)1, in the dry food storage area, staff personal belongings were observed, one black jacket and one white tote bag were hanging on the first shelf to the left side of the door. Additionally, one black jacket and one black backpack were observed on the second self from the bottom on the right side of door. DA 1 stated that these items belong to kitchen staff and acknowledged they should not be in the food storage area as they can lead to cross-contamination, potentially causing food borne illness. b.During a concurrent observation and interview on 12/9/2024 at 8:22 a.m., with DA 3, in the dry food storage area, there was a container of potatoes on the bottom shelf without labeling. DA 3 stated proper labeling is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their infection control policy for two of three sampled residents (Resident 130 and 53) by: 1.Ensuring staff performed hand hygiene after providing care for a resident and before going to Resident 130's room. 2. Ensuring staff doffed (systematic removal of personal protective equipment [PPE: equipment worn to minimize exposure to injury or infection] to prevent infection and contamination after administering medication to Resident 53. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. a. During a review of Resident 130's admission record, the admission Record indicated Resident 130 was admitted to the facility on [DATE] with diagnoses including generalized weakness, cerebrovascular accident (CVA: stroke, loss of blood flow to a part of the brain), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 15 of 35 residents rooms met the 80 square feet ([sq. ft.] unit of area equal to a square one foot long on each side) per residents in multiple resident rooms. Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34 housed two residents per room, and Rooms 18, 20, 21, 35 and 36 housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents. Findings: During an observation on 12/12/2024 at 11:59 a.m., the following rooms were observed room [ROOM NUMBER], 20, 21, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and room [ROOM NUMBER] did not meet the requirement of 80 square feet per residents. During a review of the Client Accommodations Analysis Form, dated 12/12/224, provided by the Administrator (ADM) on 12/12/2024, the Client Accommodations Analysis Form indicated Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34 were occupied by two residents per room and had a total square…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to develop and implement appropriate methods to measure the success of actions implemented addressing the continued concerns from the Resident Council pertaining to a delay in call light response during the hours of 11 p.m. to 7 a.m., and failed to address the delivery of Activities of Daily living (ADLs – routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) care. This deficient practice has the potential to affect all 73 residents who reside in the facility to not receive the quality care necessary to meet their highest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct a timely Interdisciplinary Team ([IDT] health care professionals who work together with the resident to plan the residents plan of care) meeting for one of three sampled residents (Resident 1). The facility failed to ensure Resident 1's was given the opportunity to meet with the IDT to discuss any updates or concerns she has in her current plan of care. These deficient practices resulted in a delay in communication between Resident 1 and the IDT causing frustration and anxiety to the Resident 1 and had the potential to delay in the delivery of needed care and services. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including displaced fracture (broken bone) of the medial condyle of left femur (inside part of knee), left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided the appropriate care and services to maintain her Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) by failing to provide Resident 1 with a commode (portable toilet) on 7/11/2024. This failure resulted in Resident 1 being forced to use a bedpan (container used to collect urine or feces used while lying or sitting in bed) which caused Resident 1 to feel embarrassed and degraded. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including displaced fracture (broken bone) of the medial condyle of left femur (inside part of knee), left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), left hemiparesis (weakness and paralysis) following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was seen by the psychiatrist as indicated per the physician orders. This failure resulted in Resident 1 not receiving the required behavioral health care services and placed Resident 1 at risk to suffer further mental anguish and decreased quality of life. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including displaced fracture (broken bone) of the medial condyle of left femur (inside part of knee), left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and left hemiparesis (weakness and paralysis) following cerebral infarction ([stroke]lack of blood flow to brain). During a review of Resident 1's History and Physical (H&P) dated 5/3/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was offered and provided a shower and was dressed in her personal clothing and not in a hospital gown. These deficient practices resulted in Resident 3 not receiving a shower for 28 days and her family's preference of her being dressed in her personal clothing and not a hospital gown, not being followed. This deficient practice had the potential to lower Resident 1's self-esteem. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a disease affecting how one thinks and understands), hemiplegia (inability to move one side of the body), hemiparesis (weakness on one side of the body) of the left side of her body, and generalized muscle weakness. During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who had poor safety awareness and was at risk for injury, had a call light button (device used to call nursing staff) within reach. This deficient practice resulted in a delay in Resident 1's care and services and had the potential for Resident 1 to act without assistance and sustain a fall/injury. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), muscle weakness and rheumatoid arthritis (a disease that causes pain, swelling, stiffness, and loss of function in the joints). During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 6/28/2024, the MDS indicated Resident 2 had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents'( Resident 3) who was dependent on staff for care was returned and repositioned every two hours This deficient practice put Resident 3 at risk for skin breakdown leading to pressure injuries/ulcers wounds created by extended pressure on the skin). Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (disease affecting how one thinks and understand), hemiplegia (inability to move one side of the body), hemiparesis (weakness on one side of the body) to her left side, and generalized muscle weakness. During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 8/7/2024, the MDS indicated Resident 3 had severe cognitive impairment and was rarely or never understood by others. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions ([EBP] precautions utilized to prevent the spread of multidrug resistant organisms [MDROS - bacteria that resist treatment with more than one antibiotic [medication that treat bacterial infections] for one of three sampled residents (Resident 1) who had a pressure injury wound (wound caused by pressure on the skin) on her sacrum (buttocks), when Certified Nursing Assistant 1 (CNA 1) did not use an isolation gown when performing high contact activities such as repositioning and removing Resident 1's incontinent brief (a disposable undergarment designed to absorb urine and feces). These deficient practices resulted in Resident 1's care needs being provided without the use of EBP and placed Resident 1 at increased risk of acquiring an infection. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with…

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

Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) Responsible Party (RP) was assisted in filing a grievance when Resident 1's RP found three tablets of Bictegravir- Emtricitabine-Tenofovir Alafenamide Fumarate 50-200-25 (an anti- human immunodeficiency virus medication) left in Resident 1's 30-day supply for 7/2024. This deficient practice resulted in Resident 1's RP feeling frustrated that concerns related to Resident1's medication administration was not addressed and had the potential for mismanagement of Resident 1's medication regimen. Findings: During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted at the facility on 12/1/2023 with a diagnosis of human immunodeficiency virus disease ([HIV] a condition where a virus attacks the body's immune system) and placement of a Percutaneous Endoscopic Gastrostomy Tube ([PEG] a feeding tube inserted through the stomach to allow a person to receive nutrition and/or medication administration). During a review of Resident…

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

Based on interview and record review, the facility failed to account for the disposition of eight Morphine Sulfate (a drug used to treat moderate and severe pain and can be addictive) tablets in one of two emergency medication kits (receptacle that holds emergency medications) in the facility. This failure resulted in missing medications which could potentially be accidentally ingested by a resident or the medications to be diverted to an unknown recipient. Findings: During a telephone interview on 6/13/2024 at 11:43 a.m., Licensed Vocational Nurse 3 (LVN 3) stated on 6/8/2024 he came to work at 3 p.m. to 11 p.m. and he and Licensed Vocational Nurse 6 (LVN 6), who was the outgoing (7 a.m. to 3 p.m.) licensed nurse counted the individual controlled medications of the residents and checked the emergency medication kit inside the locked compartment of the medication cart. LVN 3 stated the emergency medication kit had been opened because it had a red tag on it. LVN 3 stated he and LVN 6 reconciled the contents of the emergency medication kit and identified there were 8 morphine tablets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, Licensed Vocational Nurse (LVN) 2 failed to ensure the pain medication for one (Resident 1) of five sampled residents was documented immediately in the narcotic sheet (document used to keep track of inventory of narcotic [medication that is highly addictive] medications) after the medication was administered, in accordance with the professional standards of practice. This failure has the potential for Resident 1 to be subjected to risk of undermedication and/ or overmedication due to untimely documentation of administered pain medication. Findings: During a review of Resident 1's admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted at the facility on 2/25/2022 with diagnosis including diabetes mellitus (a serious condition where the blood glucose, also known as blood sugar level of the body, is too high) with neuropathy (a condition when nerve damage leads to pain, numbness, and weakness). During a review of Resident 1's Order Summary, the Order Summary indicated Resident 1 has an order of Norco (is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct an Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference involving one of three sampled residents (Resident 1) and Resident 1's Responsible Party (RP1) prior to discontinuing Resident 1's speech therapy (treatment that improves ability to talk and use other language skills). This deficient practice violated the Resident 1 and RP 1's rights to be informed and the right to participate in resident's plan of care. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV- is a virus that attacks the body's immune system), hemiplegia (unable to move one side of body) affecting right side, and percutaneous gastrostomy tube (PEG-Tube- surgically placed tube into the stomach, used to administer medication and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) who had a gastrostomy tube (G-tube- surgically placed tube into the stomach, used to administer medication and nutrition), had measures in place to prevent the g-tube from being inadvertently dislodged a second time on 3/31/2024. The facility failed to revise Resident 1's care plans to include interventions to prevent future unintentional dislodgements of the G tube and the facility failed to investigate to determine the cause of Resident 1's multiple G-tube dislodgements. This deficient practice resulted in Resident 1 requiring to be admitted to the hospital for surgical intervention to replace the G-tube and had the potential for malnutrition (not enough nutrients) and underdosing of medications. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including a percutaneous gastrostomy tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 required in service training and skills checklist for abuse and dementia were provided to two of four sampled Certified Nursing Assistant (CNA 3 and 4). This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings: During a concurrent interview and record review on 5/3/2024, at 2:00 p.m., with Medical Record , Certified Nursing Assistant (CNA) 3 and CNA 4 employee files were reviewed. MR stated there were no CNA skills checklist or abuse and dementia trainings present in both employee files. MR stated Director of Staff Development was let go on 5/2/2024. During an interview on 5/3/2024 at 4:52 p.m., with the Director of Nursing (DON, the DON stated, they do not have the CNA skills checklists or abuse and dementia trainings for CNA 3 and CNA 4. During a review of the facility ' s policy and procedure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a care plan to place floor mats next to Resident 1 ' s bed and to have Resident 1 ' s bed in the lowest position, for one of three sampled residents (Resident 1) who was assessed as high risk for falls. This deficient practice resulted in Resident 1 falling from her bed, which was in a high position and landing on the floor without floor mats in place. Resident 1 was transferred to a General Acute Care Hospital (GACH) where she was assessed with a non-displaced (broken bone that remains in the proper alignment) left intertrochanteric fracture (fracture of the thigh bone that connects to the hip bone). Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of generalized muscle weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS]) a standardized assessment and care screening), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services for two of three sample residents (Resident 1and 2) by: 1. Failing to document the presence of a low air loss mattress (special mattress that ensures air circulation around the skin and protects the residents from bedsores [injury to skin]) on the treatment administration record, ([TAR] a report that serves as a legal record of the treatments a resident was receiving) for Resident 1 and 2. 2. Failing to ensure Resident 1 had an order for a low air loss mattress. These deficient practices had the potential to result in poor wound healing for Resident 1 and 2. Findings: a. During a review of Resident 1's admission record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis of malignant neoplasm of prostate (cancer of the prostate [accessory gland that makes the fluid that transport sperm]), cardiac arrest (heart stops), and unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to notify the responsible party (RP) when Resident 1 had a 12-pound (lbs- measurement) weight loss for one of three sampled residents (Resident 1). This deficient practice had violated the resident's responsible party's right to be inform of the care or services provided. Findings : During a review of Resident 1's admission record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis of diabetes mellitus without complications ( elevated levels of sugar in the blood ), Hypertension ( High blood pressure ), and acute respiratory failure with hypoxia ( the lungs can't get enough oxygen to the blood ). During a review of Resident 1 's history and physical (H&P) report dated 12/7/23, the H&P indicated resident 1 had fluctuating capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident rights were maintained for two of four sampled residents (Resident 3 and 4) when the facility failed to A. Notify Resident 3's physician when Resident 3's blood sugar was 404 milligrams (mg-unit of measurement) / deciliter (dL- unit of measurement) on 2/3/2024 and 432 mg/dL on 2/19/2024. B. Notify Resident 4's physician when Resident 4's blood sugar was 428 mg/dL on 2/26/2024, 405 mg/dL on 2/28/2024 and 425 mg/dL on 3/1/2024. These deficient practices resulted in Resident 3 and 4's physician being unaware of high blood sugar levels causing a delay in needed assessments and services for Resident 3 and 4. Findings: A. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition when blood sugar is too high), atrial fibrillation (irregular and often very rapid heart rhythm) and hyperlipidemia (too many fats in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care plan interventions for three of four sampled residents (Resident 1, 3, and 4) were implemented. The facility failed to implement: A. Resident 1's care plan intervention to use an air mattress (device used to prevent skin breakdown). B. Resident 3 and 4's care plan interventions to call the physician for blood glucose (sugar) levels over 400 milligrams (mg-unit of measurement) / deciliter (dL- unit of measurement). These deficient practices had the potential to result in delayed care and services and decline in Resident 1, 3, and 4's health. Findings: A. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV- is a virus that attacks the body's immune system), hemiplegia (unable to move one side of body) affecting right side, and percutaneous gastrostomy tube (PEG-Tube- surgically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident rights were maintained for two of three sampled residents (Resident 1 and 2) when the facility failed to: A. Notify Resident 1 's Responsible Party (RP) 1 when Protonix (medication used to treat gastroesophageal reflux disease [GERD-when stomach acid flows back into the throat]) was discontinued on 1/9/2024. B. Honor RP 1's wishes to retain Resident 1's air flow mattress (mattress that help prevent skin breakdown by promoting blood flow and stimulating circulation in the body). C. Conduct an Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference involving Resident 2 following Resident 2's fall on 2/13/2024. These deficient practices violated the Resident 1 and RP 1's rights causing mistrust and frustration directed toward the facility; and Resident 2 not having an IDT Care Conference placed Resident 2 at risk for future falls. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify and provide a written notice to the responsible party (RP 1) prior to moving one of four sampled residents (Resident 1). These deficient practices resulted in the violation of Resident 1's and RP 1's rights to be informed of room changes. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV- is a virus that attacks the body's immune system), hemiplegia (unable to move one side of body) affecting right side, and percutaneous gastrostomy tube (PEG-Tube- surgically placed tube into the stomach, used to administer medication and nutrition). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/13/2024, the MDS indicated Resident 1 had severe cognitive impairment (ability to think, learn, remember, use judgement, and make decisions).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of four sampled resident's (Resident 1) responsible party's (RP 1) complaint regarding Resident 1 's accidental Gastrostomy tube (G-tube- surgically placed tube into the stomach, used to administer medication and nutrition) dislodgement which resulted in a hospitalization was formally logged as a grievance (complaint) and investigated as indicated in the facility's policy and procedures. This deficient practice resulted in RP1 's anxiety and worry that the facility will not address the circumstances leading to Resident 1's G-tube being accidently removed. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV- is a virus that attacks the body's immune system), hemiplegia (unable to move one side of body) affecting right side, and percutaneous gastrostomy tube (PEG-Tube- surgically placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise one of four sampled resident's (Resident 2) care plan to include the recommendations from the director of rehabilitation (DOR- healthcare professional who oversees the facility's program that helps residents regarding strength and mobility) of reminding Resident 2 to ask for assistance when getting up. This deficient practice placed Resident 2 at higher risk for future falls. Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including fracture (break) of left shoulder, muscle weakness and encephalopathy (damage or disease that affects brain function). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment and was usually understood and could be understood by others. During a review of Resident 2's Change of Condition (document to communicate a resident's condition to the health care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy ensuring the accurate receiving and reconciliation (process of verifying physician orders to medication) of home medications for one of one sampled resident (Resident 1). The facility failed to track and document the date, time, or quantity of Bictegravir/emtricitabine/tenofovir alafenamide (medication used to treat human immunodeficiency virus (HIV-virus that attacks body' immune system) when nursing staff received the medication from Resident 1's Responsible Party (RP). This deficient practice had the potential for inaccurate inventory of medications causing medication shortages and underdosage of medication. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including HIV. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/13/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity by not providing not providing privacy bag for Resident 1 ' s indwelling urinary catheter bag (drains urine from the bladder into a bag outside your body). This deficient practice had the potential for Resident 1 to feel embarrassed and have low self-esteem (when someone lacks confidence about who they are and what they can do). Findings: During a review of Resident 1 ' s admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (chronic condition that affects how the body processes sugar), and hypertension (high blood pressure). During a review of Resident 1 ' s Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 12/11/23. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort. for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to identify resident using methods of identification prior to medication administration of one of two sampled residents (Resident 2) according to the facility ' s policy and procedure (P&P). This deficient practice had the potential for medication error for Resident 2 including receiving incorrect medications. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (chronic condition that affects how the body processes sugar), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and dysphagia (swallowing difficulties). During a review of Resident 2 ' s History and Physical (H&P), dated 10/28/23, indicated, Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set [(MDS), a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and provide intervention for pain for two of two sampled residents (Resident 10 and 168) when: a. Resident 10 was not assessed for pain before, during and after wound care dressing change. b. Resident 168 was not assessed for pain when Resident 168 was admitted under hospice care on 12/23/2023. These failures resulted in Resident 10 and Resident 168 continue to suffer from pain. Findings: a.During a review of Resident 10's admission Record ( Face sheet), the Face sheet indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, stage 4 pressure ulcer ( wound that extend below the subcutaneous fat into your deep tissues like muscle, tendons, and ligaments) of sacral region (bottom of the spine), stage 2 pressure ulcer (wound that affect the upper layer of your skin, open wound), of left heel, right third, fourth, and fifth toes with scabs, diabetes mellitus (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 medication refrigerator temperature was between 36-46 degrees Fahrenheit and the Refrigerator Temperature log were not missing readings on 11pm to 7am, 7am to 3pm, or 3pm to 11pm shifts on 12/27/2023. This deficient practice had the potential for harm to residents due to potential undetected temperature excursions, the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. Findings: During a concurrent observation and record review on 12/27/2023 at 6 pm in the medication storage room at station one, the medication refrigerator temperature was noted to be 12 degrees Fahrenheit. Reviewed the Refrigerator Temperature Log indicated the temperature had not been checked on the 11pm to 7am, 7am to 3pm, or 3pm to 11pm shifts on 12/27/2023. The top of the Refrigerator Temperature Log indicated, Please maintain the refrigerator between 36-46 degrees Fahrenheit. During an interview on 12/27/2023 at 6:10 pm with the Registered Nurse Supervisor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 storage, preparation and distribution of food was done under sanitary conditions for residents who eat food from the kitchen by: 1.Failing to maintain refrigerated food temperatures at safe levels. 2. Putting open date and label the food stored in the refrigerator These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting (throwing up), diarrhea (loose stool), and fever and can lead to other serious medical complications and hospitalization. Findings: During an initial kitchen tour on 12/26/2023 at 8:30 a.m.,observed in the walk-in refrigerator there were food items that were not labeled with a use by date as follows: a. Five plates of salad with lettuce, cheese, ham, and eggs wrapped with plastic wrap with no label and date. b.Four plates of cheesecake wrapped in plastic wrap with no label and date. c. Seven cups…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations to meet the resident's needs by failing to ensure the resident's television was in working order for one of two sample residents (Resident 24). This deficient practice had the potential to negatively impact the psychosocial well-being of the resident. Findings: During a review of Resident 24's admission Face Sheet indicated Resident 24 was admitted to the facility on [DATE]. Resident 24 had diagnoses that included history of fall, congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should), and cerebrovascular accident (CVA - stroke; damage to the brain from interruption of its blood supply). During a review of History and Physical Examination, dated 5/ 2/ 2018, has the capacity to make decisions. During a review of Resident 24's Minimum Data Set (MDS, a standardized comprehensive assessment tool, and care-screening tool) dated 3/2/18, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 3 failed to checked blood sugar before meals as ordered by physician for one of three sampled residents (Resident 55). This failure had the potential to result in inaccurate assessment of effectiveness of diabetic medications related to the management of type 2 diabetes mellitus ([DM] a condition in which the body fails to metabolize (process) glucose (sugar) correctly) and can lead to hypoglycemia (low blood sugar). Findings: During an interview on 12/26/2023 at 2:10 p.m. with Resident 55, Resident 55 stated the licensed nurses always checked his blood sugar after he eats his breakfast, and the results are between 150-250 milligram per deciliter ([mg/dl]-unit of measurement). During a review of Resident 55's admission Record (Face Sheet), the Face Sheet indicated Resident 55 was admitted to the facility on [DATE], with a diagnosis that include DM. During a review of the Minimum Data Set (MDS, a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the family (FM 1) and physician for one of three sampled residents (Resident 1) were notified when transportation was not available to transport Resident 1 to a General Acute Care Hospital (GACH) on 9/1/2023, per the physician's order, and failed to notify Resident 1's physician when Resident 1 had no bowel movement from 9/3/2023 to 9/5/2023. This deficient practice resulted in a delay in evaluation and treatment when Resident 1 complained of abdominal pain and was not transferred to the GACH until 9/5/2023 (four days after the transfer was ordered by Resident 1's physician on 9/1/2023). Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. The Face Sheet indicated Resident 1's diagnosis included vascular dementia (a decline in thinking skills caused by conditions that blocks or reduces blood flow to various…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Lactulose (a medication use to treat constipation [difficulty passing feces]), as prescribed, was administered to one of three sampled residents (Resident 1) when Resident 1 did not have a bowel movement for three days. When an order was obtained for Resident 1 to be transferred to a General Acute Care Hospital (GACH) on 9/1/2023, Resident 1 was not transferred, per the physician's order, until 9/5/2023 (four days after the order to transfer to the GACH on 9/1/2023) These deficient practices resulted in Resident 1's complaints of abdominal pain and a delay in evaluation and treatment. Resident 1 was transferred to a GACH on 9/5/2023 and was treated with a soap suds enema (a mixture of a mild soap and warm water injected into the colon in order to stimulate a bowel movement) twice in the GACH's Emergency Department (ED). Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation on the Medication Administration Record ([MAR] a record of all mediations administered to a resident) accurately reflected medications administered to three out of five sampled residents (Residents 1, 2 and 3). These deficient practices resulted in the inaccurate documentation that Seroquel ([Quetiapine] a medication used to treat psychotic disorders [a mental disorder characterized by a disconnection from reality]), was administered to Resident 1, Prednisone (a medication used to decrease inflammation [swelling]) was administered to Resident 2 and Empagliflozin ([Jardiance] a medication used to improve glucose [blood sugar (b/s)] control in people with type 2 diabetes ([DM] a chronic condition which affects the way the body processes b/s) was administered to Resident 3. These deficient practices placed Residents 1, 2 and 3 at risk for increased and/or uncontrolled behaviors which could affect the safety of other residents, 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.