Shoreline Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address the following for one of five sampled residents (Resident 3): 1. Failed to ensure Resident 3's foley catheter (f/c: a hollow tube inserted into the bladder to drain or collect urine) urine output was monitored and documented.2. Failed to implement Resident 3's care plan for monitoring R for edema (swelling caused by excess fluid trapped in the body's tissues) and urine output. These deficient practices placed Resident 3 at risk for complications related to unmanaged fluid balance. Findings During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), cellulitis (a skin infection that causes swelling and redness) of left and right lower limb, and…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 61) was positioned above 30 degrees while enteral feeding (G-tube - the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) was being delivered.This failure had the potential to place the resident at risk for aspiration (accidental breathing of food, liquid, or stomach contents to the airway and lungs).Findings:During an observation on 6/22/2026 at 3:12 p.m., Resident 61 was lying in bed supine, halfway down the bed. The resident's head was against the back rest of the bed with the neck bent forward.During an interview on 6/22/2026 at 3:20 p.m. with Certified Nurse Assistant (CNA) 4, CNA 4 stated, Resident 61 was lying lower than what she should be when the tube feeding was running. CNA 4 stated when the resident needs to be repositioned, the tube feeding (medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) should be turned off.During a concurrent observation and interview on…

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

Based on observation, interview, and record review, the facility failed to implement non-pharmacological interventions for one of one sampled resident (Resident) 26 prior to administering pain medication.This failure had the potential to place the resident at risk for the increased use of unnecessary medications.Findings:During an interview and record review on 6/24/2026 at 10:14 a.m. with Licensed Vocational Nurse (LVN) 2, Medication Administration Report (MAR), for month of June was reviewed. The MAR indicated that no non-pharmacological interventions were implemented for the entire month of June for Resident 26. Licensed Vocational Nurse (LVN) 2 stated there should be documentation of non-pharmacological interventions before giving the medication because we need to make sure we are not giving unnecessary medications.During an interview and record review on 6/25/2026 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 4, the MAR and Progress Notes for month of June were reviewed. The MAR and Progress Notes indicated that no non-pharmacological interventions were implemented for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one of 24 sampled residents (Resident 9) dialysis subclavical (anatomical structure situated directly beneath the clavicle (collarbone) port was covered. This deficient practice had the potential to delay or lack of identifying complications (such as pain, infection, accidental trauma, and dislodgement) of the dialysis access site and could lead to a delay provision of dialysis treatment. Findings During an observation on 6/23/2026 at 8:34 a.m., Resident 9's right dialysis port, located beneath the collarbone, was noted to be exposed with tape residue present. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), dementia (a progressive state of decline 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 and interview, the facility staff failed to implement its policy and procedure (P&P) titled, Infection Prevention and Control Program: Infection Prevention-Foley Catheter and Central Lines revised 12/2024, for one out of 24 sampled residents (Resident 9) by failing to ensure staff took off the non-sterile gloves (everyday disposable gloves that are clean and safe for general use, but have not undergone special treatments to kill all microorganisms) prior to putting on sterile gloves to apply a clean dressing on Resident 9's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) subclavical part of the body situated directly beneath the collarbone) port (surgically created site that allows blood to safely flow through a dialysis machine for filtering) This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.Findings: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 1) was admitted back to the facility after Resident 5 was evaluated and cleared by the General Acute Care hospital (GACH) to return to the facility on 6/5/2026.These deficient practices resulted in a delayed admission from the GACH back to the facility from 6/5/2026 to 6/12/2026 and had the potential to cause psychosocial harm top Resident 1.Findings:During review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1 with diagnoses of but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS-a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) documented Resident 1's refusal to allow belongings to be inventoried for one of three sampled residents (Resident 1). This failure resulted in the facility being unable to determine the contents of Resident 1's backpack, including the amount of cash Resident 1 later reported missing.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]. Resident 1 had diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing) with acute exacerbation (sudden worsening of breathing symptoms), left lower limb cellulitis (a skin infection that causes swelling and redness), and muscle weakness (reduced muscle strength). During a review of Resident 1's History and Physical (H&P), dated 4/14/2026, the H&P indicated Resident 1 was able to make her own medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe and unobstructed egress and flooding of water from under the exit door for four of four sampled residents (Resident's 1, 3, 6 and 7) when staff positioned Resident 1's bed partially blocking the exit door and when heavy rain allowed water to enter through the exit door, creating an unsafe exit route. This deficient practice had the potential to impede the safe evacuation for Residents 1, 3, 6, and 7 during an emergency and placed residents, staff and visitors to slip and fall from the water on the floor. 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 diagnosis including displaced transverse fracture (when a bone is broken horizontally into two pieces, and the pieces have separated) of the right patella (kneecap). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/3/2026, 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 provide a quality living environment for one of the four sampled residents (Resident 1) when Resident 1 was placed in a bed in front of a flood-prone exit door. This deficient practice resulted in Resident 1's clothing becoming wet and had the potential for unnecessary damage to her clothing, which could cause emotional distress to Resident 1. 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 displaced transverse fracture (when a bone is broken horizontally into two pieces, and the pieces have separated) of the right patella (kneecap).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 1's cognition (the ability to think and reason) was moderately impaired and required supervision or touch assistance (helper provides verbal cues and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide toileting hygiene care after a bowel movement for one of three sampled residents (Resident 25). This failure had the potential to result in Resident 25 developing further skin breakdown. Findings: During a review of Resident 25's admission record, the admission record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure (diffculty or inability to breath), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of right buttock, and neuromuscular dysfunction of bladder (condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle coordination resulting in difficulty urinating or incontinence). During a review of Resident 25's History and Physical (H&P), dated 3/24/2025, the…

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

Based on observation, interview, and record review, the facility failed to ensure the protection and promotion of Resident Rights for one of six sampled residents (Resident 21) by not covering Resident 21's genital area and failing to close the privacy curtain during care. This failure had the potential to result in residents not being treated with dignity and respect, not receiving care in a manner that promotes quality of life. During a review of Resident 21's admission Record, the admission Record indicated the facility readmitted Resident 21 on 9/12/2024 with diagnoses including hemiplegia (a condition where one side of the body is completely paralyzed) and hemiparesis (a condition involves a weaker, less severe form of paralysis one side of the body) following cerebral infarction (an ischemic stroke) affecting right dominant side and cognitive communication deficit (someone has trouble communicating because they're struggling with thinking skills that are important for understanding and using language). During a review of Resident 21's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 22 and 325) had Interdisciplinary Team (IDT: group of professionals from different departments coordinate care and address the multifaceted needs of resident) meetings to discuss plan of care and discharge goals. This deficient practice had the potential to violate Resident 22 and 325's right to be an active participant in their plan of care and delay the services needed. Findings: a. During a review of Resident 22's admission record (Face Sheet), the Face Sheet indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 22 and 325) had Interdisciplinary Team (IDT: group of professionals from different departments coordinate care and address the multifaceted needs of resident) meetings to discuss plan of care and discharge goals. This deficient practice had the potential to violate Resident 22 and 325's right to be an active participant in their plan of care and delay the services needed. Findings: a. During a review of Resident 22's admission record (Face Sheet), the Face Sheet indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a resident's Advance Directive (AD-a written document that tells your health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself) upon admission for one of the four sampled residents (Resident 10). This deficient practice had the potential to cause conflict with the residents' wishes regarding health care decisions in cases where they are unable to make decisions for themselves. Findings: During a review of Resident 10's admission Record, the admission Record indicated the Resident 10 was admitted on [DATE] with diagnoses including cerebral infarction (an ischemic (blockage and loss of blood flow to the brain, causing tissue death) stroke, and metabolic encephalopathy (a change in how the brain works due to an underlying condition). During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 10's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY (Cross Reference F686 and F726) Based on observation, interview, and record review, the facility failed to notify the responsible parties, and the physician of a change of condition (COC) for two out of 16 sampled residents. The facility failed to inform: a. Resident 35's physician of a COC when Resident 35's left foot suspected deep tissue injury (SDTI, a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. It typically results from sustained pressure or shear forces that compromise blood flow, leading to subsequent tissue necrosis. Recognizing a suspected deep tissue injury is crucial for timely intervention to prevent progression to more severe wounds) was noted to have a foul (bad) odor, an area of eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base sides, and/or edges of the wound), and slough (dead tissue that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans for three of 11 sampled residents (Resident 35, Resident 52 and Resident 57) when: a. Resident 35's care plan titled Has actual impairment to skin integrity related to (r/t) left heel blister (a painful skin condition where fluid fills a space between layers of skin)initiated [DATE] was not updated until [DATE] to indicate Resident 35 had a left heel suspected deep tissue pressure injury (SDTI, a form of unrelieved pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. It typically results from sustained pressure or shear forces that compromise blood flow, leading to ischemia and subsequent tissue necrosis. Recognizing a suspected deep tissue injury is crucial for timely intervention to prevent progression to more severe wounds) and the facility failed to initiate and implement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 following were completed for two of three sampled residents: a. Resident 57 was seen by a neurologist as ordered b. Resident 63's decision making capacity was determined. This failure resulted in Resident 57 not being assessed by a neurologist potentially missing diagnostic test or services and Resident 63 potentially losing their right to make their own health care decisions and/or delaying care or treatment. Findings: During a review of Resident 57's admission record, the admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by underlying metabolic disorders or conditions), cerebral infarction (stroke - loss of blood flow to a part of the brain), and a lower spinal cord compression fracture (break in the bone). The admission record indicated 57's Family member (FM 7) was the the residents responsible party/resident's representative. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure facility staff were competent when caring for two out of 16 sampled residents (Resident 35 and Resident 57) with pressure injuries (areas of damaged skin and tissue caused by sustained pressure) by failing to: a. Ensure treatment nurse (TXN 1) was competent in performing and documenting weekly wound assessments per the facility's Wound Management and Prevention Policy and Procedure (P/P) for Resident 35. b. Ensure TXN 1 was competent in completing a change of condition (COC) assessment and notifying the physician when a change in Resident 35's left heel suspected deep tissue pressure injury (SDTI, a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. It typically results from sustained pressure or shear forces that compromise blood flow, leading to ischemia and subsequent tissue necrosis. Recognizing a suspected deep tissue injury is crucial for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social services to two (2) out of four sampled residents (Resident 15 and 325) by failing to assess the resident's psychosocial needs and trauma screening upon admission. This deficient practice had the potential for delay in the delivery of care and services. Findings: a. During a review of Resident 15's admission record , the admission record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including influenza (also known as the flu - a contagious respiratory illness caused by influenza viruses, post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and anxiety disorders (persistent and excessive worry that interferes with daily activities). During a review of Resident 15's History and Physical (H&P), dated 1/21/2025, the H&P indicated Resident 15 had the capacity to understand and make decisions. 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 provide pharmaceutical services that meet the needs of its residents, as evidenced by: 1. Failed to keep a separate record of emergency drug usage for drugs retrieved from the Cubex (a computer-controlled system that automates drug dispensing in a health facility). 2. Failed to ensure there were signatures of the licensed nurses who witnessed the non-controlled drugs disposition performed on 3/13/25. 3. Failed to ensure nurses checked the medications against the orders for accuracy when receiving medication delivered by the pharmacy, for Residents 377 and 429. (See also F-759, 760) 4. Failed to ensure nurses would consult with MD for an order to crush medications before crushing medications (Resident 67). These deficient practices had the potential for medication errors, adverse effects, and drug diversion. Findings: 1. During an interview on 4/15/25 at 12:03 PM, the director of nursing (DON) stated the pharmacy did not send Cubex transaction daily, During an interview on 4/15/25 at 12:43 PM, DON presented discrepancy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to ensure its medication error rate was less than five (5) percents (%). Three medication errors out of 31 total opportunities yielded a medication error rate of 9.68%, in 2 of 4 sampled residents (Residents 429 and 377) observed during medication administration (med pass). This deficient practice of med pass error rate at 9.68% exceeded the 5 % threshold and had the potential of adversely affecting residents' health condition. Findings: During a review of Resident 429's admission record, the admission record indicated Resident 429 was admitted to the facility on [DATE] with diagnoses included hypertension (high blood pressure) and heart failure. During a review of Resident 429's physician order dated 4/13/25 at 7:16 PM, the physician order indicated benazepril 20 mg 1 tablet orally one time a day for hypertension. A further review of Resident 429's physician orders did not reveal an order for vitamin C 500mg; however, there was a physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (refer to F-755 and 759) Based on observation, interview, and record review, the facility failed to ensure two (2) of 4 sampled residents (Residents 377 and 429) were free of significant medication errors. The facility failed to ensure: 1.Resident 377 received morphine sulfate (a potent opioid for pain management) ER (extended release, release drug slowly into the body over an extended period of time) tablet 15 milligrams (mg, unit to measure mass) as per order; instead, Resident 377 received morphine sulfate immediate release (IR, release drug into the body right away). 2.Resident 429 received benazepril (generic for Lotensin, a type of medication to treat high blood pressure) 20 mg as per ordered. Instead, Resident 429 received benazepril 40 mg. These failures led to significant medication errors that let to insufficient pain relief for Resident 377 and resulted in Resident 377 requested and received additional pain relief more frequently for breakthrough pain and had the potential to cause hypotension (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 the standardized recipes and portion sizes for lunch menu was followed on 4/15/25 when: 1.cook used small scoop size to serve Barbeque (BBQ) chicken for residents who were on ground texture modified diet. Four residents on ground texture diet received 2 2/3 ounces (oz.) of chicken instead of 3 oz. per the menu. 2.15 residents on mechanical soft diet (diet for residents who experience chewing or swallowing limitations, food texture is modified by chopping or grinding), received bbq chicken cut into inconsistent sizes instead of ground bbq chicken per menu and spreadsheet (food portion and serving guide) 3.Facility failed to ensure staff followed food production recipes for the puree diet (food that is blended to a pudding consistency, no chewing required). Ten residents on pureed diet received plain pureed chicken and bbq sauce on top instead of pureed chicken with bbq sauce mixed in per the recipe. These deficient practices have the potential to result in meal dissatisfaction, decreased nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: a. follow transmission-based precautions (TBP) for one of three sampled residents (Resident 64) in contact isolation for clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea), b. follow enhanced barrier precautions (EBP) and indwelling catheter (type of flexible tube which a clinician passes through the urethra and into the bladder to drain urine) was not touching the floor for one of three sampled residents (Resident 70), and c. report an outbreak of C.diff to the local and state health departments. This failure had the potential to prevent an outbreak from spreading and transmit infectious diseases placing all residents at an increased risk of infection. Findings: a. During a review of Resident 64's admission record , the admission record indicated Resident 64 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pancytopenia (a condition in which there 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 monitor the immunization status for the Influenza (flu: a contagious respiratory illness) and Pneumococcal (PC: bacterial infection that causes serious lung infections) vaccinations (medication to prevent a particular disease) for two of five sampled residents (Resident 12 and 49). This deficient practice resulted in Resident 12 and 49's incomplete medical records. Findings: a. During a review of Resident 12's admission record (Face Sheet), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD: a chronic lung disease causing difficulty in breathing), atrial fibrillation (irregular and rapid heart rhythm), and hypertension (HTN: high blood pressure). During a review of Resident 12's History and Physical (H&P), dated 3/23/2025, the H&P indicated Resident 12 has the capacity to understand and make decisions. During a review of Resident 12's Minimum…

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

Based on interview and record review, the facility failed to provide documented evidence of facility employees' screening, education, offering (vaccination), and current Corona virus disease, ([COVID-19] a highly contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This deficient practice had the potential to place the facility staff and residents at risk for outcomes such as severe pneumonia (inflammation of lungs that cause difficulty breathing) which could lead to hospitalization due to COVID-19. Findings: During a concurrent interview and record review on 4/17/2025 at 11:34 a.m. with the Infection Prevention Nurse (IPN), the IPN stated she does not have the Covid-19 vaccination status for on-call (employees not actively performing job duties but remain under the employer) and part time employees and indicated she should have the Covid-19 vaccination statuses for the on-call and part time employees. The IPN stated she does not have the Medical Doctor (MD) or other licensed professional's Covid-19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report immediately and not later than twenty-four hours after receiving an allegation of abuse to the state agency as indicated in the facility's policy and procedure (P/P) for one of six sampled residents (Resident 2). As a result of this deficient practice Resident 2 had the potential to experience additional mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) from Resident 2's alleged abuser, family member (FM) 4 causing Resident 2 increased anxiety (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). (cross reference F600 and F610) 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 confirmed physical abuse, major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate an allegation of abuse as indicated in the facility's policy and procedure (P/P) for one of six sampled residents (Resident 2). As a result of this deficient practice Resident 2 had the potential to experience additional mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) from Resident 2's alleged abuser, family member (FM) 4 causing Resident 2 increased anxiety (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). (cross reference F600 and F609) 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 confirmed physical abuse, major depressive disorder (a mental health condition that causes a persistently low or…

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

Based on interview and record review, the facility failed to complete a written bed-hold form upon transferring for one of three sampled closed record review residents (Resident 72). This deficient practice had a potential to result in placing the residents at risk for not knowing their rights and not being able to return to the facility. Findings: During a review of Resident 72's admission Record, the admission Record indicated the facility admitted Resident 72 on 1/14/2025 with diagnoses including aftercare following joint replacement surgery (a surgery to restore the function of a joint) and history of falling. During a review of Resident 72's Nursing Progress Notes, dated 1/15/2025, the Nursing Progress Notes indicated, the resident had an un-witnessed fall on 1/15/2025 and was transferred to a general acute care hospital. During a review of Resident 72' Bed-hold notification, undated, the Bed-hold notification indicated that 'to be completed upon transfer' section on the form remained blank. During an interview on 4/17/2025 at 9:08 a.m., with Registered Nurse Supervisor (RNS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Falling Star Program, dated 3/20/2024, that indicated, if the resident has fallen in the last 30days, staff would place a falling star sticker on their door tag to ensure one of one sampled resident (Resident 11) remained free of accident by not placing a star sticker on resident's door post. Resident 11 had four times falls in the past four months. This failure had the potential for Resident 11 to sustain injuries from falling, due to lack of proper supervision that would be indicated by a falling star sticker. Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility Resident 11 admitted Resident 11 on 8/17/2022 with diagnoses including Dementia (Progressive loss of mental abilities like memory, thinking, and reasoning, so severe that it interferers with daily [NAME]) and history of transient ischemic attack (a temporary interruption…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) titled, Oxygen, Use of, revised 5/2021, that indicated, the oxygen cannula or mask, and the disposable humidifier would be changed at least every seven days, by not replacing the nasal canula after being used more than seven days for one of one sampled resident (Resident 52). This failure has the potential to compromise the resident's safety and well-being and spread of infection. Findings: During a review of Resident 52's admission Record, the admission Record indicated the facility admitted Resident 52 on 4/17/2024 and readmitted on [DATE] with diagnoses including acute respiratory failure (difficulty breathing) with hypoxia (a condition where there is not enough oxygen [life sustaining element of air] to supply the body) and chronic obstructive pulmonary disease (COPD-a progressive lung disease that makes it hard to breathe due to damaged airways and lung tissue). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician face-to-face visit was made by a physician at least once every 60 days for one of three sampled residents (Resident 49). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment and services. Findings: During a review of Resident 49's admission record (Face Sheet), the Face Sheet indicated Resident 49 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (heart unable to pump enough blood to meet the body's needs), and HTN. During a review of Resident 49's Minimum Data Set [MDS] a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 49's cognitive skills (the mental action or process of acquiring knowledge 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 two sampled residents (Resident 52) was free of unnecessary psychotropic medicine (any drug that affects brain activities associated with mental processes and behavior) by failing to ensure there was evidence of non-pharmacological intervention or evaluation of environmental triggers for resident 52's routine use of temazepam (generic for Restoril, a hypnotic/psychotropic used to aid in sleeping) for inability to sleep. This deficient practice had the potential to place Resident 52 at risk for using psychotropic medicine for excessive duration which could lead to the development of adverse effects and/or dependency. Findings: During a review of Resident 52 's admission Record, the admission Record indicated Resident 52 was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included cerebral infarction ( blood flow to the brain is interrupted causing brain cells to die), acute embolism and…

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

Based on observation, interview and record review, the facility failed to ensure one of 24 sampled resident (Resident 44) food preferences were honored when strawberry Flavored Gelatin was placed on Resident 44's lunch tray, despite Strawberry being listed as a allergy and disklike on Resident 44's meal tray ticket. This failure had the potential to result in decreased meal satisfaction and consumption and negatively affect Resident 44 nutritional status. Findings: During a review of Resident 44's Nutrition-Quarterly Evaluation dated 1/31/2025 indicated resident food dislikes includes strawberries allergy. During an observation of lunch service in the kitchen on 4/15/2025 at 11:30AM, DA1 served strawberry Gelatin to resident 44. During a dining observation on 4/15/2025 at 1:00PM, Resident 44 was eating lunch in the room. Resident 44 stated today's desert is strawberry gelatin and I am allergic to strawberries but they still put the strawberry gelatin on my tray. Resident 44 stated kitchen staff know I am allergic, but they still served the strawberry gelatin. Resident 44 stated I am…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five sampled residents (Resident 40) with range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) concerns had complete and accurate medical records by failing to: 1. Accurately indicate the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) providing Resident 40's RNA services for active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms and legs and sit to stand transfers (ability to come to a standing position from sitting) on 7/2/2024, 7/3/2024, 7/4/2024, 7/15/2024, 7/16/2024, 7/17/2024, 7/18/2024, 7/22/2024, and 7/25/2024. 2. Accurately indicate the RNA providing Resident 40's RNA services for AAROM to both arms and legs on 4/15/2025. These failures resulted in inaccurate medical records for the provision of…

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

Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA: committee that focuses on identifying and addressing quality deficiencies in resident care) failed to ensure effective oversight of the facility and implementation of their Quality Assurance and Performance Improvement (QAPI: systemic approach to improve the quality of care and services provided to residents) plan. This deficient practice had the potential to have reoccurring deficient practices that can impact the quality of care for the residents. Findings: During an interview on 4/18/2025 at 4:39p.m. with Administrator (ADM), ADM stated QAPIs are projects for areas of concern that require improvement, identify negative trends, and initiate a plan to improve the facility. During an interview on 4/18/2025 at 4:59p.m. with ADM, ADM stated they had recently initiated a QAPI plan for skin on 4/15/2025. ADM stated weight loss and skin correlate with one another and had a discussion regarding one resident who had a pressure injury (localized damage to the skin and underlying soft…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) 1 failed to administer medication on time in accordance with written orders of the attending physician for five of five reviewed residents This deficient practice of failing to administer medications in accordance with the physician orders increased the risk of Residents 1,2, 3,5, and 6 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization. Findings: During concurrent observation, interview and record review on 3/3/2025 at 11:09 p.m., with LVN 1 and the Director of Nursing (DON), inspected Medication Cart #1 after medication administration. Observed Resident 1,2,3,5, and 6, 9 a.m. medications were not given at scheduled time. Reviewed Medication Administration Record (MAR) for Resident 1,2,3,5, and 6 and was not signed (documented) as given). LVN 1 stated medications of Resident 1,2,3,5,6 was not given at 9a.m.LVN 1 stated she will notify Resident…

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

Based on observation, interview and record review, the facility failed to label with an open date, when a multi-dose vial of Humulin N (a medication that lowers levels of glucose-sugar in the blood to manage diabetes mellitus-DM - high blood sugar) 100 IU vial (10 milliliter [ml-unit of measurement]) was opened, in medication cart #2. This deficient practice had the potential for loss of efficacy of residents' insulin, had the potential for unintentional medication administration of possibly expired medications for residents. Findings: During a concurrent observation and interview on 3/3/2025 at 12:31 p.m., with Licensed Vocational Nurse (LVN 2) of medication cart #2, observed a vial opened vial of Humulin R 100 IU vial 10ml, (Lot number D767980A, expiration date of august 2027) was found in the medication cart without an open date label. LVN 2 stated whoever opened the Humulin R vial, should have placed an open date on the label. LVN 2 stated she was not the one that open the Humulin R vial and no knowledge on when it was open. LVN 2 stated she will discard the Humulin R vial and…

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

Based on observation, interview, and record review, Licensed Vocational Nurse (LVN 2) failed to take off used gloves and wash hands after performing blood sugar check to resident. This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: During an observation and interview on 03/03/25 at 12::31 a.m. with Licensed Vocational Nurse (LVN2), LVN 2 was observed finishing blood sugar check, witness by surveyor and Director of Nursing (DON) leaving resident room, with used dirty gloves after performing blood sugar check and went down the hallway towards her medication cart to dispense the lancets used to do blood sugar check. LVN 2 admits she supposed to take off her used gloves and wash her hands before leaving the room and not to walk outside the room with dirty used gloves in the hallway. LVN 2 stated I should bring my cart closer by the room door where I was doing my blood sugar check, I am not supposed to walk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was: 1. implemented for 1 of 3 sampled residents (Resident 114) when nursing staff assist Resident 114 with fracture of the fourth thoracic vertebrae (upper back) during her turning and repositioning in bed), 2. revised for 1 of 3 sampled residents (Resident 115) to include a dialysis emergency kit (E-Kit- supplies including gauze, tape and clamp used to stop bleeding) in Resident 115's interventions to address possible bleeding emergencies. 3. formulated for 1 of 3 sampled residents (Resident 53) who was prescribed and taking a medication Plavix (a medication used to prevent clots forming in the blood vessels to prevent a stroke, heart attack or death, with prolonged and excessive bleeding as an adverse or side effect). These failures had caused Resident 114 to be uncomfortable when assisted by the nursing staff during turning and repositioning and had the potential for delay of care and services 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 staff failed to: 1. Properly store lentils and black beans according to the facility's policy and procedure. 2. Properly place thawing meat such as fish and chicken appropriately in the refrigerator when the thawing fish was placed on top of hard-boiled eggs and raw vegetables were placed next to thawing chicken. These deficient practices have the potential to place 62 residents who are served food from the facility's kitchen at risk for foodborne illness. Findings: During an observation on 4/13/2024 at 6:47 a.m. of the facility's dry food storage, there was one open bag of lentils and one open bag of black beans both closed with plastic ties. During an observation on 4/13/2024 at 7:05 a.m. of the facility's #1 refrigerator, there was chicken defrosting at the bottom of the refrigerator in red liquid at a metal tray next to a plastic bin of raw vegetables that has cabbage and zucchini. It was observed in the facility's #1 refrigerator, at the third shelf, there was raw fish on ice defrosting in a metal tray, the metal…

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

Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 164 and Resident 2) were free from risk of contracting infection when: a. the facility failed to properly store one of one sampled resident's (Resident 164) oxygen tubing (a device that provides additional oxygen through the nose) when Resident 164's oxygen tubing was found on the floor. b. Resident 2's foley catheter (a tube that is inserted into the bladder, allowing the urine to drain freely into a collection bag, which must be strapped and/ or secured) was not secured to prevent from touching the floor. These deficient practices have the potential to spread germs and bacteria from the floor to Resident 164 and Resident 2. Findings: A. During an observation on 4/13/2024 at 8:10 a.m., in Resident 164's room, Resident 164's oxygen tubing was found on the floor to the right of Resident 164's bed. During an interview on 4/13/2024 at 8:10 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the oxygen tubing should not be on the floor. LVN 1 stated the oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship program policy for three of three sampled residents (Resident 27, 59 and 164) by not completing the McGreer's Criteria (criteria used to determine appropriate use of antibiotics). This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings: During a review of Resident 27's admission Record, the record indicated Resident 27 was admitted on [DATE] with the diagnoses including urinary tract infection (bacterial infection of the bladder). During a review of Resident 27's Minimum Data Set ([MDS]-a standardized resident assessment and care screening tool) dated 4/2/2024 indicated Resident 27's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 27 required supervision from facility staff to complete activities of daily living (ADLs- eating, drinking,…

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

Based on observation, interview and record review, the facility failed to ensure the call lights of two of two sampled residents (Resident 53 and Resident 42) were fixed in a timely manner. This failure has the potential for delay of care and services to Resident 53 and Resident 42. Findings: A. During a review of Resident 53's admission Record (face sheet) dated 2/26/2024, the face sheet indicated Resident 53 was admitted to the facility with diagnoses including cerebral infarction (also known as stroke- a medical condition that happens when there is a loss of blood flow to the part of the brain). During a review of Resident 53's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/4/2024, the MDS indicated the MDS indicated Resident 53 was able to make independent decisions that were reasonable and consistent, requires one-person substantial/ maximal assist (helper does more than half the effort, the helper lifts or holds trunk or limbs and provides more than half the effort) to complete her activities of daily living ({ADLs} task such as bathing/…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of three sampled residents (Resident 27 and Resident 116) received care consistent with standards of practice by failing to: A. monitor Residents 116's left upper extremity for skin breakdown per care plan and physician orders. B. monitor Resident 27 for the side effects of Aspirin (medication to thin blood) consistent with the facility policy. These deficient practices: A. resulted in a delay in care and services for Resident 116, whose wound on the left upper extremity was not assessed and not treated for approximately six hours leading to discomfort and risk or skin infections. B. resulted in a lack of assessment for Resident 27 and the potential to cause a delay in needed services. Findings: A. During a review of Resident 116's admission Record (Face Sheet), the Face Sheet indicated Resident 116 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (brain disorder that causes unintended or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents maintain their function and joint mobility) program for one of three sampled residents (Resident 10) when RNA was provided four times a week instead of five times a week as per the physician order. This deficient practice had a potential to place Resident 10 at risk for a decline in range of motion (ROM). Findings: During a review of Resident 10's admission Record, the record indicated Resident 10 was admitted on [DATE] with the diagnoses including a history of falling and difficulty in walking. During a review of Resident 10's Minimum Data Set ([MDS]-a standardized assessment and care screening tool) dated 3/12/2024 indicated Resident 10's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 10 was dependent on facility staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 47) medication regimen review (MRR-) thorough evaluation of the medication regimen of a resident) order clarification for Ibuprofen (medication is used to treat pain) to be given with food was acted upon. This deficient practice had the potential to result in Resident 47 experiencing side effects of being administered Ibuprofen (Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are widely used to relieve pain, reduce inflammation, and bring down a high temperature.) on an empty stomach. Findings: During a review of Resident 47's admission Record (Face Sheet), the record indicated Resident 47 was admitted on [DATE] with the diagnosis of orthostatic hypotension (low blood pressure when standing after the person has been sitting or lying down) and syncope (fainting or passing out). During a review of Resident 47's Minimum Data Set ([MDS]- a standardized assessment and screening tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to maintain an accurate documentation of Restorative Nursing Assistant (RNA- nursing aide program that helps residents maintain their function and joint mobility) weekly progress report for one of two sampled residents (Resident 48) when the report dated 4/10/2024 was not complete. This deficient practice placed Resident 48 at risk for a decline or improvement in RNA progress to go undocumented. Findings: During a review of Resident 48's admission Record, the record indicated Resident 48 was admitted on [DATE] with the diagnoses including difficulty walking and muscle weakness. During a review of Resident 48's Minimum Data Set ([MDS]-a standardized assessment and care screening tool) dated 1/31/2024 indicated Resident 48's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. During a review of Resident 48's RNA weekly progress report dated 4/10/2024 was blank.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary drugs by failing to: 1.Obtain an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for the use of a psychotropic medication (drug that affects brain activities associated with mental processes and behavior) for depression (persistent sadness and a lack of interest or pleasure)per the facility's policy and procedure (P&P). 2. Implement a care plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments) for depression per facility's P&P. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including pericardium disease (an inflammation of the pericardium or sac that contains your heart), hypertension (high blood pressure) 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.