Alexandria Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 14) who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment, received services consistent with professional standards of practice, by failing to ensure: 1. Licensed Nurses (LNs) followed the physician's order for a 1200 cc (cubic centimeter - unit of measurement used for liquids, (1cc equivalent to 1 ml (milliliter) - metric unit of measurement used for liquids) a day fluid restriction (limiting the total amount of liquids you consume each day) and monitored Resident 14's fluid intake. 2. LNs obtained a physician's order to monitor Resident 14's intake and output (I&O - the measurement of all the fluids that go into a person's body and all the fluids that leave it). 3. The facility developed and implemented a comprehensive, resident centered Care Plan (CP) addressing the 1200 cc a day fluid restriction. 4. LNs notified 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 safely use bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) for four of four sampled residents (Resident 14, 77, 82 and 108) by failing to ensure: 1. Resident 14's half (1/2) bed rails (a 1/2 (half-length) bed rail is a safety barrier that covers only the top portion of a bed, typically near the user's torso) had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and complete bed rail assessment on its use. 2. Resident 77's 1/2 bed rails had a physician's order, informed consent and a comprehensive, person-centered care plan for its use. 3. Resident 82's 1/2 bed rails had a physician's order, informed consent, bed rail assessment and comprehensive, person-centered care plan for its use. 4. Resident 108's 1/2 bed rails had a physician's order, complete bed rail 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) by failing to:1.Ensure Licensed Vocational Nurse (LVN) 7 administered benazepril (medication to treat high blood pressure), aspirin (medication that helps prevent blood clots [clumping of blood]), fish oil (supplement to treat high cholesterol), and refresh tears eyes drops (medication to treat dry eyes) per the physician's orders on 5/18/2026. during the routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely) for one of six sampled residents (Resident 140) reviewed for Accidents. 2.Ensure LVN 7 did not document the administration of benazepril, aspirin, and fish oil prior to leaving the medication for self-administration for one of six sampled residents (Resident 140) reviewed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately in one of two medication rooms (Med Room Station 1) and one of four medication carts (Med Cart Station 3) observed during the Medication Storage and Labeling task by failing to: 1. Label the house supply of tuberculin purified protein derivative (PPD) (Aplisol - an injectable solution used in the skin test to detect tuberculosis [TB - a bacterial infection that primarily affects the lungs] infections) with an open date in accordance with manufacturer's requirements in Med Room Station 1. 2. Ensure the removal and disposal of Resident 112's hydrocodone-acetaminophen (used to treat moderate to severe pain) bubble pack (a medication packaging system that contains individual doses of medication per bubble) slot #28 with broken seal and was covered with tape in Med Cart Station 3. 3. Ensure the removal of expired medication, Resident 29's morphine, in Med Cart Station 3. These…

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

Based on observation, interview, and record review, the facility failed to follow the menu to meet the nutritional needs of 68 to 164 residents, when staff did not provide the three (3) ounce (oz, unit of measurement) portion size of pork roast indicated on the menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) and served 1.5 oz portion instead. This failure had the potential to result in a decrease in food flavor, a decrease in food and nutrient intake that could result in unplanned weight loss. Findings: During a review of the facility's menu spreadsheet titled Spring 2026, dated 5/18/2026, the spreadsheet indicated residents on a regular texture diet would include the following foods on the tray: Pork Roast 3 oz During an observation on 5/18/2026 at 11:53 a.m. of the food preparation, the roast pork was not uniform in size, some were bigger while some were smaller.During an interview on 5/18/2026 at 12:25 p.m. with [NAME] 1, [NAME] 1 stated he cut the pork roast from scratch as they were not individually pre-portioned. [NAME] 1 stated he did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature and flavor when hot foods were not served hot and pork roast, and seasoned black beans were not seasoned well and tasted bland. These failures had the potential to result in 157 of 164 facility residents including Resident 149, Resident 34, Resident 50, and Resident 163 to be at risk of unplanned weight loss, a consequence of poor food intake and receiving food from the kitchen.Findings: a). During a review of Resident 149's admission Record (AR), the AR indicated the facility initially admitted Resident 149 on 3/16/2017 with diagnosis including, but not limited to gastrointestinal reflux disease (GERD, stomach acid or contents frequently flow back in to the esophagus [the tube connecting the mouth and stomach]) without esophagitis (swelling or irritation of the tissues lining the esophagus), anxiety disorder (excessive fear or worry about a specific situation), and anemia (a condition in…

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

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed corn bread was too sticky and did not fall from the spoon during the spoon tilt test (a method used to determine the stickiness of the food and ability of food to hold together) and the puree smothered cabbage did not hold its shape and it was flat on the plate causing it to touch the other food items. These failures had the potential to result in difficulty swallowing and difficulty in eating, and a decrease in food and nutrient intake to 33 of 33 residents on a puree diet (foods that are soft, pudding like consistency and hold its shape), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).Findings: During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Spring Menus, dated 5/18/2026, the spreadsheet indicated residents on a puree diet/International Dysphagia Initiative ([IDDSI]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 5/18/2026.This deficient practice had the potential to result in hunger and frustration for 157 to 164 residents, including Resident 163.Findings: During a review of Resident 163's admission Record (AR), the AR indicated the facility admitted Resident 163 on 5/1/2026 with diagnosis including, but not limited to gastrointestinal reflux disease (GERD, stomach acid or contents frequently flow back in to the esophagus [the tube connecting the mouth and stomach]) without esophagitis (swelling or irritation of the tissues lining the esophagus), essential hypertension (HTN, increased blood pressure), type 2 diabetes mellitus (a chronic condition where body does not make enough insulin [natural hormone produced by the pancreas] or cannot use it properly resulting to increase of blood sugar levels.During a review of Resident 163's Order Summary, dated 5/1/2026, the report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen and storage areas were not free from dirt and debris. a. Walk-in refrigerator racks had white dirt residue, black dirt and dry food particles. b. Walk-in refrigerator floor contained dry lettuce, trash and tape debris. c. Dry storage floor had cream of wheat particles. 2. Kitchen storage surfaces were not of cleanable surfaces a. Two (2) metal racks in the walk-in freezer had amber discoloration and rust. b. Four (4) of 4 racks had paint coming off in the dry storage area. c. Sixty-six (66) of 66 residents' trays had cracks, chips, and scratches. d. Three (3) drying racks were rusted with amber discoloration. 3. Mislabeled foods in the dry storage room area indicated expired foods. 4. There was no thermometer in the dry storage area. 5. One (1) dented (a metal container with a depression or hollow made by pressure or impact) can was stored…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two (2) of five sampled residents (Resident 83 and 141) reviewed for medication administration task by failing to:1. Ensure that the Psychotropic Medication Administration Disclosure had the physician's signature, and date when the resident signed the consent. 2. Ensure that Licensed Vocational Nurse (LVN) 7 and Registered Nurse (RN) 5 accurately documented Resident 141's administered medications as ordered on 5/16/2026 and 5/19/2026. These deficient practices had the potential to result in incomplete, inaccurate, and delayed records that could lead to miscommunication between healthcare providers and resident harm.Findings: 1. During a review of Resident 83's admission Record (AR), the AR indicated that the facility admitted the resident on 4/17/2026 with diagnoses including cerebral infarction (also known as ischemic stroke occurs when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care was provided consistently for one of one sampled resident (Resident 16) reviewed under hospice and end of life care area who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to: 1. Ensure Resident 16's medical records included documentation of the Certified Home Health Aide (CHHA) visit notes, the hospice plan of care, and the hospice calendar. 2. Ensure Hospice Provider (HP) 1 hospice calendar was followed for the CHHA visits on multiple days for the month of 1/2026 and 2/2026. These deficient practices had the potential to negatively affect Resident 16's physical comfort, psychosocial well-being, and had the potential to result in a delay or a lack of necessary care and services. Findings: During a review of Resident 16's admission Record (AR), the AR indicated that the facility admitted the resident on 10/21/2026, with diagnoses including malignant neoplasm (a tumor that can invade…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. A disposable (one time use) yellow gown with a tear hanging on the washing machine was disposed of properly in the trash after being used. 2. Five out of six linen carts on the units were not covered with a permeable (material that allowed liquid or gas to pass through)/mesh material observed during infection control task. These deficient practices had the potential to cause cross-contamination (the invisible transfer of harmful germs, allergens, or chemicals from one object, surface, or food to another) of infection among residents and staff. Findings: 1.During an observation on 5/21/2026 at 2:00 p.m., inside the laundry area, observed a yellow disposable gown hanging on the washing machine. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat one of one sampled resident (Resident 161) with respect and dignity when Certified Nurse Assistant (CNA) 3 failed to maintain privacy for Resident 161 while providing Activities of Daily Activities (ADL - basic tasks that must be accomplished every day for an individual to thrive) care. This deficient practice had the potential to cause emotional distress and affect the resident's self-esteem and cause a loss of dignity and decline in psychosocial wellbeing. Findings: During a review of Resident 161's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility originally admitted Resident 161 on 6/16/2023, and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a temporary brain malfunction caused by chemical imbalances in the body rather than a direct head injury), urinary tract infection (UTI - an infection in the…

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

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of five sampled residents (Resident 4) reviewed for unnecessary medications by failing to ensure bupropion (medication used to treat depression [persistent feelings of sadness and loss of interest that can interfere with daily living]) was prescribed and monitored for specific, measurable behavioral manifestations. This deficient practice had the potential to result in the administration of unnecessary psychotropic medication and placed residents at increased risk for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication therapy, such as sedation, drowsiness, dry mouth, blurred vision, muscle tremor, agitation, and possibly leading to impairment or decline in their mental or physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP-is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of five sampled residents (Resident 14) addressing the resident`s use of Insulin ( a medication to treat high blood sugar level) Aspart injection solution (a fast-acting, man-made version of human insulin). This deficient practice had the potential to result in a delay of nursing care and medical interventions for the residents. Findings: During a review of Resident 14's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility originally admitted Resident 14 on 6/6/2024, and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra…

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

Based on observation, interview, and record review, the facility failed to provide wound treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to administer wound care treatments per the physician's orders when calcium alginate dressings (a dressing that absorbs wound fluid resulting in a gel-like substance that promotes moist wound healing) were applied without a physician's order for one sampled resident (Resident 11). These deficient practices had the potential to result in a delay of healing or worsening of wounds on Resident 11's left toe and left leg. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility originally admitted the resident on 12/26/2023 and most recently admitted the resident on 2/9/2026 with diagnoses that included pressure injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of the sacral region (tailbone) Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 171) received proper care and services by failing to ensure the resident`s urinal bottle (a portable, handheld container designed to collect urine when a person cannot get to the bathroom) was labeled with a date it was given, the resident's initials, and room number. This deficient practice had the potential to increase the risk for urinary tract infection (UTI - when germs infect the urinary tract or bladder infection). Findings: During a review of Resident 171's admission Record (AR), the AR indicated that the facility admitted the resident on 5/08/2026, with diagnoses including cellulitis of abdominal wall (a bacterial infection of the skin and underlying tissues in the belly), cirrhosis of the liver (a condition which the liver is scarred and permanently damaged), and depression (a serious mood disorder that causes persistent sadness, loss of interest in activities. During a review of Resident 171's Minimum Data Set (MDS, a resident assessment 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.

Based on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of six sampled residents (Resident 140) reviewed for Accidents by failing to ensure Licensed Vocational Nurse (LVN) 7 administered benazepril (medication to treat high blood pressure) per the physician's orders on 5/18/2026 during the routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely). This deficient practice had the potential to result in increased blood pressure in the resident leading to organ damage and possible hospitalization. Cross-reference F755 and F689. Findings: During a review of Resident 140's admission Record (AR), the AR indicated that the facility admitted the resident on 5/9/2022, with diagnoses including…

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

Based on interview and record review, the facility failed to follow professional standards of nursing practice for one of four sampled residents (Resident 1) by failing to ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's Change of Condition (COC) on 3/26/2026 related to the resident's reported facial trauma. This deficient practice had the potential to result in the failure to identify continued or worsening clinical deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/7/2024 with diagnoses including Parkinson's disease (a progressive brain disorder that causes problems with movement, balance, and muscle control), age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]), and osteoarthritis (occurs when the cartilage that cushions the ends of bones in the joints gradually…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the physician regarding a resident's significant change of condition for one of three sampled residents (Resident 1). The facility identified Resident 1 had shortness of breath on 1/16/2026 at 7 p.m. while on (BiPAP) machine (a noninvasive ventilator used to assist breathing by delivering pressurized air through a mask) but did not notify the Medical Doctor.This deficient practice placed Resident 1 at risk of developing complications. Findings:During a review of Resident 1's Face Sheet (admission Record), undated, the Face Sheet indicated the facility originally admitted Resident 1 on 1/9/2026, with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), moderate persistent asthma (is a long-term lung disease that inflames and narrows the airways, making it difficult to breathe), and personal history of other venous thrombosis (or deep vein thrombosis, DVT - is a serious condition where a blood clot forms in a deep vein, most…

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

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1) to address that Resident 1 had a personal history of other venous thrombosis (or deep vein thrombosis, DVT - is a serious condition where a blood clot forms in a deep vein, most commonly in the legs or thighs, and is dangerous if the clot breaks loose and travels to the lungs), and embolism (is an obstruction or blockage in a blood vessel). This failure had the potential to delay provision of necessary care for Resident 1. Findings:During a review of Resident 1's Face Sheet (admission Record), undated, the Face Sheet indicated the facility originally admitted Resident 1 on 1/9/2026, with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and personal history of other venous thrombosis and embolism. 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 implement its policies and procedures related to residents and/or responsible party notification rights for one of three sampled residents (Resident 1) when Resident 1 received an order for x-ray (a photographic or digital image of internal parts of the body) of bilateral (both sides) hips, which Resident 1 or responsible party were not informed about.This deficient practice denied Resident 1 and the responsible party the rights to know, to understand, and to make informed decisions related to Resident 1's care. Findings:During a review of Resident 1's admission Record, undated, the admission Record indicated an admit date on 12/25/2026 with diagnoses including displaced intertrochanteric fracture of right femur (a break in the hip bone on the right thigh bone), displaced fracture of epiphysis (a bone injury where the upper part of thigh bone separates from rest of the bone), anxiety disorder (excessive worrying that interferes with daily activities), and major depressive disorder (persistent feeling of sadness and loss 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 maintain accurate and complete medical record for one of three sampled residents (Resident 2) by:Failing to accurately document notification of the physician on 1/10/2026, when Resident 2 had an incident of fall.Failing to ensure Registered Nurse 2 (RN 2) documents her (RN 2) intervention on 1/20/2026, after Resident 2's fall incident.Failing to completely document incidents on Resident 2's fall on 11/13/2025.Failing to document date and time of Family Member 1 (FM 1) notification on 5/16/2023, of Resident 2's change in condition.These failures had the potential to result in the medical records containing inaccurate and incomplete documentation.Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 9/22/2022, and readmitted on [DATE], with diagnoses that included traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) were free from physical restraint (a strap or other thing that holds a person in place) by failing to monitor Resident 2 on the use of bed alarm device (a safety tool used in hospitals, nursing homes, and home care to detect when a person is attempting to leave their bed, alerting caregivers to prevent falls, or potential emergencies).This failure had the potential to result in unnecessary restraint and placed the residents at risk of agitation (a state of extreme mental and physical restlessness) and entrapment (situation where a resident becomes caught, trapped, or tangled in the bed frame, mattress, or side rails while attempting to move, get out of bed, or during the use of restrictive device).Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 9/22/2022, and readmitted on [DATE], with diagnoses 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 a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 2).This failure had the potential for confusion of care and had the potential to result in Resident 2's fall. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 9/22/2022, and readmitted on [DATE], with diagnoses that included traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury), unspecified (unconfirmed) chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and muscle weakness.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 10/31/2025, the MDS indicated Resident 2's cognitive (mental action or process of…

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

Based on interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) by failing to provide clean and sanitary utensils to Resident 1. This failure had the potential to place Resident 1 at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverage) and placed Resident 1 at risk for infection. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/9/2025, with diagnoses that included unspecified (unconfirmed) epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), immunodeficiency (a condition where the body's immune system, its natural defense against illnesses is weakened or not working properly) and essential hypertension (high blood pressure with no single, identifiable medical cause).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's 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.

Based on interview and record review, the facility failed to clarify the physician's order for one of three sampled residents (Resident 1) by failing to:1. Ensure licensed nurses clarify the two physician orders of famotidine (medication used to decrease amount of acid in the stomach). On 11/1/2025 to 11/4/2025, Resident 1 received two doses of famotidine at 6:30 a.m., and at 9 a.m. 2. Ensure licensed nurses follow the physician order to administer guaifenesin (medication used to treat chest congestion) and dextromethorphan (medication used to treat cough)- guaifenesin medication every six hours as needed. On 11/20/2025, Resident 1 received the two medications with only three hours in between.These failures had the potential to result in Resident 1 experiencing side effects (any unintended response to a medicine or treatment that happens in addition to its main purpose) like nausea, vomiting, drowsiness (feeling unusually sleepy) and/or low blood pressure.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its infection control measures for two of three sampled residents (Residents 2 and 6) who were on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to:a. Ensure Registered Nurse 4 (RN 4) wore a mask, gloves, and gown before disconnecting and flushing (pushing fluid through an intravenous [IV-within a vein]) Resident 2's IV line. b. Ensure Licensed Vocational Nurse 2 (LVN 2) wore a mask, gloves, and gown at Resident 2's bedside. c. Ensure LVN 3 wore a gown at Resident 3's bedside while providing gastrostomy tube (gtube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) care.These failures had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminants from one surface to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by:Failing to develop a care plan on legionnaires disease (a severe form of a lung infection called pneumonia caused by a bacterium known as legionella) when Resident 1 had presumptive positive (a test administered by local health professionals is positive) legionella (naturally found in [NAME], but becomes a health risk when they grow in man-made water systems and the contaminated water is aerosolized - tiny particles suspended in the air, leading to inhalation and causing lung illness) upon return to the facility on [DATE].Failing to develop a care plan on Resident 1's use of azithromycin (medication used to treat infection) when Resident 1 had azithromycin on 11/30/2025.These failures had potential for delay in the delivery of necessary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to accurately document oxygen device used by Resident 1 on [DATE].This failure had the potential to result in confusion in care and the medical records containing inaccurate documentation.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE], with diagnoses that included hereditary (something passed down from one generation to the next) and idiopathic (a disease or condition arises from an unknown or spontaneous cause) neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and history of falling.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated [DATE],…

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

Based on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) program and infection prevention and control program for one of three sampled residents (Resident 1) by failing to monitor Resident 1 for the use and adverse effects (undesired or harmful effects) of azithromycin (antibiotic medication used to treat infection) on 11/29/2025 to 12/2/2025.This failure had the potential to increase antibiotic resistance (do not respond to a drug) from unnecessary or inappropriate antibiotic use and had the potential for Resident 1 to experience an adverse reaction.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/20/2021, with diagnoses that included hereditary (something…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) with indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to:1.Ensure Resident 1's urinary catheter stoma (a surgically created opening on the abdomen that allows waste to be diverted from the body to the outside) had a wound dressing (a material placed directly on a wound to protect it and help it heal).2. Ensure Resident 1's indwelling urinary catheter tubing was anchored (secured) to the resident's thigh.3. Ensure Resident 1 was monitored for the presence of urinary tract infection (UTI- an infection in the bladder/urinary tract). 4. Ensure licensed nurses provided Resident 1's urinary catheter care as indicated on the resident's Care Plan.These deficient practices had the potential to cause Resident 1 urinary catheter-associated complications including UTI, discomfort, and pain. Findings: During a review of Resident 1's admission Record (undated), the admission Record…

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

Based on observation, interview, and record review, the facility failed to ensure that one of four emergency exit doors (Exit Door 3) was free from obstructions.This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress (designated emergency exit door) access in the event of an emergency. Findings: During a concurrent observation and interview on 7/28/2025 at 7:54 a.m. with Licensed Vocational Nurse (LVN) 2, observed Exit Door 3 (the emergency exit door located at Station 3's hallway between resident Room A and resident Room B) was blocked by a Geri-chair (a specialized chair with wheels designed to help people with limited mobility sit, recline, and stand up more easily) and a chair. LVN 2 stated the Geri-chair and the chair blocked the emergency exit door. LVN 2 stated blocked emergency exit door had the potential to cause delays in services in case of an emergency. During an interview on 7/28/2025 at 10:37 a.m. with the Director of Nursing (DON), the DON stated the blocked emergency exit door (Exit Door 3) posed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach consisting of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within residents reach for three of three sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in the delay in the residents' care and not receiving assistance timely. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/27/2021, with diagnoses that included unspecified (unconfirmed) chronic kidney disease (CKD-a condition where the kidneys are damaged and cannot filter blood properly, leading to a buildup of waste and fluid in the body), dementia (a progressive state of decline in mental abilities) and…

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

Based on interview and record review, the facility failed to implement a person-centered care plan for one of three sampled residents (Resident 1) by failing to ensure care plan was followed on the use of low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers [a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear and may lead to deep tissue injury]). This deficient practice had the potential for delayed provision of necessary care and services and had the potential for the development of pressure ulcers or injuries for Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/27/2021, with diagnoses that included unspecified (unconfirmed) chronic kidney disease (CKD-a condition where the kidneys are damaged and cannot filter blood properly, leading to a buildup of waste and fluid in the body),…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcer (a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 1) by failing to ensure the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) machine was functioning as indicated in the Operators Manual. This deficient practice had the potential for Resident 1 to develop pressure ulcers or injuries. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/27/2021, with diagnoses that included unspecified (unconfirmed) chronic kidney disease (CKD-a…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 2) by failing to ensure the physician order was followed. This deficient practice had the potential to result in medication error and can cause hypotension (low blood pressure). Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 3/8/2021, with diagnoses that included unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), essential hypertension (HTN- high blood pressure) and dysphagia (difficulty in swallowing). During a review of Resident 2 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 2/12/2025, the H&P indicated Resident 2 did not have the capacity to understand and make…

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

Based on interview and record review the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 2). This deficient practice resulted to Resident 2's medical records contain inaccurate documentation and had the potential to cause confusion in Resident 2's care. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 3/8/2021, with diagnoses that included unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), essential hypertension (HTN- high blood pressure) and dysphagia (difficulty in swallowing). During a review of Resident 2 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 2/12/2025, the H&P 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 resident assessment tool) dated 3/6/2025, the MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of two sampled residents (Resident 2) when on 2/17/2025 at 6:25 p.m., Certified Nursing Assistant (CNA) 1 witnessed Resident 3 hit Resident 2 with closed fits, hitting Resident 2 on the right side of Resident 2's head. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 3 while under the care of the facility. Resident 2 had pain scale (a tool used by doctors to measure how much pain someone is feeling) of 3 out of 10 (you feel a noticeable pain that might distract you a bit, but you can still manage it and adapt to it), requiring acetaminophen (a pain reliever) 325 milligrams (mg-unit of measurement) two (2) tablets by mouth. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive person-centered care plan (CP-a document outlining a detailed approach to care customized to an individual resident's needs) by failing to: 1. Develop and implement a care plan for Resident 145's use of side rails (SR or bed rail, adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of five sampled residents reviewed under the Accidents care area. This deficient practice had the potential to result in a delay in the provision of necessary care and services for residents using SRs. 2. Implement the care plan intervention to monitor the side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Pradaxa (an anticoagulant [blood thinner] medication used for atrial fibrillation [Afib - a condition with irregular, fast heart rate caused by poor blood flow]),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in accordance with professional standards for three (3) of three (3) sampled residents (Resident 51, 137, and 129) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. The deficient practice increased the risk that Residents 51,137, and 129 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 51's admission Record, the admission Record indicated the facility originally admitted Resident 51 on 3/5/2019 and readmitted the resident on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four (4) of five (5) sampled residents (Residents 94, 21, 27 and 129's) investigated under accidents by failing to: 1. Ensure there was no furniture or equipment on top of Resident 94, 21, and 27's floor mats for a long period of time. 2. Ensure Resident 129's bed was not left in the elevated/high position while unattended by staff. These deficient practices had the potential to place Residents 94, 21, 27, and 129 at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death. Findings: a. During a review of Resident 94's admission Record, the admission Record indicated the facility originally admitted Resident 94 into the facility on 3/10/2023 and readmitted on [DATE], with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound…

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

Based on interview and record review the facility failed to: a. Dispose of medications in a manner that was not retrievable (able to get back) in one (1) of two (2) inspected Medication Rooms (Medication Room Station 2). b. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled or Antibiotic Drug Record accountability logs for three (3) of six (6) sampled records awaiting disposal (removal, destroying) in the Controlled Substances (CS - also known as Controlled Drug and Controlled Medications [CD, CM - medications which have a potential for abuse and may also lead to physical or psychological dependence]) locked cabinet. As a result, control and accountability of CS ' s and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for medication diversion (the transfer of a medication from a lawful to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents' drug regimen were free from unnecessary drugs (any drug in excess) for two (2) of four (4) sampled residents (Resident 10 and 141) for unnecessary medication review. 1. Resident 10's duplicate medication orders for the same indication remained as active drugs on the Medication Administration Record (MAR - a record of medications administered to a resident), starting 1/19/2025. 2. Resident 141 did not have monitoring for the side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Pradaxa (an anticoagulant [blood thinner] medication used for atrial fibrillation [Afib - irregular, often rapid heart rate that commonly causes poor blood flow]), between 1/1/2025 and 1/30/2025. These deficient practices had the potential to cause Resident 10 and Resident 141 to receive suboptimal (less than the highest standard or quality) care leading to the use of unnecessary medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five (5) sampled residents (Resident 21 and 358) drug regimen was free from unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (a medication that affects brain activity associated with mental processes and behavior) medications by failing to ensure: 1. Resident 21 had a specific, measurable target behavior related to the use of sertraline (an antidepressant [against depression] medication used for depression or bipolar disorder), starting 12/7/2024. 2. Quetiapine fumarate (an antipsychotic [a class of medication used to treat psychiatric disorders]) and sertraline HCl (a medication to treat depression [persistent feelings of sadness)] were prescribed, administered, and monitored for specific measurable behavioral manifestations for Resident 358. These deficient practices had the potential to result in unnecessary medication administration and placed Resident 21 and 358 at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 29 total opportunities contributed to an overall medication error rate of 10.35% affecting two (2) of five (5) residents observed for medication administration (Resident 109 and 257). The medication errors were as follows: 1. Resident 257 did not receive a form of aspirin (a medication used to treat peripheral vascular disease [PVD - a condition that affects blood vessels] and Deep Vein Thrombosis [DVT - a condition that forms blood clots in the body] in those with atrial fibrillation [an irregular, fast heart rate]) as ordered by Resident 257's physician. 2. Resident 109 received metformin (a medication used to treat high blood sugar levels) and aspirin at a different time than ordered by Resident 109's physician. These failures had the potential to result in Resident 257 and Resident 109 to experience medication adverse effects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for three (3) of three (3) sampled residents (Resident 51, 129 and 137) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. This deficient practice increased the risk that Residents 51, 129 and 137 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven (7) ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solutions in the foil pack (package made of foil protecting the inhalation solution from light and degradation) for Resident 72, in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 1 T2). 2. Remove and discard from use one (1) expired eye drop medication bottle for Residents 115 in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 2 T). 3. Store or label one (1) insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial for Resident 258, in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 1 T2). 4. Remove and discard from use two (2) open Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs])…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of: a. Twenty seven (27) of 27 residents on puree diet (diet consisting of food with soft pudding-like consistency) and 15 of 15 residents on soft mechanical diet (diet consisting of chopped and soft foods), received less portion for pureed rice and pureed corn as staff did not level off number eight (#8, ½ cup) scoop. b. Seven (7) of 7 residents on puree diet and ten (10) of 10 resident on regular texture (no restriction) got mashed potatoes with their tacos in substitution for rice. c. 1 of 1 sampled resident had no alternate menu posted in Station 3 and the room. These failures had the potential to result in decreased food and nutrient intake resulting to unintended (not planned) weight loss. Findings: a. During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled Diet Guide Sheet, dated 1/28/2025, the spreadsheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appetizing temperature when sliced pears were dished out at 11:45 a.m. with temperature of 68 degrees Fahrenheit (°F, a degree of temperature) and the coleslaw was left out in trayline from 12:00 to 12:25 p.m. with a temperature of 75°F. This failure had a potential to result in 149 of 155, including Resident 91, facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: a. During a review of Resident 91's admission Record, the admission Record indicated the facility initially admitted Resident 91 on 12/24/2021 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM 2, a disorder characterized by difficulty of blood sugar control and would healing), chronic kidney disease stage 3 (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and essential hypertension (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.

Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree tortilla was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) and puree corn did not hold its shape for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4). These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 27 of 27 residents on puree diet, resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled, Diet Guide Sheet, dated 1/28/2025, the spreadsheet indicated residents on dysphagia puree diet would include the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. Refrigerator and Freezer floors had dirt build up. b. Vents had dust buildup 2. Preparation [NAME] 1 washed the towel cloth in the preparation sink area while the chicken was thawing on the other sink causing water splatters to go the chicken. 3. Three (3) of four (4) light bulbs in the dry storeroom area were not covered 4. Two (2) dented cans were found with non-dented cans. 5. Twenty one of 21 resident's trays were cracked and chipped. 6. Pots and pans stacked wet. 7. Staff was wearing a bracelet during food preparation. 8. Expired food items of three (3) residents in the refrigerator 9. Residents' freezer temperature was not monitored; there was no thermometer and ice cream stored in it was not rock-solid. These failures had the potential to result in harmful bacterial…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. The trash in the handwashing area was not lined with plastic b. The dumpster's (large trash container designed to be emptied into a truck) surroundings had liquid, food juices spills and trash on the ground and the dumpster was not fully covered. These failures had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 149 of 156 facility residents. Findings: a. During an observation on 1/28/2025 at 11:30 a.m., in handwashing area, the trash bin was not lined with plastic. During a concurrent observation and interview on 1/29/2025 at 12:44 p.m. with the Dietary Supervisor (DS), the DS stated the trash can by the handwashing machine was not lined and they must put plastic in it as it was not sanitary and for infection control. b. During a concurrent observation and interview on 1/29/2025 at 12:40 p.m. of the dumpster area with the Dietary Supervisor (DS), the DS stated the garbage floor needed to be sprayed and clean as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two of three sampled residents (Resident 33 and 94) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings: a.During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 11/18/2020 and readmitted the resident on 5/2/2024 with diagnoses that included heart failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), displaced comminuted fracture (a bone that is broken in at least two places) of the shaft of the right femur (the thigh bone),…

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

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one of three sampled residents (Resident 10) investigated under the Environmental Task by failing to maintain the cleanliness of Resident 10's electric stand fan. This deficient practice has the potential to negatively affect the resident's quality of life. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted the resident on 12/7/2022 and readmitted in the facility on 5/28/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized weakness. During a review of Resident 10's History and Physical (H&P) dated 5/29/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment 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 observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for one (1) of one sampled resident (Resident 95) investigated during a review of the physical restraints care area when the facility failed to obtain a physician's order, perform an assessment, obtain an informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment), and develop a care plan for the use of pillows tucked underneath the fitted sheet. These deficient practices had the potential to result in the restriction of the residents' freedom of movement, a decline…

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

Based on interview and record review, the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for one of five sampled residents (Resident 48) investigated under PASRR care area, by failing to submit a new Level 1 PASRR for Resident 48, who had a discrepancy in the previous PASRR Level I screening and ensure it was completed accurately. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 48. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted the…

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

Based on interview and record review the facility failed to ensure resident comprehensive care plans (CP - a written course of action that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) regarding smoking were updated after a change of condition for one of five sampled residents (Resident 62) reviewed under the Accidents care area. This deficient practice had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives regarding the resident's care needs. Findings: During a review of Resident 62's admission Record, the admission Record indicated the facility admitted the resident on 5/27/2019 and readmitted the resident on 1/4/2025 with diagnoses that included seizures (abnormal electrical activity in the brain), difficulty walking, and muscle weakness. During a review of Resident 62's Minimum Data Set (MDS - resident assessment tool), dated 1/9/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS…

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

Based on observation, interview, and record review, the facility failed to provide quality of care in accordance with professional standards of practice to meet the resident's physical, mental, psychosocial needs for one of one sampled resident (Resident 147) investigated under rehab and restorative care area by failing to: 1. Conduct the interdisciplinary team meeting (IDT-a coordinated group of experts from several different fields) with the resident's responsible party regarding the resident's refusals to participate in physical therapy treatments. 2. Inform Resident 147's physician regarding the resident's refusals to participate in physical therapy treatments. These deficient practices had the potential to result in Resident 147's decline in mobility, strength, and overall physical function, leading to increased dependence to providers. Findings: During a review of Resident 147's admission Record, the admission Record indicated the facility admitted the resident on 11/29/2024 with diagnoses including nondisplaced intertrochanteric fracture (break-in bone) of right femur (thigh…

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

Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, the breakdown of skin integrity due to pressure) for one of one sampled resident (Resident 86) investigated under pressure injury by failing to ensure Resident 86's low air loss mattress (LALM, a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) had a physician's order and care plan developed. This deficient practice had the potential for the development and worsening of pressure injuries to Resident 86. Findings: During a review of Resident 86's admission Record, the admission Record indicated the facility admitted the resident on 8/27/2021 with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (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 residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) out of one sampled resident (Resident 137) investigated under the urinary catheter or UTI care area when the facility failed to ensure Residents 137's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential to result in the resident's urine to not flow freely which may lead to the development of an UTI. Findings: a. During a review of Resident 137's admission Record, the admission record indicated the facility originally admitted Resident 137 on 5/21/2024 and readmitted the resident on 1/9/2025, 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), type 2 diabetes mellitus (DM 2 - 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 observation, interview, and record review, the facility failed to monitor Resident 69's change in condition for significant weight loss for one of two sampled residents (Resident 69) investigated under the nutrition care area. This deficient practice had the potential to place the resident at risk for further weight loss. Findings: During a review of Resident 69's admission Record, the admission Record indicated the facility admitted the resident on 11/18/2019 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 69's Weights and Vitals Summary, the Weights and Vitals Summary indicated: - 1/2/2025, 152.8 pounds (lbs. -a unit of measurement) - 12/2/2024, 163.7 lbs. - 11/4/2024, 165.7 lbs. - 10/6/2024, 165.5 lbs. - 7/3/2024, 170.3 lbs. During a review of Resident 69's 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.

Based on observation, interview, and record review, the facility failed to ensure the safe and appropriate use of side rails (SR or bed rail - adjustable, rigid, plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of five sampled residents (Resident 145) reviewed under the Accidents care area by failing to: 1. Attempt to use appropriate alternatives prior to installing bilateral (both sides) upper (at the head and shoulder area) SRs. 2. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from bilateral upper SRs use. 3. Review the risks and benefits of bilateral upper SRs with the resident or resident representative and obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). 4. Develop and implement a Care Plan (CP - a written course of action that helps a resident achieve outcomes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards to two of two sampled residents (Resident 116 and 120) by failing to document if Resident 116's Humulin (a hypoglycemic medication/insulin-a hormone that lowers the level of sugar in the blood) and Resident 120's Lispro (a hypoglycemic medication) doses were administered or not administered. This deficient practice had the potential to result in inaccurate documentation in the medical records regarding the residents' medication administration. Findings: a. During a review of Resident 116's admission Record, the admission Record indicated the facility originally admitted the resident on 6/30/2023 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 116's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure resident urinals were labeled with a resident identifier for one of two sampled residents (Resident 357) reviewed during the Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) care area. 2. Ensure resident's hand-held nebulizer (HHN - a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing was placed inside the plastic storage after use for one (1) out of two (2) sampled residents (Resident 21) reviewed under the Respiratory care area. This deficient practice had a potential to spread infections and illnesses among residents. Findings: a. During a review of Resident 357's admission Record, the admission Record indicated the facility admitted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) for two of three sampled residents (Resident 1 and Resident 2) were managed by failing to: 1. Ensure Resident 1 and Resident 2 had their enteral feeding supplies labeled with the licensed nurse's signature, date, and time. 2. Ensure Resident 1 received the enteral feeding at the required time. 3. Ensure Resident 1 and Resident 2's total amount of enteral feedings were monitored. These deficient practices had the potential to result in residents receiving inaccurate amount of formula as ordered and enteral feeding supplies harboring bacteria and transmitting to residents. Findings: a. During a concurrent observation and interview on 12/30/2024 at 12:35 p.m., with Registered Nurse 2 (RN 2), observed Resident 1's enteral feeding water bag without a signature of the licensed nurse, dated 12/30/2024 at 12:00 a.m., was connected to the…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 5) who was refusing to shower. This deficient practice had the potential for delayed provision of necessary care and services. Findings: During a record review of Resident 5's admission Record, the admission record indicated the facility admitted Resident 5 on 12/7/2022, with diagnoses that included other partial intestinal obstruction (the intestine is only partially blocked, allowing some food, liquid, and gas to pass through, but not a complete blockage where nothing can move through), left shoulder bicipital tendinitis (inflammation of the tendon that connects the biceps muscle to the shoulder and elbow), and primary osteoarthritis (causes joint pain, swelling, and tenderness that can affect a person's mobility and quality of life). During a record review of Resident 5's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings),…

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

Based on interview and record review, the facility failed to ensure a resident was provided supervision to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 4). On 12/17/2024, at 7:10 p.m., Resident 4 walked out of the facility unassisted with no front wheel walker (FWW- a mobility aid that helps people with limited upper body strength or who need help bearing weight while walking). This deficient practice resulted to Resident 4's elopement and can potentially place Resident 4 at risk for injury, fall and accidents. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 11/1/2023, with diagnoses that included unspecified (unconfirmed) anemia (a condition where the body does not have enough healthy red blood cells), alcohol abuse (a pattern of drinking too much alcohol too often) and personal history of transient ischemic attack (TIA- or mini stroke, happens when there's a temporary disruption in the blood supply to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical record for two of three sampled residents (Resident 4 and Resident 5) by: 1. Failing to accurately document Resident 4's history of elopement (the act of leaving a facility unsupervised and without prior authorization) in the Elopement Evaluation on 12/17/2024 after Resident 4 had elope. 2. Failing to accurately document shower was provided to Resident 5 on 12/2024. These deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: a. During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 11/1/2023, with diagnoses that included unspecified (unconfirmed) anemia (a condition where the body does not have enough healthy red blood cells), alcohol abuse (a pattern of drinking too much alcohol too often) and personal history of transient ischemic attack (TIA- or mini stroke,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comfortable and safe temperature level for two of four sampled residents (Resident 3 and Resident 4) by failing to ensure the facility temperature was between 71 degrees Fahrenheit (°F, unit of measurement for temperature) to 81°F as indicated in the facility ' s policy and procedure (PnP). This deficient practice had the potential to cause serious medical problems and altered comfort level. Findings: During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/18/2020 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body)following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right non-dominant side, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and essential hypertension…

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

Based on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of four sampled residents (Residents 2) by failing to ensure Resident 4 was not in procession of a sharp tool. A wire cutter was in Resident 2 ' s possession in the resident ' s room. This deficient practice had the potential to cause injury or harm to Resident 2 and other residents. Findings: During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 6/15/2024 with diagnoses including essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), benign prostatic hyperplasia (BPH – a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and gout (a type of inflammation that causes pain and swelling in the joints). During a record review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident ' s medical doctor and responsible party timely when a resident was noted with purple discoloration to the left eye for one of three sampled residents (Resident 1). This deficient practice could have resulted in a delay of appropriate necessary care and treatment to Resident 1 and had the potential for missed opportunities by the responsible party to be involved with care and decision-making. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with medical history including acute systolic heart failure (a chronic condition in which the hears does not pump blood as well as it should) , atherosclerosis of aorta ( plaque buildup on the inner walls of the aorta), hyperlipidemia (elevated cholesterol), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anemia (low red blood cells), 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 Certified Nursing Assistant 10 (CNA 10) knock and request permission before entering the resident`s room for three of four sampled residents (Resident 42, 45, and 155) reviewed under dignity care area. This deficient practice has the potential to affect the resident's sense of self-worth and self-esteem. Findings: a. A review of Resident 42's admission Record indicated the facility admitted the resident on 10/27/2023 with diagnoses including diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar), difficulty walking, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). A review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/11/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive person-centered care by failing to: 1. Ensure Resident 7 had a care plan addressing her extrapyramidal symptoms (movement disorders that include muscle spasms, motor restlessness, tremors [shaking or trembling movements in one or more part of the body], decreased body movement, rigidity, and abnormal movements) and movement disorder diagnosis for one of three sampled residents reviewed under activities of daily living care area. Cross-reference F676 2. Ensure Resident 29 had a care plan for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use for one of one sampled resident reviewed under insulin care area. 3. Ensure Resident 126 had a care plan to address the use of quetiapine (an antipsychotic drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) for one of five sampled residents reviewed under unnecessary medications care area.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's licensed nursing staff failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites for: 1. One of five sampled residents (Resident 1) investigated during review of unnecessary medications. 2. One of four sampled residents (Resident 306) investigated during review of medication administration facility task. This deficient practice had the potential for adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Findings: 1. A review of Resident 1's admission Record indicated the facility admitted the resident on 6/2/2017 and readmitted the resident on 11/7/2023, with diagnosis of type 2 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for four of seven sampled residents (Residents 13, 99, 67, and 306) investigated under the Medication Administration and Storage and Labeling task, by failing the following: 1. To ensure Oxycodone-Acetaminophen 5-325 milligrams (mg, a unit of weight), a controlled drug (a drug or chemical whose manufacture, possession, or use is regulated by a government), was readily available and the change of shift Controlled Drug Record (designed for dispensers of controlled substances to keep track of the pharmaceuticals as legally mandated) was properly reconciled with the Medication Administration Record (a report detailing the drugs administered to a resident by a healthcare professional at a treatment facility) by the licensed nurses for Resident 13. This deficient practice had the potential for drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was free from unnecessary drugs for four of five sampled residents (Residents 112, 27, 54, and 126) investigated during review of unnecessary medications by: 1. Failing to monitor behavioral manifestations and side effects (an often harmful and unwanted effect) of psychotropic (any drug that affects behavior, mood, thoughts, or perception) use for Residents 112, 27, 54, and 126. 2. Failing to provide an adequate indication and by failing to monitor behavioral manifestations for Resident 126's use of quetiapine. These deficient practices placed the residents at risk of receiving unnecessary psychotropic medications without monitoring and evaluating the effectiveness of the antipsychotic medication. Findings: 1.a. A review of Resident 112's admission Record indicated the facility admitted the resident on 9/22/2022, with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough…

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

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three medication errors out of 28 total opportunities contributed to an overall medication error rate of 10.71% affecting two of four sample residents (Resident 67 and 306) observed for medication administration performed by Licensed Vocational Nurse (LVN) 2 and LVN 3. The facility failed to: 1. Ensure LVN 2 did not mix Resident 67's aspirin (medication used to reduce pain and inflammation) and thiamine (also known as vitamin B1, supplement used for growth, development, and function of cells) together and administer through Resident 67's gastrostomy tube (GT - a soft tube inserted during surgery into the stomach through the belly to deliver food and medications a person with difficulty or inability swallowing, also known as an enteral tube). 2. Ensure LVN 3 rotated Resident 306's insulin lispro (a fast-acting medication used to control high blood sugar) injection site. These deficient practices had the potential to result in reducing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menus are developed and prepared to meet resident choices by failing to: 1. Follow the diet menu and the dietician's recommendation to have 1/2 cup of apple sauce during lunch and dinner for one of 14 sampled residents (Resident 22) investigated during review of dining observation task. This deficient practice had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices and of their preference. 2. Used small scoop size to serve corn for residents on regular diet and on dysphagia advanced diet (includes moist foods in bite sized pieces for residents who have chewing and or swallowing difficult) and served less protein to residents on renal diet. 83 residents on regular texture diet and 35 residents on dysphagia advanced received less corn. Five residents on renal diet received 2.5 ounces of protein instead of 3 ounces. 3. Ensure staff followed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was prepared by methods that conserved texture, appearance and served at appetizing temperatures for 152 out of 158 residents who received food from kitchen and for residents 7, resident 71 and resident 74 who complained the food did not look appetizing to eat. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss. Findings: a. During initial facility tour on 1/8/2024 at 8:00AM, complaints about the temperature and flavor of food were identified. During an observation in the kitchen on 1/8/2024 at 11:00AM Cook1 (CK1) was preparing the lunch menu. CK1 said the lunch includes Coditos con [NAME] (Elbow Macaroni with chicken and tomato soup) and fiesta corn (corn with red and green peppers). During the same observation CK1 had cooked the macaroni pasta and cubed chicken in a large container. During the observation tomato soup base was…

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

Based on observation, interview and record review, the facility failed to provide nutritional supplements during lunch on 1/8/2024 as ordered by the physician for 17 out of 60 residents who were on nutritional supplements. This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss. Findings: During an observation of the tray line service for lunch on 1/8/2024 at 12:30PM, residents who were on nutritional supplements during lunch meal did not receive the supplements on the tray. During the same observation, there was a beverages cart that had water and juice in cups, individual cartons of milk and nondairy beverages. There were no nutritional supplements on the beverages cart. During a concurrent observation and interview with Dietary Aide (DA1) on 1/8/2024 at 12:30PM, DA 1 was adding food items and beverages on the lunch trays. DA 1 said the beverage cart contains all the beverages that will be served during lunch today. DA 1 was looking at the individual resident specific meal ticket (a paper that lists residents' food,…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Several food items were not dated or labeled in the walk-in refrigerator. One box of beef patties and one box of pork sausage links were stored uncovered in the walk-in freezer. One juice box containing orange juice blend with manufactures use by date of 11/10/2023 exceeding storage period for juice was connected to the juice machine and in use. 2.One can opener blade was dirty, serving utensils/scoops were dirty with dried food, floor, and walls behind the range area (stove and oven) were dirty. The floor next to the oven was dirty with sticky and greasy residue and the back wall of the oven had orange color stains. Under the food preparation counter next to oven was not maintained clean and there were food debris. There was Trash on the floor under food preparation counter. 3.Resident food brought from outside of the facility, including leftovers, were stored in the nursing unit resident refrigerator with no date.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care was provided consistently for four of four sampled residents (Resident 110, 28, 105, and 126) investigated addressing hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to: a. Ensure there was documented evidence interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meetings were held to collaborate with hospice representatives the hospice plan of care for Resident 110. b. Ensure hospice staff, including licensed vocational nurse (LVN) and hospice aide (HA), provided nursing and visitation notes to the facility for Residents 28, 105, and 126. c. Ensure hospice staff, including LVN and HA visited according to the hospice calendar provided to the facility for Residents 28, 105, and 126. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection prevention and control measures for nine of 18 sampled residents investigated addressing the care area of infection control (Resident 1, 7, 12, 42, 45, 155, 48, 66, 103, and 146) by: 1. Failing to label the urinal bottle (a container used to collect urine) of Resident 1 to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). 2. Failing to label the respiratory breathing treatment (involve inhaling medications using a nebulizer/humidifier device [a small machine that turns liquid medicine into a mist that can be easily inhaled]) tubing of Resident 112 of when it was last changed. 3. Failing to keep Resident 7's oxygen tubing off the floor. 4. Certified Nursing Assistant 10 (CNA 10) failing to perform hand hygiene (wash or sanitize) before going in and out of residents' rooms to answer the call light for Residents 42, 45, and 155. 5. CNA 10…

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

Based on interview and record review, the facility failed to ensure the informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) for the administration of olanzapine (a medication used to treat mental disorder including schizophrenia [chronic and severe mental disorder that affects how a person thinks, feels, and behaves, and bipolar disorder [a condition that causes extreme mood swings that include emotional highs and lows]) was completed to include the dosage (amount of medicine), route (way a medication is taken), frequency, and indication (valid reason) for one (Resident 3) out of two sampled residents investigated under the dementia care area. This deficient practice may result in inaccuracy of resident's medical record and violated the resident and resident's representative to be fully well-informed regarding the use of the medication and its potential risks and side effects (expected, well-known reaction that occurs with a predictable…

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

Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one out of three sampled residents (Resident 22) investigated during review of environment facility task. This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being. Findings: A review of Resident 22's admission Record indicated the facility admitted the resident on 5/4/2023, with diagnosis of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 22's History and Physical (H&P), dated 5/17/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/11/2023, 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 interview and record review, the facility failed to ensure there was documented evidence that a resident or the resident's representative was provided information on home health (a wide range of health care services that can be given in the home for an illness or injury) services and durable medical equipment (DME - equipment that is considered medically necessary as prescribed by a physician for use in a patient's home) upon discharge for one (Resident 152) out of three sampled residents investigated during review of closed records. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. Findings: A review of Resident 152's admission Record indicated the facility admitted the resident on 10/28/2023 with diagnoses including intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head), generalized muscle weakness, difficulty walking, and dysphagia (difficulty…

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

Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve a resident's ability to carry out activities of daily living (ADL - activities such as bathing, dressing, grooming, oral care, mobility, elimination, dining, and communication) when Resident 7 was not provided services to address Resident 7's extrapyramidal symptoms (movement disorders that include muscle spasms, motor restlessness, tremors [shaking or trembling movements in one or more part of the body], decreased body movement, rigidity, and abnormal movements) and movement disorder for one of three (Resident 7) sampled residents reviewed under activities of daily living care area. This deficient practice had the potential for Resident 7 to have decreased oral intake and decline in independence with eating. Findings: A review of Resident 7's admission Record indicated the facility originally admitted Resident 7 on 12/7/2022 and readmitted the resident on 7/30/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease…

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

Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to one of two sampled residents (Resident 85) reviewed under the pressure ulcer care area by failing to ensure the residents' low air-loss mattresses (LALM, an air mattress covered with tiny holes) were set according to the physician's order. The deficient practice had the potential for development and worsening of pressure ulcers to the residents. Findings: A review of Resident 85's admission Record indicated the facility originally admitted the resident on 12/20/2020 and readmitted the resident on 12/9/2023, with diagnoses dementia (a general term for impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and muscle weakness. A review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/12/2023, indicated the resident had severely…

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

Based on observation, interview and record review, the facility failed to provide a nutritional supplement to a resident who had a weight loss of 18.57% in six months for one out of 13 (Resident 92) sampled residents investigated during review of dining observation task. This deficient practice placed Resident 92 at risk for continued weight loss and complications related to nutritional and hydration status. Findings: A review of Resident 92's admission Record indicated the facility admitted the resident on 5/31/2023 and readmitted the resident on 10/30/2023 with diagnoses including urinary tract infection (UTI - also known as bladder infection, an infection in the urinary system), metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood due to illness or organs that are not working well), and history of falling. A review of Resident 92's History and Physical dated 10/31/2023 indicated Resident 92 had the capacity to understand and make decisions. A review of Resident 92's Minimum Data Set (MDS - a standardized assessment and care screening tool),…

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

Based on observation, interview and record review, the facility failed to observe professional standards of quality to one out of one sampled resident (Resident 157) by: 1. Failing to document insertion of intravenous (IV - therapy that delivers medications directly into a vein) line for Resident 157. 2. Failing to label the peripheral IV site with the date the line was inserted to indicate how long the IV line had been on Resident 157's left wrist. These deficient practices had the potential to expose Resident 157 to infection and IV therapy complications. Findings: A review of Resident 157's admission Record indicated the facility admitted the resident on 11/16/2023, with diagnoses that included right shoulder abscess (a swollen area within body tissue, containing an accumulation of pus), hypertension (high blood pressure), muscle weakness. A review of Resident 157's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/1/2024, indicated the resident had the ability to make self-understood and understand others. The MDS 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 the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice by failing to administer Resident 7's supplemental oxygen as ordered by the physician for one out of three sampled residents (Resident 7) reviewed under the respiratory care area This deficient practice had the potential for Resident 7 to desaturate (condition of low blood oxygen level) and experience respiratory problems. Findings: A review of Resident 7's admission Record indicated the facility originally admitted Resident 7 on 12/7/2022 and readmitted the resident on 7/30/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow) and generalized muscle weakness. A review of Resident 7's History and Physical (H&P), dated 8/2/2023, indicated Resident 7 was alert and oriented and had a diagnosis of fibromyalgia. A review of Resident 7's MDS,…

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

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice related to pain management to one out of two sampled residents (Resident 13) reviewed under the pain management care area by failing to assess and document the resident's pain every shift per physician's order. This deficient practice placed the resident at risk for having unmanaged pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. Findings: A review of Resident 13's admission Record indicated the facility admitted the resident on 3/16/2017, with diagnoses including arthropathic psoriasis (a chronic, autoimmune [body's immune system attacks and destroys healthy body tissue by mistake] form of arthritis that causes joint inflammation and occurs with the skin condition psoriasis [thick areas of discolored skin covered with scales]), anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (a mental health…

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

Based on observation, interview, and record review, the facility failed to ensure a resident diagnosed with dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being by failing to implement person-centered care plan interventions for Resident 105, who was observed with door closed during multiple observations when the resident was exhibiting verbal outbursts for one of three sampled residents (Resident 105) reviewed under the dementia care area. This deficient practice had the potential to affect Resident 105's safety and well-being. Findings: A review of Resident 105's admission Record indicated the facility admitted the resident on 4/13/2023 with diagnoses including seizures (a sudden, uncontrolled burst of electrical activity in the brain) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). 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 ensure a resident who is receiving Eliquis (Apixaban, used to prevent serious blood clots from forming due to a certain irregular heartbeat or after hip/knee replacement surgery) is monitored for side effects (an often harmful and unwanted effect) as indicated in the plan of care for one of one sampled residents (Resident 55) reviewed for anticoagulant use. This deficient practice placed the residents at risk for unnecessary medication and undetected side effects. Findings: A review of Resident 55's admission Records indicated the facility admitted the resident on 5/16/2018 and readmitted the resident on 11/8/2021, with a diagnosis of quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs). A review Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/6/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on an anticoagulant (a group of medications that decrease…

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

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of seven medication carts (Med Cart #4) inspected while investigating medication and labeling tasks. The facility failed to discard the insulin glargine injection pen (medication that lowers the level of glucose [sugar] in the blood) after 28 days of opening per facility protocol for Resident 20. The insulin glargine injection pen was opened on 12/8/2023. This deficient practice had the potential for administering less potent (lessening of physical or chemical effect) medication that is ineffective in controlling blood sugar levels. Findings: A review of Resident 20's admission Record indicated the facility admitted the resident on 12/28/2020, with diagnoses that included type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with hyperglycemia (high blood sugar). A review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/6/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented by: 1. Failing to document Resident 7's pregabalin (also known as Lyrica, a medication used to treat nerve and muscle pain) oral capsule 100 milligrams (mg - a unit of measure) administration on [DATE] at 6:00 a.m. for one of two sampled residents reviewed under the pain care area. This deficient practice had the potential for facility staff to not know if the medication was administered or not and administer an additional dose of medication. 2. Failing to document the name and title of the individual who pronounced the resident dead and by failing to ensure the physician indicate in the resident's medical record the cause of death of the resident who expired in the facility on [DATE] for one of three (Resident 153) residents sampled residents identified during closed record reviews. This deficient practice had the potential to result in inaccurate documentation in the medical record…

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

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control program during a Coronavirus Disease-2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) outbreak (a sudden increase in occurrences of a disease) for three of five sampled staff (admission Director [AD], Licensed Vocational Nurse 1 [LVN 1] and Certified Nursing Assistant 1 [CNA 1]) by: 1. Failing to ensure admission Director wore a N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while walking in the front lobby. 2. Failing to ensure CNA 1 wore a N95 respirator while walking in the hallway carrying a clear plastic bag of thrash. 3. Failing to ensure LVN 1 wore N95 respirator while in the hallway going to the nurse ' s station. These deficient practices had the potential to result in the spread of COVID-19 to other residents and staff. Findings: a. During…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of three sampled residents (Resident 1) by failing to ensure Resident 1's urinary collection bag was covered with a privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/29/2023 with diagnoses that included displaced fracture (the ends of the bone have come out of alignment) of epiphysis (made of spongy cancellous bone covered by a thin layer of compact bone) of right femur (thigh bone), age related osteoporosis (the bones become brittle and fragile) and hypertension (uncontrolled elevated blood pressure). A review of Resident 1 ' s History and Physical, dated 12/5/2023, indicated the resident had no decision- making capacity. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/5/2023, indicated Resident 1 had intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 F842 Resident Records - Identifiable Information §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are— (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident ' s records, regardless of the form or storage method of the records, except when release is— (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) 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.

F842 Resident Records - Identifiable Information §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident ' s records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and 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 protect the resident ' s rights to be free from physical abuse by failing to implement safety measures to prevent resident to resident altercations for three of six sampled residents (Resident 1, Resident 2, and Resident 6). This deficient practice resulted in Resident 1, Resident 2, and Resident 6 experiencing physical abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted Resident 1 on 2/26/2020 and readmitted the on 2/06/2023 with diagnoses of psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and major depressive disorder (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 1's Minimum Data Set (MDS - a standardized screening and assessment tool) dated 8/18/2023 indicated the resident was moderately impaired in cognitive skills (ability to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services that meet professional standards of quality for five of five sampled residents (Resident 9, 8, 3, 6, and 7) by failing to ensure licensed nurses: 1. Obtain and document Resident 9 and 8's vital signs (measurements of the body's most basic functions; vital signs routinely monitored are body temperature, heart rate, respiration rate, blood pressure [the pressure of circulating blood against the blood vessel walls] and oxygen saturation [oxygen level in the blood]) as ordered by the resident's physicians. 2. Document administration of Paxlovid (300/100) Oral Tablet Therapy Pack 20 x 150 milligrams (mg, a unit of measure) &10 x 100 mg (Nirmatrelvir-Ritonavir, an antiviral medications) for Resident 9. 3. Follow physician's orders for monitoring Resident 3, 6, 7, 8 and 9 for signs and symptoms of chest congestion, cough, increased shortness of breath, or worsening confusion, malaise, and/or muscle pain, nausea, vomiting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post no smoking/oxygen in use sign outside the residents' door for two of two sampled residents (Resident 2 and 10), who were receiving oxygen therapy (medical treatment where a person receives extra oxygen to help them breathe better). This deficient practice had the potential to result in residents, staff and visitors not observing oxygen safety precautions. Findings: a.A review of Resident 2's admission Record indicated the facility readmitted the resident 8/18/2023 with diagnoses including unspecified dementia (a decline in cognitive abilities, such as memory loss and problem-solving skills) without behavioral disturbance and dysphagia (difficulty swallowing). A review of Resident 2's History and Physical, dated 1/25/2023 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident received oxygen therapy as ordered by the physician for one of two sampled residents (Resident 2). This deficient practice could l result in oxygen toxicity, which can cause lung damage, respiratory distress, and other serious health complications due to unnecessary oxygen administration or higher than necessary rate of oxygen administration. Findings: A review of Resident 2's admission Record indicated the facility readmitted the resident on 8/18/2023 with diagnoses including unspecified dementia (a decline in cognitive abilities, such as memory loss and problem-solving skills) without behavioral disturbance and dysphagia (difficulty swallowing). A review of Resident 2's History and Physical, dated 1/25/2023 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making.…

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

Based on observation, interview, and record review the facility failed to provide documentation in the resident's medical record that indicated education was provided to the resident or the resident's representative regarding the benefits and risks of pneumococcal immunization (a way to protect a person against several types of pneumonia [lung infection] status) prior to administration of the pneumococcal vaccine (a preparation that is used to stimulate the body's response against pneumococcal diseases) for two (Residents 3, and 6) of five sampled residents. This deficient practice resulted in incomplete resident's records and violated the resident or the responsible party's rights to make an informed decision. Findings: a. A review of Resident 3's admission Record indicated the facility admitted the resident on 7/26/2023 with diagnoses including difficulty in walking, muscle weakness, cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of left lower limb (left lower leg), and sepsis (he body's overwhelming 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 implement an effective pest control program by failing to prevent flies from being inside the facility. This deficient practice increases the risks in creating unsanitary living conditions for the residents, staff, and visitors. Findings: On 8/8/2023 at 12:34 p.m., during a concurrent observation and interview with Registered Nurse 1 (RN 1), observed a fly on the glass doors in hallway. RN 1 verified seeing the fly and indicated the fly could have come from the facility ' s entrance. On 8/8/2023 at 12:40 p.m., during an interview with Infection Prevention Nurse (IP), IP stated that flies create maggots (small, soft-bodied worm like immature form of insect). IP stated that flies land on warm environments that have foul odor, like old food. IP stated that if outdoors, flies would land on feces (animal waste). IP indicated that if a fly were to land on a resident's wound and create maggots, it would create more bacteria (micro in size organisms that can cause disease) on the wound, spreading to other parts 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 follow menu for residents when three of six residents (Resident 2, Resident 3, and Resident 4) on a renal diet (diet that is low in sodium, potatssium, phosporus and protein for person with kidney disease) got one-half (½) cup mashed potato instead of ½ cup buttered noodles. This deficient practice had the potential to increase nutritional value for sodium and potassium content not consistent to the physician ' s diet order. Furthermore, this deficient practice of serving inaccurate food items may result in decreased food intake and weight loss further compromising the medical status of residents getting wrong food items in their meal. Findings: A review of Resident 2's admission Record indicated the facility initially admitted the resident on 5/1/2023 and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD - last stage of long-term kidney disease), dysphagia (difficulty swallowing), and anemia (a condition in…

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