Culver West Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for two of five sampled residents (Resident 26 and Resident 33), the facility failed to assess the individual needs and food preferences to ensure the menus and/or the resident's food plan met the nutritional needs and preferences for Resident 26. This deficient practice had the potential for insufficient food intake and weight loss for Resident 26. Findings: During a record review, Resident 26's admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included congestive heart failure (CHF- a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other body organs), chronic obstructive pulmonary disease (COPD-), atrial fibrillation (Afib-irregular heart beat), peripheral neuropathy (any nerve damage outside of the brain and spinal cord) and repeated falls. During a record review, Resident 26's Minimum Data Set (MDS - a resident assessment tool) dated 01/31/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 66) was served with the correct food portion per facility menu spreadsheet when serving meals to residents on 4/30/2025. This deficient practice had the potential for Resident 66 to suffer unintentional weight loss. Findings: During a record review of Resident 66's admission record (face sheet - a document containing demographic and diagnostic information) indicated, Resident 66 was admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses: hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), essential primary hypertension (abnormally high blood pressure not caused by a medical condition), and muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength). 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, for two of two sampled residents (Resident 19 and Resident 71) the facility staff failed to: 1. Observe infection control measures by failing ensure Certified Nurse Assistant (CNA) 2 put on and use (don) personal protective equipment (PPE- not limited to gowns, and gloves) while providing Activities of daily leaving (ADL- self-care tasks necessary for daily functioning and maintaining independence) to Resident 19 who was on enhanced barrier precaution (EBP- infection control measures that expand the use of PPE, during high-contact resident care activities to reduce the spread of multidrug-resistant organisms (MDROs - These are microorganisms, typically bacteria, that have become resistant to multiple classes of antibiotics). 2. Ensure that an indwelling catheter (a flexible tube that is used to drain urine in the bladder) bag (a device forcollecting urine) was labeled with date and time to indicate the indwelling catheter bag was changed. These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff consulted with a physician, the Interdisciplinary team (IDT - a group of professionals from different specialties working together to provide care) or the faciity Bioethics committee (a group of individuals, often including doctors, nurses, ethicists, and community members, who help navigate complex moral and ethical questions in healthcare and research) regarding vaccinations for one of five sampled residents (Resident 33) who did not have a resident presentative and did not have the mental ability to make decisions. This deficient practice violated Resident 33's right to be supported and represented supported in making decisions regarding vaccinations and placed Resident 33 at increased risk for in infection and/or hospitalization. Cross reference F552 Findings: During a record review, Resident 33's admission Record indicated the facility initially admitted Resident 33 on 3/10/2021 and readmitted Resident 33 on 7/30/2023 with diagnoses including adult failure to thrive (a state of decline in older adults…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one out four sampled Resident (Resident 19) by failing to ensure the resident's call light was in working condition and within reach. This deficient practice had the potential to negatively impact on the psychosocial well-being of the residents or result in delayed provision of necessary and emergent services. Findings: During a record review, Resident 19's admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included indwelling urethral catheter (flexible tube, that is inserted into the urethra (the tube carrying urine from the bladder) and into the bladder to drain urine or administer fluids) hematuria (blood in the urine), difficulty walking, type II diabetes mellitus (condition in which the body has trouble controlling blood sugar and using it for energy), obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential lifesaving equipment, automated emergency defibrillator (AED, a portable device that can be used to treat a person whose heart has suddenly stopped working) machine at the designated nursing stations, Unit nursing stations and North and South Nursing stations. This deficient practice resulted in delayed life saving measures during Resident 1 ' s emergency resuscitation attempts by the facility staff on [DATE] at 7:34 PM. Findings: During a review of Resident 1's admission Record, dated [DATE], the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs), weakness, and paroxysmal atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications). During a review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST-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, facility failed to ensure that the Licensed nurse (LVN) notified Resident 1 ' s family member (FM) about a change of condition (COC -a sudden or acute deviation from a patient ' s baseline that may lead to complications or death if left untreated) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled Change of condition management guideline revised 9/11/2023, by failing to notify Resident 1 ' s FM after a COC occurred on 8/6/2024. This deficient practice violated Resident 1 ' s FM ' s right to be notified of Resident 1 ' s care services provided and had the potential to result in lack of proper care and services. Findings: A review of Residents 1 ' s admission Record indicated the facility initially Resident 1 on 9/1/2011 and readmitted Resident 1 on 8/30/2024 with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN - elevated blood pressure), and dementia (impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reasonable accommodation of needs for one of three sampled residents (Resident 1) by failing to ensure Resident 1 ' s call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach as indicated in the facility ' s Policy and Procedures (P&P) titled Call Light Answering revised on 9/11/23. This deficient practice had the potential for Resident 1 not to receive emergency care or have a delay in care and services that could result in a fall or accident. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/29/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems), acute and chronic respiratory failure (acute respiratory failure-occurs when there is a sudden decrease in the ability to exchange oxygen and carbon dioxide between the lungs and blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse and Crime Reporting effective 9/11/2023, by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 4/23/2024. This deficient practice had the potential to place Resident 1 at risk for elder abuse and delay onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated. Findings: A review of Resident 1's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare and store food in safe and sanitary condition and/or manner to prevent growth of microorganisms when: 1. Hairnets were not worn in the kitchen according to the facility's policy and procedures. 2. Hand hygiene and apron change were not performed during dishwashing when transition from dirty dishes to clean dishes. 3. Drinks and other food items were left at bedside for Resident 33 without proper storage and/or refrigeration for over 14 hours. Those deficient practices had the potential to cause foodborne illness (infections or irritations of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals) among 75 of 85 residents, who received the food from kitchen. Findings: a. A review of the Facility Resident Census and Minimum Data Set (MDS - a standardized assessment and care screening tool and matrix (is used to identify pertinent care categories), indicated there were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate storage and conduct inventory for personal belongings for homelike environment for one of six sampled residents (Resident 38). This deficient practice resulted in Resident 38 storing personal belongings in several boxes on the floor and the resident complaining of having lost some personal belongings. Cross Reference F584 Findings: A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood) and morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). A review of Resident 38's History and Physical Examination dated 11/9/23 indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Provide appropriate bed to accommodate one of six sampled residents (Resident 38). 2. Ensure call light was within reach for one of 28 sampled Residents (Resident 29). These deficient practices had the potential to result in Resident 38 developing new pressure injuries (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), and for staff not to meet Resident 29's needs, which could place the resident at risk for incidents. Findings: a. A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood) and morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). A review of Resident 38's History and Physical Examination dated 11/9/23 indicated, Resident 38 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of six sampled residents (Resident 38). This deficient practice resulted in Resident 38 storing personal belongings in boxes on the floor. Cross Reference F557 Findings: A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood) and morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight). A review of Resident 38's History and Physical Examination dated 11/9/23 indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/1/24, indicated the resident had intact cognition (capable of remembering, learning new things, concentrating, or 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 assess and identify environmental hazards and risk factors for accidents for one of twenty-eight sampled Residents (Resident 35). This deficient practice had the potential to result in, harm through ingestion of hazardous liquid leading to poisoning and/or allergic reactions (A condition in which the immune system reacts abnormally to a foreign substance), unnecessary hospitalizations, and even death. Findings: A review of Resident 35's admission record indicated Resident 35 was initially admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (high sugar in the blood), chronic obstruction pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), pneumonia (an infection that inflames the air sacs in one or both lungs) and congestive heart failure (CHF- a condition that develops when your heart doesn't pump enough blood for your body's needs.) A review of Resident 35'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 ensure one of four sampled residents (Resident 65) received continuous feeding of isosource 1.5 (Nutritional formula) as per physician's order, This deficient practice had the potential to cause inadequate nutrition for Resident 65. Findings: A review of Resident 65's admission Record indicated Resident 65 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including moderate protein-calorie malnutrition (poor nutrition), dysphagia (swallowing difficulties), and gastro-esophageal reflux disease (a common condition in which the stomach content move up into the esophagus). A review of Resident 65's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/1/24, indicated Resident 65's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were impaired. The MDS indicated Resident65 was dependent to substantial/maximal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain was managed in a timely manner for one of four sampled residents (Resident 33). This deficient practice resulted in Resident 33 experiencing unnecessary pain. Findings: A review of Resident 33's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including atherosclerotic heart disease (hardening of the arteries [blood vessels that distribute oxygen -rich blood to the entire body] cause by buildup of plaque [small, abnormal patch of tissue on a body part or an organ] in the inner lining of an artery of native coronary [relating to heart] artery with unspecified angina), autonomic neuropathy (damage to the nerves that control automatic body function), and heart failure (when heart muscle does not pump blood as well as it should). A review of Resident 33's History and Physical (H&P - physicians' examination of patient), dated 7/26/23, indicated Resident 33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to: 1. Provide functioning call light to one of six sampled residents (Resident 37). 2. Ensure call light was within reach for one of 28 sampled Residents (Resident 29). This deficient practice had the potential for staff not to the needs for Residents 37 and 29, which could result in physical and emotional harm to the residents. Findings: a. A review of Resident 37's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (a disease that results in blood sugar being too high), lung transplant, heart failure and major depressive disorder (decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts). A review of Resident 38's History and Physical Examination dated 4/3/24 indicated, Resident 37 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) for two of five selected residents (Residents 1 and 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included, legal blindness (some vision, but the field of vision may be very narrow or blurry. Or may have blind spots that glasses cannot correct), generalized anxiety (usually involves a persistent feeling of anxiety or dread that interferes with how you live your life), and major depressive disorder (a common and serious medical illness that negatively affects how…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 abuse prevention policy by failing to report an alleged abuse related missing funds to the state agency (Department of Public Health) within 2hrs after the allegation was reported by Resident 1. This deficient resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place all 77 residents in the facility at risk of elder abuse through misappropriation of funds. Findings: On 1/23/2024 at 9:25am an unannounced visit was made to the facility to investigate an allegation regarding Physical abuse of Resident 1. A review of Resident 1 ' s admission record indicated; facility originally admitted the 72yr old female on 08/24/2018 with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), morbid Obesity (weight is more than 80 to 100 pounds above their ideal body weight), abnormality of Gait and mobility (an unusual walking pattern that may be caused by underlying health conditions) and weakness.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the care, assistance, and supervision needed to ensure an environment free of risks and hazards for one out of one sampled resident (Resident 1), by failing to safely transfer Resident 1 from the wheelchair to the bed with an ordered Hoyer lift (a patient lift used by caregivers to safely transfer patient) on 1/4/2024. This deficient practice resulted in Resident 1 falling on 1/4/2024 during the transfer sustaining a laceration (deep cut) on the right lateral (outer part) leg with bleeding severe enough to require transport to the hospital. Findings: On 1/23/2024 at 9:25am an unannounced visit was made to the facility to investigate an allegation regarding Physical abuse of Resident 1. A review of Resident 1 ' s admission record indicated; facility originally admitted the 72yr old female on 08/24/2018 with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), morbid Obesity (weight is more than 80 to 100 pounds above their ideal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for one of four sampled residents (Resident 1) by not providing showers as Resident 1 preferred. This deficient practice had the potential to negatively affect Resident 1 ' s wellbeing, level of satisfaction with life, self-worth, and self-esteem due to lack of and/or delay in receiving sufficient services to maintain good grooming and personal hygiene. Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life), and acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate and report allegations of either verbal abuse (mocking, insulting, ridiculing; yelling, with the intent to intimidate), neglect (failure to provide necessary care and services to avoid harm), or physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of four sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedure within five (5) working days of the allegation. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which could also lead to a delay in prevention abuse for all 84 residents in the facility. Cross Reference: F610 Findings: A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 24 hours or in accordance with state or federal law for one of four sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect all 84 facility residents from abuse. Cross Reference F609. Findings: A review of admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs), major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life), and acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 1 ' s Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a resident who is incontinent of bowel and bladder receives appropriate treatment and services to prevent reoccurrence of urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) for one of four sampled residents (Resident 2) by failing to ensure Resident 2 ' s skin remained clean, dry and free of irritation. This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being and had the potential for formation of pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and a buildup of bacteria and a reoccurrence of infection. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of two sampled residents (Residents 1 and 2) for specific target behaviors for the use of Risperdal and Zyprexa (antipsychotic medications used to treat psychosis, a mental disorder characterized by a disconnection from reality) respectively. This deficient practice had the potential to result in overuse of an antipsychotic medication, without adequate indication for use, nonpharmacological interventions, or monitoring for the effectiveness and/or ineffectiveness of the medication; and could increase Resident 1 and Resident 2 ' s risk of adverse drug reactions and potential to not recognize or address the residents ' underlying causes of behavior (e.g., pain, discomfort) or psychosocial stressors (e.g., loneliness). Findings: 1. A review of Resident 1 's admission Record indicated the facility admitted the resident on 5/25/2022 and readmitted on [DATE]. Resident 1 's diagnoses included Dementia (a progressive disease 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 maintain the facility pest free (free of cockroaches and flies), maintain the facility clean, prevent pest harborage areas, and maintain an effective pest control program. As a result of the noncompliance, Resident 1 was transferred to the general acute care hospital 1 (GACH 1) on 8/23/2023, and reported maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1 ' s left heel wound upon admission in the Emergency Department (ED). Resident 1 needed intravenous (IV – administering fluid medication through a needle or tube inserted into a vein) antibiotics (medication that fight bacterial infection) and amputation (removal of the limb) below the knee (BKA) was performed. Findings: A. A review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II DM, sepsis (a life-threatening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its incident reporting for residents and visitors ' policy for one of 10 sampled residents (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours for Resident 1 after they were made aware by General Acute Care Hospital 1 (GACH 1) that maggots were found in Resident 1 ' s left heel wound. This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents at risk for neglect. Findings: During a review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 10 sampled residents by failing to implement a comprehensive and resident-centered care plan regarding Resident 1 diagnosis and left heel wound. This deficiency findings placed Resident 1at risk of further delay of wound healing and treatment of the disease. Findings: A review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II diabetes mellitus ((DM-a chronic condition that affects the way the body processes blood sugar [glucose]), sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for three of 10 sampled residents (Resident 1) according to the residents' needs and professional standard of care. These deficient practices placed Resident 1 at risk to develop a pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence) or at risk of poor wound healing of the current pressure ulcer. Findings: A. A review of Resident 1 ' s admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type II DM, sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of Resident 1'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 ensure one of 10 sampled residents, Resident 1 received the nutritional management for patient with diabetes by administering the ordered enteral tube feeding (TF - a method of supplying nutrients directly into the stomach) formula of Diabetisource (a unique carbohydrate blend includes pureed fruits and vegetables to help with the nutritional management of patients with diabetes or stress-induced hyperglycemia (high blood sugar), instead Resident 1 was observed receiving Fibersource TF (formulated with fiber to meet the nutritional needs for tube feeding patients with normal or elevated calorie and/or protein requirements and has higher carbohydrate content). This deficient practice resulted in Resident 1 receiving the incorrect TF formula and not receiving the correct nutrition ordered by the physician and puts resident at risk of hyperglycemia (high blood glucose). Findings: A review of Resident 1 ' s admission Record indicated 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.

Based on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services as follows: 1. [NAME] 1 failed to describe how to properly calibrate (calibration is the process of configuring an instrument to provide a result for a sample within an acceptable range) thermometers; 2. [NAME] 1 failed to describe acceptable quaternary ammonium compound (a type of chemical that is used to kill bacteria, viruses, and mold) sanitizer range; 3. Trayline Staff 1 failed to describe how to properly sanitize when manually washing dishes; and 4. Trayline Staff 1 failed to describe when to discard the ReadyCare vanilla shakes. These failures had the potential to result in unsafe and unsanitary food preparation and production and food-borne illness. Findings: 1. During an interview on 10/25/2021, at 7:47 a.m., with Dietary Supervisor (DS), she stated cooks and trayline staff calibrated thermometers. During a concurrent observation and interview on 10/25/2021, at 7:48…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free of accidents and hazards for three out of three residents, (Resident 28, Resident 46 and Resident 69) by failing to 1. Pad bed siderails for Resident 28, 2. Safely store Resident 46's personal belongings, 3. Assist Resident 69 while pouring hot coffee in a common area of the facility. These deficient practices had the potential to result in accidents and/or harm to the residents. Findings: 1. A review of Resident 28's admission Record indicated, the facility admitted Resident 28 on 07/30/2021 with diagnoses including: generalized idiopathic epilepsy (form of epilepsy in which seizures come from the entire brain at once) and epileptic syndromes (group of features usually occurring together i.e. types of seizures commonly seen, part of the brain involved, usual course), intractable (hard to control), with status epilepticus (seizure lasts longer than five minutes or seizures occur close together), hyperlipidemia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: a. Administer the correct amount of oxygen (O2-a gas necessary to sustain life) per physician's order for two of six sampled residents (Residents 19 and 31). Residents 19 and 31 were on oxygen therapy. b. Date and initial oxygen nasal cannulas (devices used to deliver supplemental oxygen placed directly on a resident's nostrils) for five of six sampled residents (Residents 31, 45, 49, 54, and 234). Residents 31, 45, 49, 54, and 234 were on oxygen therapy. These deficient practices had the potential for to develop respiratory distress and or respiratory infection for Residents 19, 31, 45, 49, 54, and 234. Findings: 1. A review of Resident 19's admission Record, indicated the facility originally admitted Resident 19 was originally on 2/18/2021, and was readmitted on [DATE], with diagnoses not limited to asthma (long term lung disease making it more difficult to breathe) related to congestive heart failure (CHF-a heart condition which the…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when seven lunch items at the trayline (A system of food preparation, used in hospitals, in which trays move along an assembly line) were measured below the required temperature set by the facility's policy. This deficient practice had the potential to result in food-borne illness in medically vulnerable residents who consumed the food prepared by the facility kitchen. Findings: During a concurrent observation and interview on 10/25/2021, at 11:35 a.m., with Dietary Supervisor (DS), in the kitchen, the DS stated that temperature of hot foods set up at the trayline should be at least 140°F (Fahrenheit-Unit of temperature). Seven lunch items on the steam table at the trayline were measured as follows: a) white rice: 129.6°F; b) corn: 129.6°F; c) regular beef patty: 125°F; d) pureed meat sauce: 124 - 135°F; e) pureed zucchini: 132°F; f) pureed pasta: 136.4°F; and g) alternative chicken: 137°F. A review of…

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

Based on observation, interview and record review, the facility failed to follow menu as written for residents on puree diet (a texture-modified diet in which all foods have a soft, pudding-like consistency). 11 of 81 residents on pureed diet received inaccurate portion. This deficient practice had the potential for residents to receive inadequate protein and caloric intake when not following the menu, which could result in undernutrition or overnutrition and further compromise the residents' health status. Findings: A review of the facility's recipe titled, Whole Grain Spaghetti with Zesty Meat Sauce, undated, indicated that pureed pasta's regular portion should be served with a #8 scoop providing a half cup, and pureed meat sauce's regular portion would be 6 oz (ounces). During a concurrent observation and interview on 10/25/2021, at 12:24 p.m., with [NAME] 1, in the kitchen, [NAME] 1 was using a #12 scoop providing a third cup for pureed pasta and a serving spoon providing 8 oz for pureed meat sauce. When asked about the serving size, [NAME] 1 stated she made a mistake on 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 food was prepared per the recipe and methods that conserved flavor and failed to have performance improvement activity addressing the concern of food palatability for Resident 17. This deficient practice had the potential to result in decreased food intake for the residents who consumed food prepared in the facility. Findings: A review of Resident 17's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 17's diagnoses included, but were not limited to, fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), and muscle weakness. A review of Resident 17's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 7/19/2021, indicated Resident 17 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for…

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

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when two(2) raw meats in a refrigerator were kept beyond their use by date. This deficient practice had the potential to affect the food quality and to result in food-borne illness to the residents who may consume the food. Findings: During an observation on 10/25/2021, at 8:24 a.m., with Dietary Supervisor (DS) and [NAME] 1, in the kitchen, the following items were observed in a 3-door refrigerator (i.e. refrigerator #2): a) approximately 20 pounds of raw chicken was in a metal pan with a label indicating that its use by date was 10/21/21; and b) approximately 5 pounds of bacon was in a metal pan with a label indicating that its use by date was 10/23/2021. During a concurrent interview on 10/25/2021, at 8:24 a.m., [NAME] 1 stated that raw meats should be used within 3 days. [NAME] 1 further stated she should not use the expired items and did not know why she missed the expired meat items. According…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care for two of 39 sampled residents (Residents 63 and 236) in a manner that promoted or enhanced resident's dignity and respect by failing to ensure urinary drainage bags (designed to collect urine drained from the bladder via catheter or sheat) were covered with a privacy bag. This deficient practice had the potential to cause psychosocial harm to the residents and violate residents' right to be treated with dignity. Findings: A review of Resident 236's admission Record indicated Resident 236 was re-admitted in the facility on 10/21/2021, with diagnoses including, pneumonia (infection that inflames air sacs in one or both lungs which may fill with liquid), diabetes mellitus (DM-a condition that affects the body processes blood sugar), cellulitis (bacterial skin infection) of bilateral lower leg, obstructive and reflux uropathy (a disorder characterized by the blockage of the normal flow of contents of the urinary tract) 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 a call light (a device used to notify the nurse the resident needs assistance) that was easily accessible to one of two sampled residents (Resident 58). This deficient practice had the potential for delayed care for Resident 58. Findings: A review of Resident 58's admission Record, indicated Resident 58 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection that causes redness, swelling, and pain) weakness, and anemia (low levels of red blood cells in the body). A review of Resident 58's Minimum Data Set (MDS - a standardized resident care screening and assessment tool), dated 09/16/2021 indicated Resident 58's cognition (ability to understand, remember, learn, and make decisions of daily living) was moderately impaired. The same MDS indicated, Resident 58 needed extensive assistance with bed mobility, transfer, walking in room and corridor, locomotion on and off the unit, dressing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for one of the 39 sampled residents, (Resident 11). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: A review of Resident 11's admission Record indicated Resident 11 was admitted to the facility on [DATE], with diagnoses including type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]), and cerebral infarction (occurs because of disrupted 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 observation, interview and record review, the facility failed to implement person-centered care-plan interventions (measurable short-term and long-term objectives, timetables, and actions to meet the needs of each resident) per facility policy for two of two residents (ResidentS 58 and 28). This deficient practice had the potential to not meet the physical, psychosocial, and functional needs of the resident and cause harm. Findings: A review of Resident 58's admission Record, indicated Resident 58 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection that causes redness, swelling, and pain) weakness, and anemia (low levels of red blood cells in the body). A review of Resident 58's Minimum Data Set (MDS - a standardized resident care screening and assessment tool), dated 09/16/2021 indicated Resident 58's cognition (ability to understand, remember, learn, and make decisions of daily living) was moderately impaired. The same MDS indicated, Resident 58 needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were trained on how to operate, and use approprate low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) settings that were consistent with manufacturer's guide and physician order for one of 39 sampled residents (Resident 234). These deficient practices placed Resident 234 at risk to develop a pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence). Findings: A review of Resident 234's admission Record, indicated the facility admitted Resident 234 on 10/11/2021, with diagnoses not limited to fracture (break in a bone) of the sacrum (bone at the bottom of the spine and lies between the fifth segment of the spine and the tailbone), emphysema (lung condition that causes shortness of breath), thoracic aortic ectasia (enlargement of the aorta [main artery that carries blood away from the heart to the rest of the body], malnutrition (lack of sufficient nutrients in the body), hypoxemia (low level of oxygen in the…

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

Based on observation, interview and record review, facility failed to ensure that a indwelling catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage from the bladder) urinary bag drainage was off the floor for one of 39 sampled residents (Resident 236). This deficient practice had the potential to result in urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder and urethra) for Resident 236. Findings: A review of Resident 236's admission Record, indicated the facility re-admitted Resident 236 on 10/21/2021, with diagnoses that included, but not limited to, pneumonia (infection that inflames air sacs in one or both lungs which may fill with liquid), diabetes mellitus (DM-a condition that affects the body processes blood sugar), cellulitis (bacterial skin infection) of bilateral lower leg, obstructive and reflux uropathy (a disorder characterized by the blockage of the normal flow of contents of the urinary tract) and weakness. A review of Resident 236's Minimum Data Set (MDS- a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to change enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals, administered through a tube into the stomach) syringes (used for measurement and administration of medicines, flushes and feeds via oral or enteral routes) daily per facility's Enteral Feedings-Safety Precautions policy and procedures for two of 39 sampled residents (Residents 45 and 48) . This deficient practice had the potential to result in infection that can lead to complications. Findings: a. A review of Resident 45's admission Record, indicated the facility re-admitted Resident 45 on 8/19/2020, with diagnoses not limited to metabolic encephalopathy (problem in the brain that is caused by chemical imbalance in the blood), cerebral infarction (also called ischemic [stroke that occurs as a result of disrupted blood flow to the brain]), osteoarthritis (a condition where by protective flexible tissue at the ends of bones wear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Insertion of Peripheral Intravenous (IV) Catheter policy and procedures by not indicating the date and time of insertion of a peripheral intravenous catheter (PIV-a catheter placed into a peripheral vein to administer medication and fluids) for one of 39 sampled residents (Resident 236). This deficient practice had the potential for PIV to remain in place beyond 72 hours and was a potential risk of infection for Resident 236. Findings: A review of Resident 236's admission Record, indicated the facility re-admitted Resident 236 on 10/21/2021, with diagnoses not limited to pneumonia (infection that inflames air sacs in one or both lungs which may fill with liquid), diabetes mellitus (DM-a condition that affects the body processes blood sugar), cellulitis (bacterial skin infection) of bilateral lower leg, obstructive and reflux uropathy (a disorder characterized by the blockage of the normal flow of contents of the urinary tract) and weakness. A review of Resident 236's Minimum Data Set (MDS- 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 1) Properly date a medication for one out of one resident (Resident 145); 2) Safely secure treatment supply room (where wound care supplies and medications are kept) door. These deficient practices had a protencial to result in unauthorized access and use of biologicals (a diverse group of medicines) in treatment supply room and the use of an ineffective medication for resident. Findings: 1. A review of Resident 145's admission Record, indicated the facility admitted Resident 145 on 10/16/2021 with diagnoses including: anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that interfere with one's daily activities) hypertension (high blood pressure) and weakness (state or condition of lacking strength). A review of Resident 145's Minimum Data Set (MDS - a standardized care screening and assessment tool), dated 09/16/21, indicated Resident 145's cognition (ability to understand, remember, learn, and make decisions of daily living) was intact. The same MDS indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection precaution and prevention as one of 39 sampled residents (Resident 69) poured his own hot coffee from the coffee cart unassisted and walked out with uncovered cup. This deficient practice had the potential to result in the spread of infection to both staff and residents. Findings: A review of Resident 69's admission Record indicated the resident was re-admitted on [DATE]. Resident 69's diagnoses included, but were not limited to, bloodstream infection (bacterial or fungal infection that enters the bloodstream), urinary tract infection (UTI- infection in any part of the urinary system [kidneys, bladder, or urethra]), diabetes mellitus (DM-a condition that affects the body processes blood sugar), malnutrition (lack of proper nutrition), weakness and difficulty in walking. A review of Resident 69's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 9/10/2021, indicated Resident 69 had an 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.