Highland Park Skilled Nursing And Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 Screening accurately for one of one sampled residents (Resident 2) reviewed for PASARR. This resulted in an inaccurate evaluation that Resident 2 did not require a Level 2 PASARR, with the potential for Resident 2 not to receive the appropriate level of care Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought) and epilepsy (a chronic brain disorder characterized by recurring, unprovoked seizures [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 develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for two (2) of 20 sampled residents (Residents 21 and 46) by failing to:Include resident centered interventions to address Resident 21's risk for fall. This deficient practice has the potential to increase Resident 21's risk for falls resulting in incidents of fall and injury. Reflect Resident 46's fluid restriction as indicated on the physician's order. This deficient practice has the potential for Resident 46's fluid restriction not to be followed, which could result in respiratory complications, cardiovascular strain and fluid overload. Findings: 1. During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of difficulty walking, lack of coordination, and history of falls. 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 ensure one of one sampled resident (Resident 5) reviewed for hearing received proper treatment to improve hearing abilities by failing to follow up with Resident 55's authorization for audiogram (measures hearing sensitivity across different pitches and volume to detect hearing loss) and tympanogram (assess middle ear function [eardrum movement, fluid, pressures]) (non-invasive diagnostic tests used to evaluate ear health) after the resident's Ears, Nose and Throat (ENT) appointment on 1/21/2026. This deficient practice had the potential for Resident 55 to have increased hearing loss.Findings: During a review of Resident 55 Facesheet (admission Record), the Facesheet indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of hypertension (high blood pressure), history of falling, and difficulty in walking. During a review of Resident 55 Minimum Data Set (MDS - a resident assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervision for one (1) of 1 sampled resident (Resident 29) reviewed for smoking when Resident 29 was observed smoking by himself outside in the patio.This deficient practice has the potential for safety concerns and accidents for Resident 29. Findings: During a record review of Resident 29's Facesheet (Admissions Record), the Facesheet indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of difficulty in walking, lack of coordination and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 29's Minimum Data Set (a resident assessment tool), 1/15/2026, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 29 required partial/ moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fluid restriction (a dietary change that limits the amount of liquid a person can consume in a day) as indicated on the physician order for one (1) of two (2) sampled residents (Resident 13), who were receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) treatment. This deficient practice has the potential to cause fluid overload (a condition where there is too much fluid in the body which could result in swelling, particularly in the ankles and legs, shortness of breath and health complications) to Resident 13. Findings:During a review of Resident 13's Facesheet (admission Record), the Facesheet indicated the resident was originally admitted at the facility on 3/19/2024 and was readmitted on [DATE] with the following but not limited to diagnoses of End Stage Renal Disease (ESRD - the final, irreversible stage of kidney [they are vital 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 one (1) of four (4) sampled residents (Resident 4) reviewed and observed for medication administration was free from significant medication error (the identified preparation or administration of medication was not in accordance with the physician's order, which may have cause the resident discomfort or jeopardize health and safety) by failing to administer Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) as indicated on the physician order.This deficient practice placed Resident 4 at risk of not getting the full effect of the medication which can result in blood pressure and heart rhythm problems.Findings:1. During a review of Resident 4's Facesheet (admission Record; front page of the chart that contains a summary of basic information about the resident), the Facesheet indicated that the resident was originally admitted on [DATE] and was readmitted on [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 observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to refrigerate two unopened latanoprost eye drops (medication used to lower high pressure in the eye) in accordance with the facility policy. This deficient practice increases the risk of the residents receiving a medication that had become ineffective or toxic due to improper storage, possibly leading to health complications resulting in damage to the optic nerve (a bundle of over one million nerve fibers that transmits visual information from the retina to the brain, acting as the sole communication path for sight) and potential vision loss or blindness.Findings:During a medication cart observation and interview on 3/12/2026 at 7:54 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 7 and 36's latanoprost eye drops were observed inside the medication cart. LVN 1 stated the eye drops should be stored in the refrigerator designated for medication storage until they are open in accordance with the manufacturer'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 and interview, the facility failed to ensure one (1) of twenty (20) sampled residents (Resident 37) breathing treatment mask and tubing (deliver aerosolized medication directly to the lungs. It includes vinyl mask, medication cup and plastic tube), and respiratory set up bag was changed every seven days per facility's policy and procedure. This failure had the potential to cause respiratory tract (airways including lungs) infection which can lead to Resident 37's hospitalization. Findings: During a review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe) , presence of cardiac (an electronic device that is implanted in the body to monitor heart rate and rhythm), paroxysmal atrial fibrillation (a type of irregular heart rhythm that starts and stops suddenly, with episodes lasting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervise, monitor and provide safety measures, leading to oversight of one (1) of two (2) sampled residents (Resident 1) who attempted to elope (leave the facility without the staff's knowledge and/or supervision) multiple times prior to eloping from the facility on 1/4/2026 in accordance with the facility's policy and procedure (P&P). This failure resulted in Resident 1 eloped from the facility on 1/4/2026 around 1:20 PM which placed the resident at risk for exposure to injury, serious harm, medical complications and/or death. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to toxic encephalopathy (disease of the brain that alters brain function), depression (severe feelings on sadness and hopelessness), difficulty in walking, and lack of coordination. During a review of Resident 1's Change of Condition (COC, 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 ensure one (1) of two (2) sampled residents (Resident 1) were free from unnecessary psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) as indicated in the facility's policy and procedure and care plan by failing to ensure Resident 1:1. Had a specific indication for the use of Ativan (a medication that treats anxiety { fear characterized by behavioral disturbances}).2. Was monitored for specific manifested behavior and side effects for the use of Ativan.This deficient practice had the potential to place Resident 1 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial statusFindings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. 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 two sampled Resident (Resident 1) received treatment and care in accordance with facility's policies and procedures by failing to: 1. Call alternate transportation to ensure Resident 1 receive hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment as ordered and as scheduled on 2/12/2025. 2. Transcribe the order for Resident 1 to be monitored for fluid overload (too much fluid in the body which can raise the blood pressure [BP-the pressure of blood on the walls of the arteries as the heart pumps blood around the body] and force the heart to work harder and can also make it hard to breathe) after missing the HD treatment on 2/12/2025. 3. Administer BP medications on 2/12/2025 as ordered by the physician. These failures resulted in Resident 1 missing scheduled HD treatment and transfer to General Acute Care Hospital (GACH) 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 provide an environment free of accident hazards for one of one sampled resident (Resident 1) by failing to ensure Licensed Vocational Nurse (LVN) 2 did not leave medications at the bedside table. This deficient practice had the potential to result in accidental ingestion of the medications by other residents and cause complications from taking medications not prescribed for the residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility initially admitted the resident on 6/30/2021 and readmitted on [DATE] with diagnoses that included but not limited to end stage renal disease (ESRD-irreversible kidney failure), dependence on hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), hypertension (HTN-high blood pressure), atrial fibrillation (Afib-a condition where the upper chambers of the heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of two sampled residents (Resident 35 and 43) with respect and dignity in accordance with the facility policy by failing to ensure: 1. Certified Nursing Assistant 2 (CNA 2) sat and be at eye level while assisting Resident 35 during feeding. 2. Resident 43's urinary collection bag was covered with a privacy bag (specially designed fabric pouch that conceals and protects urinary drainage bags). This failure had the potential to negatively affect Resident 35 and 43's self-esteem which could result in problems with emotional, psychosocial, and mental well-being. Findings: 1. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (decreased mental function and loss of ability to do daily tasks including the inability to voice needs), adult failure to thrive (FTT- a decline caused by chronic diseases 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 an accurate assessment of the Minimum Data Set (MDS -resident assessment tool) for two (2) of two sampled residents (Residents 42 and 49) by failing to reflect the following on the MDS: 1. Resident 42's diagnosis of anxiety (mental disorder that involves persistent and excessive worry that can interfere with daily activities). 2. Resident 49's diagnoses of anxiety and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). This deficient practice had the potential for the facility to not develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs), which could negatively affect Residents 42 and 49's overall well-being. Findings: 1. During a review Resident 42's admission Record, 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 provide necessary respiratory services for three (3) of 3 sampled residents (Residents 49 and 54) as indicated on the facility policy by failing to: 1.Administer two (2) liters (metric unit of capacity) per minute (LPM) of continuous (without interruption) oxygen therapy (administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of low oxygen) to Resident 49 as indicated in the physician's order. The facility also failed to label and date Resident 49's plastic respiratory equipment bag (a plastic bag that holds and transports respiratory equipment), which contained a nasal cannula (NC- a tube that provides oxygen through the nose) tubing. 2. Store Resident 21's nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) equipment in a bag. 3. Administer 2 to 3 LPM oxygen therapy to Resident 54 as indicated in the…

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

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to ensure: 1. Food was labeled and stored in refrigerators, freezers and dry storage. 2. Proper sanitization of dishes by ensuring all dishes in the dishwasher were washed with a temperature of at least 120 degrees Fahrenheit (F) during use. These deficient practices have the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 50 residents consuming food by mouth. Findings: 1. During a concurrent observation and interview on 2/10/2025 at 7:49 AM in the facility kitchen with the Dietary Services Supervisor (DSS), the following food items were observed: a. Refrigerated container of sausage labeled with a use by date of 2/8/2025 b. Refrigerated container of cheese frosting labeled with a use by date of 2/8/2025 c. Refrigerated container of turkey meat labeled…

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

Based on observation, interview and record review, the facility failed to ensure two of three garbage container (dumpster) lids remained closed and were not overflowing with trash as indicated on the facility policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During an observation on 2/12/2025 at 10:27 AM in the facility's parking lot dumpster area, two dumpsters were observed with trash overflowing out of the top of both dumpsters, with lids opened due to overflowing trash. During an interview on 2/13/2025 at 1:32 PM with the Maintenance Supervisor (MS), MS stated per facility policy, boxes and trash should be compressed into the dumpsters to ensure the lids stay closed and trash should not be overflowing. MS stated the outside dumpster lids were supposed to be closed and clean to keep out flies and rodents. During a review of the facility's Policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update and revise the care plan for two (2) of 21 sampled residents (Resident 42 and Resident 33) as indicated on the facility policy when: 1. Resident 42's fall care plan was not updated and revised after Resident 42 had a fall with injury on 1/3/2025. 2. Resident 33's care plan was not revised to reflect the updated fluid restriction in accordance with the physician's order on 1/15/2025. This failure had the potential to negatively affect the provisions of care and services for Residents 33 and 42 and had the potential to place Resident 42 at risk for further falls. Findings: 1. During a review Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills) with psychotic (mental health disorder which a person loses touch with reality) disturbance, lack of coordination, generalized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality in accordance with the facility's policy for one of 21 sampled residents (Resident 42) by: a. Failing to ensure an Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) meeting was conducted after Resident 42 had a fall with an injury. b. Failing to ensure a Post Fall Evaluation was done after Resident 42 had a fall with an injury. c. Failing to ensure neurological exam (neuro check, an assessment of the brain, spine or nerves done to evaluate the nervous system function for potential brain injury) was done after Resident 42 had a fall with an injury to the eyebrow. These deficient practices had the potential to result in further falls for Resident 42. Findings: During a review Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE], with diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 43) who had an indwelling urinary catheter (Foley Catheter, tube inserted into the bladder to drain urine into a drainage bag) received appropriate care and services as indicated in the physician's orders, by failing to appropriately assess and document signs and symptoms of urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder [organ that stores urine] or urethra [the tube through which urine leave the body]). This deficient practice resulted in delayed UTI identification and had the potential to lead to worsening infection and delayed treatment. Findings: During a review Resident 43's admission Record, the admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of malignant neoplasm (cancer growth of cells) of prostate (small gland below the bladder), benign prostatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately monitor the fluid intake for one of one sampled resident (Resident 33) with fluid restrictions and on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment in accordance with the facility's policy and procedure. This deficient practice had the potential to cause fluid overload (too much fluid in the body) or increase risk for dehydration (harmful reduction in the amount of water in the body). Findings: During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function and require dialysis or a kidney transplant to survive), type 2 diabetes mellitus (DM, persistently high levels of sugar in the 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 observation, interview, and record review, the facility failed to provide pharmaceutical services by not supervising medication administration when eight (8) medications were given and left on the nightstand for one (1) of 21 sampled residents (Resident 39). This deficient practice had the potential to result in medication errors and had the potential to harm Resident 39. This also had the potential for other residents to access the medications and in the event that the medications were ingested, could cause harm to the other residents. Findings: During a record review Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE], with diagnoses of atherosclerosis (plaque buildup in the arteries) of the aorta (main artery in the body), chronic pulmonary edema (an abnormal accumulation of fluid in the lungs, making it hard to breathe), and psychosis (a mental disorder characterized by a disconnection from reality), and dementia (progressive brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 act upon the facility's Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to address the recommendation/ irregularities for the month of December 2024's MRR for one of five sampled residents (Resident 41) as indicated on the facility's MRR policy. This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Resident 41. Findings: During a review of Resident 41's admission Record, the admission record indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 temperatures of the facility's one of one Activity Room Refrigerator, which contained resident food brought by family/visitor, was checked daily per facility policy. This deficient practice had the potential for Resident 40 to experience food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents). Findings: During a concurrent observation and interview on 2/10/2025 at 8:40 AM with the Dietary Services Supervisor, in the facility activity room, the resident refrigerator was observed. The refrigerator contained a plastic bag with a food container, labeled with Resident 40's room number and bed. DSS stated this food was brought in by Resident 40's family. During a concurrent interview and record review on 2/10/2025 at 8:45 AM with DSS, the facility's Policy & Procedure (P&P) titled, Refrigerator/Freezer Temperature Log- Refrigerator in Activity Room, revised 11/2014, which was also the log, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident ' s physician/medical doctor when the resident was refusing more than 50% of his meal 3 consecutive times for one of two sampled residents (Resident 1) on 10/4/2024 to 10/5/2024. This deficient practice had the potential to delay in the necessary care and services for Resident 1 and lead to severe malnutrition. Findings: During a review of Resident 1 ' s admission Record indicated resident was admitted on [DATE] with the following diagnosis of protein-calorie malnutrition (lack of sufficient nutrients in the body), dementia (a progressive state of decline in mental abilities), Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities) and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 1 ' s History and Physical (H&P), dated 10/4/2024, indicated resident has no mental capacity to make decisions for self. During 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 observation, interview, and record review, the facility failed to promote dignity and respect for two of three sampled residents (Resident 16 and 11) for the dignity care area by: 1. Ensuring Resident 16's urinary catheter bag (tube that drains urine from the bladder into a drainage bag) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). 2. Failing to ensure facility staff did not stand above Resident 11's eye level while assisting the resident to eat. These deficient practices have the potential to affect Resident 16 and 11's self-esteem and self-worth and violates Resident 16 and 11's right to be treated with dignity. Findings: 1. A review of Resident 16's admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs) with acute exacerbation (sudden worsening 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 provide the necessary care and services to ensure the resident's abilities in activities of daily living (ADLs) for two of two sampled residents (Resident 15 and 29) of advance daily living (ADLs) care area. 1. Facility failed to ensure Resident 15 was provided communication device with the resident's primary language and failed to ensure Resident 15 with limited range of motion (ROM - movement of the joints) receive appropriate positioning in bed. 2. Facility failed to ensure Resident 29 was provided a communication device (a visual aid with symbols, pictures, or words that users can point to or select to express their thoughts and needs) with the language that the resident was able to understand. This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving appropriate care/treatment the resident needed. Findings: 1. A review of the admission record indicated Resident 15 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 16 and 36) were provided with a safe environment to prevent avoidable accidents and hazards for accidents care area. This deficient practice had the potential to place the residents at risk for falls, injuries, and delayed care. Findings: 1. A review of Resident 16's admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs) with acute exacerbation (sudden worsening in airway function and respiratory symptoms), dependence on supplemental oxygen, anxiety disorder (persistent and excessive worry that interferes with daily activities), and difficulty in walking. A review of Resident 16's History and Physical (H&P, the initial clinical evaluation and examination of the resident) dated 3/26/2024, indicated Resident 16 had the…

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

Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for fifty-two (52) residents of the facility by: 1. Facility failed to ensure that conventional oven temperature knob indicates the temperature setting. 2. Facility failed to ensure that food items inside kitchen produce refrigerator and dry storage were labeled with a received date and/ or expiration date, and expired food items were discarded and not mixed with other non-expired foods. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization. Findings: 1. During observation and interview with the Dietary Staff Supervisor (DSS) and [NAME] on 3/26/2024 at 8:31 AM, in the kitchen, DSS stated, we do not know the temperature of the oven, the knob has no settings printed on there. It 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship to reduce inappropriate antibiotic (medication used to kill bacteria and to treat infections) use by not administering antibiotic drug if the McGeers (named Infection Screening Evaluation in facility's medical record, surveillance definitions of infections in Long-Term Care Facilities) criteria were not met for two (2) of three (3) sampled residents (Residents 16 and 35) for antibiotic care area. This deficient practice had the potential for the residents to develop antibiotic resistance (when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicine and become ineffective making infections difficult or impossible to treat increasing the risk of disease spread, severe illness, disability, and death) and suffer adverse side effects from unnecessary or inappropriate antibiotic use. Findings: 1. A review of Resident 16's admission Record indicated Resident 16 was initially…

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

Based on interview and record review, the facility failed to provide education, offer, and/or document the updated Covid-19 (Coronavirus Disease 19, a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) for the year 2023-2024 vaccinations for 96 of 105 employees. This deficient practice placed the residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage. Findings: A review of the undated Employee List and Vaccines, it did not indicate how many employees were offered, received, and/or declined the updated Covid-19 for the year 2023-2024 vaccine. The Employee List indicated 3 employees were exempt from the vaccination. A review of the Covid-19 Vaccination Employee Consent or Refused, dated 11/16/2023, 11/28/2023, and 11/29/2023, indicated 3 employees received the updated Covid-19 2023-2024 vaccination offsite (not at the facility). During an interview on 3/28/2024 at 10:18 AM with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated CNA 7 the last covid vaccine offered (unable to recall when) by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of three of 13 sampled residents (Resident 5, Resident 27, and Resident 15). This deficient practice had the potential to result in delayed provision of services, delay in care and Residents 5, 27, and 15 not receiving assistance with activities of daily living (ADLs). Findings: a. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses of difficulty of walking, lack of coordination, neuralgia (severe, sharp, often shock-like pain that follows the path of a nerve) and neuritis (inflammation of the nerves), and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 5's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 11/6/2023,…

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 observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to eating was accurately documented to reflect the resident's ability to eat for one of one sampled resident (Resident 6) for the resident assessment care area. This deficient practice had the potential to negatively affect Resident 6's plan of care and delivery of necessary care and services. Findings: A review of Resident 6's admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included anorexia (lack of loss of appetite for food), legal blindness, and unspecified hearing loss. A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/7/2024, indicated Resident 6 was assessed having severely impaired cognition (mental action or process of acquiring knowledge and understanding) 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 interview and record review, the facility failed to ensure the preadmission screening assessment (PASRR - Preadmission Screening and Resident Review - a federal requirement to ensure that every person entering a Medicaid Certified Nursing Facility [NF] receive a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identity what specialized services they may need) form was accurately completed for a resident who had a mental illness for one of three sampled residents (Resident 24) for PASRR care area. This deficient practice led to the resident not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: A review of the Resident 24's admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), Type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to review and revise the care plan for one of 13 sampled residents (Resident 11) who has a history of seizures (epilepsy- abnormal electrical activity in the brain that happens quickly). This deficient practice had the potential to negatively affect the provision of care and services for Resident 11. Findings: A review of Resident 11's admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect it), paroxysmal atrial fibrillation (irregular heartbeat), and epilepsy. A review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/10/2024, indicated Resident 11 was assessed having moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making and required substantial/maximal assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary respiratory care services for one (1) of 1 sampled resident (Resident 16) for respiratory care area by failing to: 1. Ensure Resident 16's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing was changed per facility's policy. This deficient practice had the potential for Resident 16 to develop a respiratory infection. 2. Place visible oxygen signage by Resident 16's door/wall prior to entering the room. This deficient practice had the potential for harm to Resident 16 and other residents, in an event of a fire. Findings: A review of Resident 16's admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs) with acute exacerbation (sudden worsening in airway function and respiratory symptoms),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of six (6) sampled residents (Resident 40) receive all medications in accordance with the physician's order and facility's policy and procedure (P&P) when Resident 40 was observed in possession of three (3) clear red capsules on 3/28/2024. This deficient practice had the potential for Resident 40 to have an overdose of the medication, which could result in harm. Findings: A review of Resident 40's admission Record indicated Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as a stroke, damage to tissue in the brain due to loss of oxygen to the area) affecting the left non-dominant side, degenerative disease of 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 that a shower chair used by residents was in good condition and free from stains. This deficient practice had the potential for the resident to feel uncomfortable during showers and affect the resident's quality of life. Findings: During an observation on 3/28/2024, at 10:06 AM, an unnamed Certified Nursing Assistant (CNA) pushed a white shower chair and placed it outside of room [ROOM NUMBER]. The shower chair seat had brown and yellowish stains and the plastic woven backrest was ripped and worn out. During a concurrent observation and interview with Registered Nurse Supervisor 1 (RNS 1), on 3/28/2024, at 10:10 AM, RNS 1 stated the brown marks on the shower chair seat were old stains. RNS 1 stated the shower chair look old and needed to be replaced. RNS 1 stated she would not want to sit on that shower chair if she was a resident in the facility. During an interview with the Maintenance Supervisor (MS) on 3/28/2024, at 10:15 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the care plan for one (1) of three (3) sampled residents (Resident 1) to include bowel and bladder retraining assessment as indicated on the bowel and bladder screener (assessment of how the resident's bladder and bowel are working). This deficient practice had the potential for Resident 1 not to receive specific interventions to maximize control of the bowel and bladder function. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included history of falling, left hip fracture, and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/3/23, indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bowel and bladder retraining program (use of a timed schedule for voiding/bowel movement based on the resident's identified need and routine to maximize control of their bowel and bladder function as much as possible) and scheduled toileting program (use of a timed schedule for voiding/bowel movement to match the Resident's voiding/bowel habits. Appropriate Residents for this program are caregiver dependent, cognitively impaired and cannot gain control of their bowel and bladder function) were implemented for one of three sampled residents (Resident 1) as indicated on the facility policy. This deficient practice had the potential to result in not restoring the resident ' s bowel and bladder function,development of urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra), and fall. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility 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.