Kennedy Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the residents' privacy and dignity by failing to ensure the indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of three sampled residents (Resident 1).This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem.During a review of Resident 1's admission Record, it indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), obstructive and reflux uropathy (a condition in which the flow of urine is blocked and urine flows backward from your bladder into your kidneys) and depression (a mood disorder that causes persistent feeling of…

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

Based on interview and record review the facility failed to ensure residents' information was not sent to the personal cell phones of facility staff members. This deficient practice had the potential for unauthorized release of residents' information to the public. During an interview on 9/11/25 at 9:06 a.m., restorative nursing assistant (RNA 1, a certified nursing assistant (CNA) with specialized training in rehabilitation skills) stated she received text messages on her personal cellphone from the rehabilitation department regarding residents who would need to be on the RNA program. RNA 1 stated the text messages would include the name of the residents and their room number. During an interview on 9/11/25 at 10:18 a.m. the physical therapist (PT) stated when a resident needs to be on the RNA program, a group text message would be sent to the director of rehabilitation, the physical therapist, occupational therapist, director of staff development and the RNA. The PT stated the text messages would include the name of the residents, their room number and the specific RNA program.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, (Resident 1) by failing to follow and implement physician's order and when Resident 1's blood pressure was elevated according to facility's policy and procedure titled, Changes in Resident's Condition or Status.This deficient practice placed Resident 1 in delayed intervention to provide treatment for urinary tract infection (UTI- an infection in the bladder/urinary tract) as required per facility's policy and procedure upon changes in condition.During a review of Resident 1's admission Record, it indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), obstructive and reflux uropathy (a condition in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff follow physician's order and facility's policy with wearing personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) when providing care to one of three sampled residents (Resident 2) who was on an enhanced barrier precaution (utilized to prevent the spread of multi-drug resistant organisms) room. This deficient practice placed residents at a higher risk of acquiring and transmitting infections to other residents, staff and visitors in the facility.During a review of Resident 2's admission Record, it indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including sepsis (a life-threatening blood infection), urinary tract infection (UTI- an infection in the bladder/urinary tract), and chronic kidney disease (CKD-a longstanding disease of the kidneys…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 76 of 76 residents when: Improper Storage of Fooda. Improper Storage and labeling of Food b. Prepared leftover tuna stored in the refrigerator c. Dietary staff did not follow cool down methodd. Multiple food items with expiration datese. Dietary Cooks did not follow the thawing process 2. Equipment Cleanliness/Cross-contaminationa. The stove was dirtyb. The floor in front of the stove was dirtyc. Multiple large silver pans were dirty 3. Dietary staff was competent in the thawing process for large pork roast.These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour to the kitchen on 8/5/2025…

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 answer call lights in a timely manner for six of six sample (Residents 18, 28, 49, 71, 75, and 106). This failure had the potential to cause a delay in care and services necessary for the residents. Findings: During a record review, Resident 18's admission Record indicated Resident 18 was admitted to the facility on [DATE] with a diagnosis of muscle weakness (decrease in the force your muscles can generate, making it harder to move your body) and Displaced intertrochanteric fracture of the left femur (break in your thigh bone). During a record review, Resident 18's History and Physical (H&P) dated 7/18/25, indicated the resident was alert and cooperative. During a record review, Resident 18's Minimum Data Set (MDS- a resident assessment tool) dated 7/27/2025, indicated the resident was cognitively intact (mental ability to make decisions of daily living), and needed minimal to moderate assistance with activity of daily living (ADL-basic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 each resident with a nourishing and palatable diet for five out of five sampled residents (Residents 17, 18, 28, 49, and 75). This failure had the potential to result in weight loss, functional decline, dehydration, and skin impairment for Residents 17, 18, 28, 49, and 75). Resident 17 stated not getting nourishing and palatable diet makes him angryFindings: During an interview on 8/5/25 at 9:02 A.M., Resident 49 stated the food is not palatable and the dietary department is serving chicken too often at least 4 times a week. Resident 49 stated he spoke with the facility Dietary Supervisor (DS) and expressed his concerns about the food and nothing has changed. During an interview on 8/6/2025 at 9:34 A.M., Resident 18 stated the food in the facility does not taste very good and that the food tasted unseasoned and the cooks serves chicken almost every day either for lunch or dinner. Resident 18 stated she is glad she is going home on 8/8/2025. Resident 18 stated she spoke with the DS when she was admitted and gave DS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve palatable food for seven of seven residents (Residents 7, 17, 18, 24, 28, 49, and 75) reviewed for food palatability reviewed for food palatability. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss for the residents. 1. During a record review, Resident 7’s admission Record indicated the facility originally admitted the resident on 2/27/2024 and readmitted the resident on 5/17/2025 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and anemia (a condition where the body does not have enough healthy red blood cells). During a record review, Resident 7’s nutritional malnutrition, initiated 2/28/2024, indicated Resident 7 was at risk for malnutrition due to diagnosis of diabetes. The care plan goal was for the resident to not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and concurrent record review, the facility failed to ensure staff completed annual and upon hire Tuberculin (TB - is a serious illness that mainly affects the lungs) skin test, staff had TB skin test results on file, and annual physical examination completed for four out of seven employees (Licensed Vocational Nurse (LVN 1 and 2, Occupational Therapist (OT - assess a person's physical, cognitive, and emotional abilities and develop treatment plans to improve their functional skills, adapting the environment or activities as needed), and Treatment Nurse). This failure had a high probability of TB transmission to residents, guests, and staff to result in the facility.Findings: During an interview and concurrent record review on 8/7/25 at 8:42 AM, seven of seven employee files were reviewed with the Director of Staff Development (DSD) and the following were noted: 1. LVN 1 was hired on 3/14/2022. There was no annual Tuberculin (TB - is a serious illness that mainly affects the lungs) skin test for the years 2023 and 2024, no background check since 2022, no annual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allow one of six sample residents (Resident 49) to retain his personal possession(s). This failure resulted in Resident 49 feeling angry because he could not call his family member(s). Findings: During a record review, Resident 49's admission record indicated Resident 49 was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with a diagnoses of muscle weakness (lack of physical or muscle strength), paraplegia (a condition where a person has partial or complete paralysis or the lower half of their body, including both legs). During a record review, Resident 49's Minimum Data Set (MDS- a resident assessment tool) dated 7/5/2025, indicated the resident was cognitively intact (the mental ability to make decisions of daily living), and required moderate to maximum assistance with Activities of Daily Living (ADL- activities related to personal care). During a record review, Resident 49's care plan initiated on 7/15/2025,…

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.

Based on interviews and concurrent record review the facility failed to conduct a background search for one out of seven employees (Housekeeping) prior to working in the facility: This failure had the potential to expose the residents to abuse.Findings: During an interview and concurrent record review with the Director of Staff Development (DSD) on 8/7/25 at 8:42 AM, Housekeeping employee file was reviewed which indicated that Housekeeping was hired in the facility on 8/22/2024. The housekeeping employee file indicated there was no background search report. DSD stated she has been employed with the facility for 2 years. DSD stated employee background checks/search are completed to ensure that the staff that are hired do not have a criminal background and to ensure the safety of the residents. During a record review, the facility document titled Facility Assessment Tool dated 3/28/2025, under staff training/education and competencies, indicated that, New hires must undergo background checks .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and concurrent record reviews, the facility failed to implement the physician orders to administer Trazadone (medication used to treat depression) for one of one sampled resident (Resident 106). These failures resulted in Resident 106 inability to sleep and the resident feeling angry. Cross Reference F0760Findings: During a record review, Resident 106 admission record indicated Resident 106 was admitted to the facility on [DATE] with a diagnoses of human immunodeficiency virus disease (a virus that weakens the body's defense system also called HIV) and essential hypertension (high blood pressure). During a record review of Resident 106's Minimum Data Set (MDS- a resident assessment tool) dated 8/8/2025, indicated the resident was cognitively intact (mental ability to make decisions of daily living). During a record review, Resident 106's care plan initiated 8/4/2025, indicated, Resident 106 uses antidepressant medication related to depression (a serious mood disorder 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 interview and record review, the facility failed to ensure residents' Annual Minimum Data Set assessments (MDS, a standardized assessment and care screening tool) was completed in accordance with the timeline set forth by the Center for Medicare Services (CMS) system for one out of 13 sampled residents (Resident 11). This deficient practice had the potential to result in delayed services for Resident 11. During a record review, Resident 11's admission record indicated the facility originally admitted the resident on 6/2/2021 and re-admitted the resident on 6/23/2023 with diagnoses that included Alzheimer's Disease , chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should) and dementia (a progressive state of decline in mental abilities). During a concurrent interview and record review on 8/7/2025 at 10:07 AM, with the Minimum Data Set Assistant (MDSA), Resident 11's most recent Annual MDS was reviewed. MDS Assessment Reference Date (ARD - the last day of the observation or look-back period for the MDS assessment) dates and submission dates…

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

Based on interview and record review, the facility failed to ensure residents' Minimum Data Set assessments (MDS, a standardized assessment and care screening tool) were transmitted timely to the Center for Medicare Services (CMS) system for four out of 13 sampled residents (Resident 17, Resident 40, Resident 57 and Resident 63). This deficient practice had the potential to result in delayed services for Resident 17, Resident 40, Resident 57 and Resident 63. During a record review, Resident 17's admission record indicated the facility originally admitted the resident on 12/30/2023 and re-admitted the resident on 3/31/2025 diabetes mellitus (high blood sugar), dementia (a decline in mental ability severe enough to interfere with daily life), and kidney failure (a medical condition where the kidneys lose their ability to effectively filter waste and excess water from the blood, and maintain proper chemical balance in the body). During a record review, Resident 40's admission record indicated the facility originally admitted the resident on 6/2/2021 and re-admitted the resident on…

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

Based on interview and record review, the facility failed to ensure residents' Minimum Data Set assessments (MDS, a standardized assessment and care screening tool) were transmitted timely to the Center for Medicare Services (CMS) system for 11 out of 13 sampled residents (Resident 8, Resident 10, Resident 11, Resident 17, Resident 40, Resident 43, Resident 51, Resident 52, Resident 57, Resident 63 and Resident 104). This deficient practice had the potential to result in delayed services for Resident 10, Resident 11, Resident 17, Resident 40, Resident 43, Resident 51, Resident 52, Resident 57, Resident 63 and Resident 104. During a record review, Resident 8's admission record indicated the facility originally admitted the resident on 8/19/2023 and re-admitted the resident on 2/4/2025 with diagnoses including end stage renal disease (ESRD - irreversible kidney failure) and anemia (a condition where the body does not have enough healthy red blood cells). During a record review, Resident 10's admission record indicated the facility originally admitted the resident on 11/8/2023 and…

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

Based on observation, interview and record review, the facility failed to ensure the tube feeding (TF - a form of nutrition that is delivered into the digestive system as a liquid) was administered as ordered for one of two sampled residents (Resident 27). This deficient practice had the potential to cause Resident 27 to take in an inadequate amount of calories and nutrition and weight loss. During a record review, Resident 27's admission record indicated the facility admitted the resident on 7/19/2024 with diagnoses that included protein calorie malnutrition (a condition in which a person does not consume enough protein and calories to meet their body's needs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and chronic kidney disease (progressive damage and loss of function in the kidney). During a record review, Resident 27's History and Physical, dated 10/17/2024, indicated the resident was at high risk for decompensation (the loss of the ability to cope or function normally) and readmission [to a general acute care hospital]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and concurrent record reviews, the facility failed to administer Trazadone (Medication to treat depression) per physician orders for one of one sampled resident (Resident 106)These failures resulted in Resident 106 inability to sleep and feeling angry. Cross Reference F0635Findings: During a record review, Resident 106 admission record indicated Resident 106 was admitted to the facility on [DATE] with a diagnoses of human immunodeficiency virus disease (a virus that weakens the body's defense system also called HIV) and essential hypertension (high blood pressure). During a record review of Resident 106's Minimum Data Set (MDS- a resident assessment tool) dated 8/8/2025, indicated the resident was cognitively intact (mental ability to make decisions of daily living). During a record review, Resident 106's care plan initiated 8/4/2025, indicated, Resident 106 uses antidepressant medication related to depression (a serious mood disorder that affects how you feel, think, and…

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

Based on interviews and concurrent record review, the facility failed to ensure three out of seven employees (Licensed Vocational Nurse (LVN) 1, Housekeeping, Activities Assistant, and Occupational Therapist (OT - assess a person's physical, cognitive, and emotional abilities and develops treatment plans to improve their functional skills, adapting the environment or activities as needed) completed their competencies annually and or upon hire. This failure had the potential for the staff not to provide the appropriate nursing skills and related care and services for all residents in accordance with resident care plans and the facility assessment.Findings: During an interview and concurrent record review on 8/7/25 at 8:42 AM, four of seven employee files were reviewed with the Director of Staff Development (DSD and the following were noted: 1. LVN 1 was hired on 3/14/2022. There was no annual physical examination for years 2023 and 2024, there was no annual Tuberculin (TB - is a serious illness that mainly affects the lungs) skin test for the years 2023 and 2024, no background check…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call system was functional including the audible sounds to alert the staff for one out of five sampled residents (Resident 2).This deficient practice had potential in a delay in meeting the residents' needs for assistance and could lead to frustration, falls and accidents.Findings:During a review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including bilateral primary osteoarthritis of the hip (means that both hip joints are experiencing a wearing down of cartilage, leading to pain and stiffness, without any specific, identifiable cause), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 6/28/2025, indicated Resident 2's cognitive (mental action or process of…

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

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 by failing to ensure two of two shower rooms (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]) were clean and free from urine smell. This failure resulted in a foul-smelling environment and the adjacent hallway. Findings: .During a review of the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (weakening, shrinking, and loss of muscle), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities). During a review of the Minimum Data Set (MDS – resident assessment tool) dated 3/27/2025, it indicated Resident 9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 : I. Ensure one of four sampled residents (Resident 6) ' s medications were properly stored and documented according to facility ' s policy and procedures (P&P). II. Ensure the medications were administered timely as ordered by the physician for three of three sampled residents (Resident 6, Resident 8 and Resident 9) according to facility ' s P&P. This deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident ' s health and safety by failing to administer necessary medications in accordance with the physician order. Findings: 1. During a review of the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including psoriatic arthritis mutilans (a severe, rare form of psoriatic arthritis that causes significant joint damage and bone loss, often in the hands 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/or implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of four sampled residents (Resident 1) by failing to: a. Developed and implemented an individualized CP for Resident 1 ' s left lower foot wound when Resident 1 was readmitted on [DATE]. b. Developed an individualized CP for Resident 1 ' s complaint of pain and discomfort. c. Developed an individualized CP for Resident 1 ' s refusal of turning and repositioning schedules to prevent skin breakdown. d. Implementing a person-centered CP when Resident 1 had episodes of aggressiveness toward staff. These deficient practices had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1, a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted 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, interviews and record review, the facility failed to ensure the skin assessments were accurate upon admission ad the skin impairment did not get worse for one of three sampled residents (Resident 5). This deficient practice had the potential to delay the provision of necessary care and services and deterioration of residents ' current wounds. Findings: During a review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnosis including fracture of neck of left femur (a break, crack or crush injury of the thigh bone), muscle weakness (weakening, shrinking, and loss of muscle) and Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities). During a review of the Minimum Data Set (MDS – resident assessment tool) dated 4/22/2025 indicated Resident 5 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 5 required moderate to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure resident receives appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) and mobility for one of four sampled resident (Resident 1) according to facility ' s policy and procedure (P&P) titled, Repositioning. This deficient practice had the potential to place Resident 1 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 1 ' s admission Record indicated Resident 1, a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), chronic congestive heart failure (CHF-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 effectively manage one of four sampled residents, (Resident 1 ' s) pain by not properly identifying the characteristics of pain with consistent approach and a standardized pain assessment instrument appropriate to resident ' s cognitive level according to the facility ' s policy and procedure titled, Pain – Clinical Protocol. This deficient practice resulted in Resident 1 experienced unnecessary pain. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1, a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), chronic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and a past medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to one of one sampled resident (Resident 1) by failing to address behavioral health care needs and implementing a person-centered care plan when Resident 1 had episodes of aggressiveness toward staff. This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1, a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), chronic congestive heart failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preventive care consistent with professional standards of practice to one of four sampled residents (Resident 1) who was at risk for development of pressure injuries, by failing to: 1. Ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up according to physician ' s (MD) order. 2. Ensure Resident 1 ' s weight was monitored and recorded according to facility ' s policy and procedure (P&P). These deficient practices placed Resident 1 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury. Findings: During record review, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including venous insufficiency (a condition where the veins in the legs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of four sampled residents, Resident 1 ' s court delegated general power of attorney (POA – authorizes someone else to handle certain matters, such as finances or health care, on someone ' s behalf. If a power of attorney is durable, it remains in effect if the person become incapacitated for any reason, including illness and accidents) was informed of Resident 1 ' s health care decision. This deficient practice violated Resident 1 ' s legal POA to be notified and placed the resident at risk for making informed decisions he was not able to recognize based on the medical condition. Findings: A review of the Face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including unspecified dementia (a progressive state of decline in mental abilities), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure) and atherosclerotic heart disease…

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

Based on observation, interview and record review, the facility failed to ensure that a Director of Nursing (DON) works onsite for at least 8 consecutive hours a day from 11/2024 to 1/3/2025. This deficient practice had the potential for facility ' s inability to manage and oversee nursing services provided to the residents. Findings: During an interview with Registered Nurse 1 (RN 1) on 1/3/2025 at 3:17 p.m., RN 1 stated, the DON has been out of sick leave since November 2024. RN 1 stated, there is no DON interim since the DON has been out. RN 1 stated, she does now know who the clinical consultant in the facility and had not seen any and there is no managing the nursing services. During a concurrent interview and record review of the DON ' s timesheet record with Medical Record Director (MRD) as of 1/3/2024, the MRD stated, the DON does not have any timesheet record available. During an interview with Administrator-in-Training on 1/3/2025 at 3:39 p.m., AIT stated, the DON has been out on leave since November 2024. AIT stated, there is no DON interim in the facility, and they did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of two sampled residents (Resident 4) by failing to ensure that a comprehensive (CP) was developed after Resident 2 had a change of condition for dislodgment of nephrostomy tube (a thin, flexible tube inserted into the kidney through the skin to drain urine directly into a collection bag). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: A review of the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including displacement of nephrostomy catheter (it can occur when the tube falls out or becomes mispositioned, which can lead to decreased or absent urine output), and fibromyalgia (a condition that causes pain all over the body, sleep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's peripheral catheter (is a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) dressing was labeled and documented as indicated in the facility policy for one out of two sampled resident (Resident 2). This deficient practice had the potential to place residents at risk for developing infections at the IV site. Findings: A review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including polymyositis with myopathy (refers to a condition where polymyositis, an inflammatory muscle disease, is accompanied by muscle weakness, dysphagia (difficulty swallowing) and cerebral atherosclerosis (build-up of fats, cholesterol, and other substance in and on the arterial walls). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/23/2024, indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for five out of four sampled residents (Resident 1) by failing to ensure the staff was not standing over the Resident 61 while feeding and assisting her during a meal. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 1. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (a progressive state of decline in mental abilities) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/1/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement its policy and procedures (P&P) titled Resident Rights, reviewed on 4/17/2024. By failing to inform one of four sampled residents (Resident 1 ' s) legal representatives of a change in the condition or status of the resident on 8/6/2024. This deficient practice violated the resident and legal representative right to be notified and participate in changes to the plan of care. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in the bladder/urinary tract) and unspecified dementia (a progressive state of decline in mental abilities). A review of Resident 1 ' s History and Physical dated 7/21/2024 indicated, Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 7/26/2024, indicated 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 interview and record review the facility failed to ensure medical records were readily available and producible upon request for one of four sampled residents (Resident 1) as per facility policy procedures (P&P) titled Access to Personal and Medical Records, reviewed on 4/17/2024. By failing to: 1. Ensure Resident 1's medical records were kept up to date with the most recent Durable Power of Attorney (POA – authorizes someone else to handle certain matters, such as finances or health care, on someone ' s behalf. If a power of attorney is durable, it remains in effect if the person become incapacitated for any reason, including illness and accidents) for healthcare doucmentation. 2. Provide Resident 1's DPOA with a medical record release form when requested. This deficient resulted in Resident 1 ' s DPOA for healthcare not having access to medical records and important medical history and treatment records. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the follow it ' s Policy and procedure by failing to report an Unusual Occurrence (Resident elopement) within 24hrs to the State Survey Agency for one out of 3 sampled residents (Residents 1). This deficiency practice placed the health and safety of Resident 1 at risk of exposure to heat or cold exposure, dehydration, other medical complications and being struck by a motor vehicle. Findings: A review of Resident 1 ' s admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that include schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms, such as hallucinations or delusions, and mood disorder), Post-Traumatic Stress Disorder (a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), Major depressive disorder (a serious mental health condition that involves a persistent low mood, loss of interest in activities, and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitoring and supervision for one of three sampled residents (Resident 1) by failing to ensure Resident 1 did not elope from the facility (leaving the facility premises safe area without the facility's knowledge and supervision). This deficiency practice placed the health and safety of Resident 1 at risk of exposure to heat or cold exposure, dehydration, other medical complications and death. Findings: A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that include schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms, such as hallucinations or delusions, and mood disorder), Post-Traumatic Stress Disorder (a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), Major depressive disorder (a serious mental health condition that involves a persistent low mood, loss of interest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his/her individuality for five of 18 sampled residents (Residents 27, 37, 50 61, and 81) by failing to: A. Ensure staff did not stand over Resident 61 while feeding and assisting the resident during a meal. Facility failed to ensure staff are not standing over resident while feeding for Resident 61 B. Assist Resident 27 with setting-up dinner tray on the resident's bedside table. C. Assist Resident 81 clean-up food crumbs on the resident's clothes and bed linen after the resident had finished eating dinner. D. Ensure staff did not speak in a language not understood by Residents 50 and 37 in accordance with the facility's employee handbook updated 6/2021. These deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Residents 27, 61 81, and Resident 50 and 37's primary language not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents and/or responsible party (RP) was informed and consented in advance, of the risks and benefits of pneumonia (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccines and immunization (a simple, safe, and effective way of protecting people against harmful diseases, before they come into contact) for one of five sampled residents (Resident 52). This deficient practice violated the resident's right to make an informed decision regarding the use of vaccinations and immunizations. Findings: A review of Resident 52's admission Record, indicated Resident 26 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), dementia (loss of cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of the Resident 51's admission Record indicated the facility admitted Resident 51 on 05/17/2019 with diagnoses cerebral infarction (stroke- damage to tissues in the brain), malignant neoplasm of the prostate (a cancerous tumor in the gland of the male reproductive system.), overactive bladder (has an urgent need to urinate multiple times per day and/or night), dysphagia (difficulty with swallowing) abnormality with gait and mobility (alterations in the way of walking) and hypertension (high blood pressure). A review of Resident 51's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 05/11/2024, indicated Resident 51 had severe cognitive impairment (The mental ability to make decisions of daily living), required partial/moderate assistance with eating and upper body dressing. The MDS indicated Resident 51 required substantial/maximal assistance with lower body dressing, toileting, and was non-ambulatory. During an initial tour observation on 7/19/24 at 7:07 PM, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for three out of 18 sampled residents (Resident 44, 74 and 59) by failing to: 1. Ensure residents' rooms were kept with comfortable sound levels maintained for two of three sampled residents (Resident 59 and 74). 2. Ensure the window blind, bedside drawer and electric wall plug were maintained and in functional working condition for one of three sampled resident (Resident 44). These deficient practices had the potential to negatively impact the resident's quality of life and placed Residents 59, 74, and 44 an increased level of discomfort and inability to sleep during the night. Findings: 1. During a review of Resident 59's admission Record, dated 7/21/24, indicated Resident 59 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus type two, peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preventive care consistent with professional standards of practice to three of three sampled residents (Residents 1, 16, and 292), who was at risk for developing of pressure injuries (Damage to an area of the skin caused by constant pressure on the area for a long time), by failing to: 1. Ensure Resident 292 had bilateral heel protectors (devices that include foam or gel that are used to help prevent heel pressure ulcers) placed while in bed per physician's order (MD order). 2. Ensure the appropriate settings for the low air loss mattress (LALM-a mattress designed to prevent and treat pressure wounds) for Residents 1 and 16 according to MD's order and/or the facility's policy. These deficient practices placed Residents 1, 16, and 292 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and development of new pressure injury/ies. Cross…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of five sampled residents (Residents 26 and 52) psychotropic (A drug or other substance that affects how the brain works and causes changes in mood) medication regimens were managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to: 1. Ensure implementation of the facility's pharmacy recommendation for Resident 26's Risperdal (anti-psychotic medication) use. 2. Ensure the informed consents were in placed timely for Resident 52's physician's order for psychotropic medications. These deficient practices had the potential to place Resident 26 and 52 at risk of receiving unnecessary medications and/or overuse of medication and adverse consequences while using the medications. Findings: 1. A review of Resident 26's admission Record, indicated Resident 26 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: a. Ensure one of five sampled residents (Resident 66) who was on a transmission-based isolation for extended spectrum beta-lactamase (ESBL - an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that doctors use to treat infections) was placed into a private single room. b. Ensure staff wore appropriate Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to one of four sampled residents (Resident 192) who is on a transmission-based precaution room. c. Ensure one of five sampled residents, (Resident 292), who had an active infection of Escherichia coli in urine (E. coli - bacteria that normally lives harmlessly in the human intestinal tract, but it can cause serious infections if it gets into the urinary tract) 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's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure that a resident would not be allowed to keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications for one of 18 sample residents (Resident 292). This deficient practice had a potential for resident 292 to self-medicate himself and delayed necessary health intervention. Findings: A review of Resident 292's admission Record indicated Resident 292 was originally admitted to the facility on [DATE] with diagnoses that included Paraplegia (the inability to voluntarily move the lower parts of the body), Dorsalgia (low back pain, mid back pain or sciatic nerve related pain, that originate in muscles, nerves or joints), muscle weakness, immunodeficiency (The decreased ability of the body to fight infections and other diseases),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were informed, offered or followed up regarding Advance Directive (ACHD - 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) in a timely manner for four of 18 sampled residents (Resident 61). This deficient practice had the potential to cause conflict with Resident 61's wishes regarding health care. Findings: A review of Resident 61's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), type two diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities 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 interview and record review, the facility failed to implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 16) by failing to ensure that a comprehensive CP was developed and implemented for Resident 16's low-air-loss (LAL - a mattress designed to prevent and treat pressure wounds) mattress. This deficient practice had the potential to result in a negative impact on residents' health and safety and the quality of care and services received increasing the risk for Resident 16 to develop pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Cross Reference F686 Findings: A review of Resident 16's admission Record indicated the resident was originally admitted on [DATE] and was re-admitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five sampled residents (Resident 61 and Resident 63), who were at high risk for fall and injuries and who required extensive assistance during repositioning according to the residents care plan. This failure had the potential to place Residents 61 and 63 at risk for falls or injury possible fracture (break in bone) while being transferred from wheelchair to the bed solely by Certified Nursing Assistant 3 (CNA 3). Findings: A. A review of Resident 61's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), type two diabetes mellitus (DM-a long term condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest 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 interview and record review the facility failed to ensure the call lights were answered timely for three of six residents sampled (Residents 37, 50 and 59). This deficient practice resulted in a delay to services and care required by Residents 37, 50, and 59. Findings: A review of Resident 37's admission Record, dated 7/21/24, indicated Resident 37 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus type two, ulcerative colitis (an inflammatory bowel disease causing irritation and ulcers in the lining of your large intestine), generalized muscle weakness, abnormal gait and mobility, and hypertensive (high blood pressure) heart failure (a condition in which the heart has trouble pumping blood thought the body). A review of Resident 37's History and Physical (H&P), dated 7/18/24, indicated, the resident has the capacity to understand and make decisions. A review of Resident 37's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 6/5/24, indicated the…

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

Based on observation, interview and record review, the facility failed to post in a visible and prominent place daily; the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for three of three sampled days (7/19/2024, 7/20/2024, and 7/21/2024). This deficient practice had the potential to prevent residents and visitors from knowing the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) and had the potential to cause inadequate staffing. Findings: During an observation on 7/19/2024 at 9:19 p.m., located in the nurses' station, nurse staffing hours information dated 7/19/2024 was posted with missing actual nursing staffing hours. During an observation on 7/20/2024 at 9:45 a.m., located in the nurses' station, nurse staffing hours information dated 7/20/2024 was posted with missing actual nursing staffing hours. During an observation on 7/21/2024 at 9:52 a.m., located in the nurses' station, nurse staffing hours information dated 7/21/2024 was posted with missing actual nursing staffing hours. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident 29's Yupelri (Revefenacin-medication being given via inhalation [inhaling medication in the form of gas or vapor] used to help muscles around the airways of the lungs to relax) inhalation solution was stored properly per manufacturer's policy. This deficient practice had the potential to compromise the safety and effectiveness of medication, resulting in medication error when administered to Resident 29. Findings: A review of Resident 29's admission Record, indicated Resident 29 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses including asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and generalized muscle weakness. A review of Resident 29's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 palatable flood for two of six residents sampled (Residents 59 and 84). This failure resulted in bland, unpalatable food being served to the residents and surveyors. Findings: A review of Resident 59's admission Record, dated 7/21/24, indicated Resident 59 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus type two, peripheral vascular disease (PVD - a disorder that involves the narrowing of peripheral blood vessels), generalized muscle weakness, difficulty walking, hear failure and lymphedema (tissue swelling). A review of Resident 59's History and Physical (H&P), dated 6/13/24, indicated, the resident had the capacity to understand and make decisions. A review of Resident 59's Minimum Data Set (MDS - A standardized assessment and care screening tool) dated 4/11/24, indicated the resident required set up or clean-up assistance with eating, and required maximal assistance from staff for toileting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement appropriate sanitation and food handling practices by failing to discard expired food stored in the resident's nutrition refrigerators. This deficient practice had the potential to result in unsafe food management. Findings: During an observation with concurrent interview on 7/21/24 at 10:38 a.m. with the Dietary Supervisor (DS), the facility's resident nutrition refrigerator was reviewed. There was one container of food labeled with a use by date of 6/27/24 and another with a brought in date of 7/18/24. The DS stated those containers of food with past use by dates should have been thrown out, because it is past the use by date or 48 hours after the food was brought in. A review of the facility's policy and procedures (P&P), titled Foods Brought by Family/Visitors, reviewed 4/17/24, indicated, Food brought to facility by visitors and family is permitted . Family/visitors are asked to prepare and transport food using safe flood handling practices . Food brought by family/visitors that is left with 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 maintain infection control measures necessary to prevent the spread of infections by failing to ensure the staff wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) per facility policy and procedures (P&P) titled Enhanced Barrier Precautions (EBP) with an effective date of 4/1/2024 before providing care and treatment for one of one sampled resident (Resident 1) requiring enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes). This deficient practice had the potential to result in the spread of disease and infection to all 90 residents, visitors, and staffs. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnosis including malignant neoplasm of spinal cord (a disease in which malignant (cancer) cells form in the tissues of the spinal cord), type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of practice and implement the facility policy and procedure (P&P) titled, Administering Medications for one of four sampled residents (Resident 3), when resident refused her eyedrop medication. This deficient practice has the potential to result in Resident 3 in unintended complications related to the management of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve). Findings: A review of Resident 3's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including toxic encephalopathy (a chemical imbalance in the blood affecting the brain), unspecified glaucoma, and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 3/22/2024, indicated Resident 3's cognitive (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 observation, interview and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity to one of four sampled residents (Resident 2) by failing to: 1. Ensure Resident 2's received foot care and surgical wound skin treatment as ordered by the physician. 2. Implement the facility's policy and procedures (P&P) titled, Wound Care to promote healing of Resident 2's surgical wound. These deficient practices had the potential to result in Resident 2 in unintended complications related to the management of his surgical wounds. Cross Reference F755 Findings: A review of Resident 2's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including displaced spiral fracture (the parts of the bone at the break no longer line up correctly) of shaft of right fibula (calf bone) and tibia (shinbone), type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), atrial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident for one of four sampled residents (Resident 2) by failing to ensure that Resident 2's medications were not left unattended at the bedside. This deficient practice had the potential to result in Resident 2 in unintended complications related to the management of medications. Findings: A review of Resident 2's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including displaced spiral fracture (the parts of the bone at the break no longer line up correctly) of shaft of right fibula (calf bone) and tibia (shinbone), type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the discharge summary was documented by the physician for one of five sampled residents (Resident 5). This deficient practice resulted in incomplete records for Resident 5. Findings: A review of the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), heart failure (when the heart muscle cannot pump enough blood to meet the body's needs), and acute kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood). A review of Resident 5 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 12/4/2023, indicated the resident was cognitively intact (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning), and required partial/moderate assistance with dressing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) was posted daily. As a result, the actual hours of work performed per patient day by a direct caregiver were not readily accessible to residents and visitors. Findings: During an observation on 3/2/2024 at 5:41 AM, the posted DHPPD included the projected hours for 3/1/2024. The facility did not post a DHPPD to indicate the actual direct care service hours for 3/1/2024 or the projected hours for 3/2/2024. During a concurrent observation and interview on 3/2/2024 at 2:45 PM with the Director of Nursing (DON), the DON stated the Director of Staff Development (DSD) was responsible for calculating the DHPPD hours. The DON stated there were no calculated actual DHPPD hours for 3/1/2024 and no projected hours for 3/2/2024. The DON also stated the facility staff were required to post the projected and actual DHPPD staffing hours daily to allow residents and visitors to see…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effectively manage a resident's pain by not ordering and following up on physician ' s order upon admission of Resident 1 on 1/22/2024 for one five sampled residents (Resident 1). This deficient practice resulted in Resident 1 experienced unnecessary pain. Findings: A review of admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/26/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate to 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 follow its diet menu instructions with garlic bread for six out of six sampled residents (Residents 1, 2, 3, 4, 5, 6). This had the potential for residents to not receive the nutrition they need. Findings: A review of admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/26/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate to maximal assistance from staffs for activities of daily living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy regarding reporting of residents ' allegation of abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of five sampled residents (Resident 3 and Resident 4). 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 can also lead to a delay in prevention of further abuse for Resident 3 and 4. Findings: a. A review of admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 hours or in accordance with state or federal law for two of two sampled residents (Resident 3 and Resident 4). 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 can also lead to a delay in prevention of further abuse for Resident 3 and Resident 4. Cross Reference F609. Findings: a. A review of admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop a comprehensive care plan for Resident 1 ' s self-administration medications and own medications at bedside. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F761. Findings: A review of admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of six sampled residents (Resident 1) medications were properly stored and secured per facility ' s policy. This deficient practice had the potential to lead to medication under and/or overdosing which could result in serious injury, harm, and death. Findings: A review of admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/26/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow its policy on Answering the Call Light by failing to ensure the call light (a device used by a resident to call for help) for 2 of 5 sampled residents (Resident 4 and Resident 5) were answered timely. This deficient practice resulted to a delay in answering Resident 4 ' s and Resident 5 ' s request for help. Findings: A review of Resident 4 ' s admission Record (Face Sheet) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition where the lungs have a hard time loading your blood with oxygen or removing carbon dioxide) and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). A review of the Minimum Data Set (MDS, a comprehensive assessment), dated 1/19/2024, indicated Resident 4 had moderate cognitive (thought process) impairment. The MDS also indicated Resident 4 needed setup…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate resident allergies, intolerances and preferences for 1 of 5 sampled residents (Resident 5) by failing to ensure: 1. A dietary screening assessment was performed when Resident 5 was admitted to the facility. 2. Resident 5 does not receive foods she is allergic to. This deficient practice had the potential for the resident to experience an allergic reaction and had the potential for the resident to consume less food than their body needed, which could lead to weight loss and malnutrition. Findings: A review of Resident 5 ' s admission Record (Face Sheet) indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia (a chronic [long-lasting] disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping) and Coronavirus-19 (COVID-19, a virus that causes respiratory illness that can spread from person to person). The admission record indicated Resident 5 was allergic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 served was palatable and at the proper temperature. The deficient practice had a potential for resident in the facility not to eat the served food and had the potential to cause weight loss and dehydration that may result in nutritional requirements not being met. Findings: A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and muscle weakness. A review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/4/2023, indicated Resident 32 has moderately impaired cognition (mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program according to their policy and procedure by failing to ensure the Hoyer cloth slings (patient lift slings) are properly stored in a clean storage area. This deficient practice placed residents and staffs at risk at a higher risk of acquiring and transmitting infections to other residents in the facility. Findings: During an observation of the facility on 1/10/2024 at 12:03 p.m., observed shower room [ROOM NUMBER] with wet floor, shower chairs and laundry bin. Observed multiple Hoyer lift slings hanging inside the shower room, some were touching the floor. Observed the shower room with a laundry bin with no cover, full of soiled cloths, towels and linen used by the residents. During an interview with Director of Staff and Development (DSD) on 1/10/2024 at 12:06 p.m., DSD stated, the shower room is being used by multiple residents on a daily basis. DSD further stated, inside the shower room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the residents' privacy and dignity by failing to ensure the urinary catheter (foley catheter - a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of one sampled resident (Resident 1). This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem. Findings: A review of Resident 1's 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), extended spectrum beta lactamase resistance, (ESBL- a type of enzyme or chemical produced by bacteria that can cause resistance to some antibiotics when treating bacterial infections), type II diabetes mellitus (DM-a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop a comprehensive care plan for Resident 1's indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage). This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. Cross Reference F550. Findings: A review of Resident 1's 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), extended spectrum beta lactamase resistance, (ESBL- a type of enzyme or chemical produced 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 precautions were taken for resident ' s individual safety, as well as the safety of others in the facility for one of four sampled residents (Resident 3). The facility was aware Resident 3 used a personal lighter and cigarettes and oxygen concentrators were stored together in Resident 3 ' s room. This deficient practice had the potential for fire related accidents in the facility among residents, staffs, and visitors. Findings: A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including idiopathic peripheral autonomic neuropathy (happens when the nerves that are located outside of the brain and spinal cord [peripheral nerves] are damaged), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities), hypertension (HTN - elevated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of one sampled resident (Resident 3) by failing to: 1. Ensure Resident 3's nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed per facility ' s policy. 2. Ensure Resident 3's NC was not on the floor. 2. Ensure a physician's order are in place for oxygen therapy. These deficient practices had the potential for the residents to develop respiratory infection. Findings: A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including idiopathic peripheral autonomic neuropathy (happens when the nerves that are located outside of the brain and spinal cord [peripheral nerves] are damaged), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of four sampled residents (Resident 2, Resident 3, and Resident 4) who were admitted to the facility with wounds received the necessary care and services for wound care treatment as evidenced by: 1. Failing to transcribe and document the wound care specialist and medical doctor ' s recommendation on wound care treatment for Resident 2 ' s right leg chronic wound and Resident 3 ' s left ankle diabetic ulcer. 2. Failing to ensure wound care treatments were documented for Resident 4. These deficient practices had the potential to worsen Resident 2, Resident 3 and Resident 4 ' s wound and place Resident 2, Resident 3, and Resident 4 at risk for infection. Findings: A review of Resident 2 ' s admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis (a rare but severe type of bacterial infection that spreads rapidly and can destroy muscle and fat in the body),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the nursing staff failed to answer the call light or call bell promptly for one of three sampled resident's (Resident 1). This deficient practice had the potential to result in a delay in receiving the necessary care and services and to cause the resident to suffer harm and injury. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys' failure to filter waste from the blood and excrete into the urine), epilepsy (a broad term used for a brain disorder that causes seizures [may cause loss of consciousness, falls, or massive muscle spasms]), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 1's care plan for potential for falls, initiated on 9/22/2022, indicated to keep the call bell in reach and to answer promptly. A review of the Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan to address Resident 1's refusal to be repositioned and for perineal (between the legs) care for one of two sampled residents (Resident 1). This deficient practice had the potential to result in a delay in the treatment plan, lead to inadequate care, and potentially cause injury to the resident. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a progressive disease involving damage to part of the nerve cells in the brain and spinal cord), osteomyelitis (infection in a bone), and pressure ulcers (pressure injury - localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of the right and left heel. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 8/24/2023, indicated the resident was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) were provided necessary treatment and services to prevent formation of and promote healing of pressure sore (a wound caused when an area of skin is placed under constant pressure) by: -Failing to transcribe physician's orders for Resident 1's left heel pressure sore. -Failing to document and treat wound care provided for Resident 1's left heel wound from 8/25/2023 through 8/29/2023. -Failing to develop a care plan for Resident 1's left heel pressure sore for 18 days. These deficient practices had the potential to delay provision of necessary care to promote Resident 1's wound healing. Findings: A review of the admission record indicated the facility readmitted Resident 1 on 6/23/2023, with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important metal functions), dementia (memory disorders, personality changes, and impaired reasoning) and…

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

Based on observation, interview, and record review, the facility failed to provide a privacy cover for the urinary drainage bag for one of two sampled residents (Resident 1). This deficient practice caused an increased risk for Resident 1's loss of privacy and dignity. Findings: A review of Resident 1's admission record indicated the facility re-admitted the resident on 7/29/2023 with diagnoses including a pressure ulcer (pressure injury - localized damage to the skin and/or underlying soft tissue usually over a bony prominence) on the right buttocks Stage IV, attention to gastrostomy (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration), and fracture of the sacrum (triangular-shaped bone at the bottom of the spine). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 6/24/2023 indicated the resident was moderately cognitively impaired (decisions poor; cues/supervision required) and required extensive assistance with one-person assist for bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accident risk and hazard interventions for two of four sampled residents (Resident 1 and Resident 3) by failing to complete Smoking Assessments for Residents 1 and 3 and failing to initiate a smoking care plan for Resident 3. These deficient practices had the potential to place Residents 1 and 3 at risk for burns and other injuries caused by fire. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including depression (a mood disorder that causes feeling of sadness, and loss of interest), and anxiety disorder (repeated episodes of sudden feelings of fear or worry). A review of Resident 1's Smoking Observation/Assessment form dated 8/5/2023, indicated Resident 1 was a smoker, and smoked between one and two times per day. The assessment did not indicate whether or not the resident required a smoking apron, cigarette holder, supervision, or one-on-one…

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

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care and services in accordance with the Physician's Orders by failing to ensure Resident 1 was seen and evaluated by a Registered Dietician (RD-a professional who has training and education in food and nutrition). This deficient practice resulted in the failure to deliver necessary care and services for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including depression ( a mood disorder that causes feeling of sadness, and loss of interest), and anxiety disorder (repeated episodes of sudden feelings of fear or worry). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 8/9/2023, indicated the resident had intact cognition (decisions consistent/reasonable) and required extensive assistance with one person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. 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 interview and record review, the facility failed to administer four doses of Metformin (medication used to treat high blood sugar) and two doses of glipizide (medication used to treat high blood sugar) on 7/9 and 7/10/2023, per physician's order, to one of two sampled residents (Resident 1). These deficient practices jeopardized Resident 1's health and safety causing an increase in the resident's blood glucose level (hyperglycemia, blood sugar rises above a healthy range that can be dangerous and require immediate treatment) and increased the risk of medical complications, such as eye, kidney, or heart disease or nerve damage. Findings: A review of the admission record indicated the facility admitted Resident 1 on 7/8/2023, with diagnoses including Type II diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain) and atrial fibrillation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice. The physician was not informed of Resident 1's elevated blood sugar greater than 400 milligrams (mg) per deciliter (dL), or the missed doses of diabetic medications. These deficient practices caused an increased risk in Resident 1's quality of care and potentially delaying the ordering of necessary interventions. Findings: A review of the admission record indicated the facility admitted Resident 1 on 7/8/2023, with diagnoses including Type II diabetes mellitus (high blood sugar), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain) and atrial fibrillation (an irregular heartbeat). A review of Resident 1's Physician's Order, dated 7/8/2023, included but were not limited to the following: - glipizide (used to treat high blood sugar) 5 mg one time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (a device used to notify the nurse that the resident needs assistance) weas within reach for three of 42 sampled residents (Residents 44, 55 and 327). This deficient practice had the potential to delay care and emergent service necessary for Residents 44, 55 and 327. Findings: a. A review of Resident 44's admission Record, indicated the facility re-admitted Resident 44 resident on 2/9/2021, with diagnoses that included and not limited to hypokalemia (low level of potassium [important mineral and electrolytes in the body] in the blood), COVID-19 (a deadly respiratory disease transmitted from person to person) exposure, muscle weakness, and unsteadiness on feet. A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/23/2021, indicated Resident 44 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Ensure the call light (a device used to notify the nurse that the resident needs assistance) was within reach for three of 42 sampled residents (Resident 44, 55 and 327) as indicated in the care plan. 2. Ensure that low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was set as per the weight for one of four sampled residents (Resident 25). 3. Monitor and assess the enteral tube feeding (Nutrition taken through a tube directly to the stomach or small intestine) dressing per physician's order to prevent skin breakdown for one of seven sampled residents (Resident 14) as indicated in the care plan. 4. Develop and implement a person-centered care plan for Resident 56's new start of an anti-depressant medication. These deficient practices had the potential for harm, and or a delay of care and services necessary/required for Resident 14, 25, 44, 55, 56 and 327. Findings: 1a. A review of Resident 44'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, facility failed to meet professional standards of quality for five of five sampled residents (Residents 25, 37, 56, 68 and 327) by failing to: 1. Ensure to document anticoagulant (Medication used to prevent blood clots) side effects for Resident 37, 56 and 68. 2. Ensure residents received the necessary care and treatment as per physician' order by the physician for two of five sampled residents (Residents 25 and 327) These deficient practices had the potential to result in unintended adverse effects (harmful effect resulting from a medication or other intervention) related to the use Anticoagulation therapy and had the potential to affect negatively the delivery of care services. Findings: 1a. A review of Resident 37's admission Record, indicated the facility admitted Resident 37 on 6/19/2021 with diagnosis that included and not limited to sepsis (A life-threatening complication of an infection), syndrome of Inappropriate Secretion of Antidiuretic Hormone (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 licensed staff did not administer 28 doses of expired insulin (a medication used to treat high blood sugar) between [DATE] and [DATE] for one of two residents for whom expired medication was found (Resident 15). This deficient practice increased the risk that Resident 15 may have experienced medical complications due to receiving insulin that had become ineffective possibly resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 3:19 PM with the licensed vocational nurse (LVN 2) in Nursing Unit 1, one vial of Humalog (a type of insulin) for Resident 15 was found in Station 1 Medication Cart labeled with an open date of [DATE]. LVN 2 stated that Humalog insulin is only good for 28 days once it is first used or stored in the medication cart at room temperature. LVN 2 stated that administering expired medication to the residents could result in the medications not working properly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.Ensure expired insulin (a type of medication used to treat high blood sugar) was removed from the medication cart for Residents 15 and 44 in one of two inspected medication carts (Station 1 Medication Cart.) 2. Ensure medications requiring refrigeration were stored in the refrigerator per the manufacturer's requirement for Resident 55 in one of two inspected medication carts (Station 1 Medication Cart.) 3. Ensure one opened vial of eye drops were labeled with an open date per the manufacturer's requirement for Resident 4 in one of two inspected medication carts (Station 1 Medication Cart.) 4. Monitor the temperature in the medication storage room and medication storage room refrigerator in one of two inspected medication rooms (Station 1 Medication Room.) The deficient practices of failing to store or label medications per the manufacturer's requirements, remove expired medications from the medication cart, or monitor temperature in the medication storage room increased the risk that Residents 4, 15, 44,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper sanitation and food handling practices by failing to: 1. Ensure the scoopers for food thickener and flour were kept in a protected container or cover per facility's policy 2. Ensure dry food bin containers for condiments/ salad dressing packets, peanut butter single used cup and crackers were kept clean and sanitary. 3. Ensure the refrigerator and freezer temperature log was completed from the evening of 11/18/21 through the morning of 11/22/21. 4. Ensure the chlorine-based red sanitation bucket had a chlorine concentration between 50 parts per million (ppm) to 100 ppm on two separate occasions. 5. Ensure the fans above the food preparation station were clear of dust and grime buildup, the hood, sides and base of the stove were clear of grime and grease buildup, and the areas underneath the dishwashing station and corners were free from dirt and debris. These deficient practices had the potential to result in compromised food qualities, harmful bacteria growth and cross contamination that could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control measures for two of 42 sampled residents (Resident 14, 25) As a result, two Certified Nursing Assistants (CNA) did not perform hand hygiene prior to entering and exiting residents' rooms; one Housekeeper did not remove glove and perform hand hygiene prior to exiting resident's room. These deficient practices had the potential to result in the spread of diseases and infection to residents, staffs and visitors. Findings: 1. During an observation on 11/22/21 at 8:50 a.m., Certified Nursing Assistant (CNA 1) entered Resident 25's room and helped Resident 25 without first performing hand hygiene; CNA 1 exited the resident's room after care and did not perform hand hygiene. During an interview on 11/22/2021 at 8:54 a.m., CNA 1 stated she forgot to use the hand sanitizer prior to entering and exiting Resident 25's room. When asked if she used hand sanitizer prior to entering Resident 25's room, CNA 1 answered no. CNA 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure that a urinary catheter bag (A device to collect urine from the bladder) had a cover to ensure privacy and dignity for one of five sampled residents (Resident 52). This deficient practice had the potential to lowered self-esteem and violated the right to be treated with respect and dignity for Resident 52. Findings: A review of Resident 52's admission Record, indicated the facility originally admitted Resident 52 on 10/5/2021, with diagnoses not limited to malignant neoplasm (cancer) of bladder, sepsis (A life-threatening complication of an infection) Urinary Tract Infection (UTI-An infection in any part of the urinary system), anemia (A condition where the body does not have enough healthy red blood cells) in chronic kidney disease (Longstanding disease of the kidneys leading to renal failure), thrombocytopenia (a condition of not having enough platelets [Tiny cells in the blood that help form clots to slow or stop bleeding and to help wounds heal] in the blood), hyperlipidemia (a high amount of fats 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.

Based on observation, interview, and record review, the facility failed to draw the privacy curtain or close the room door during application of a medication patch to the right hip for one of four residents (Resident 6) per facility's policy and procedures titled quality of life-dignity. The deficient practice had the potential for embarrassment, humiliation, and a lowered self-esteem for Resident 6. Findings: During medication administration observation in Nursing Unit 1 on 11/23/21 at 9:00 a.m., Licensed Vocational Nurse 2 (LVN 2) was observed apply a lidocaine patch (a topical patch used to treat pain) to Resident 6's right hip. LVN 2 did not draw Resident 6's privacy curtain nor close the door to the resident's room. During an interview with LVN 2 on 11/23/21 at 9:07 a.m., LVN 2 stated she failed to draw the privacy curtain nor close the door when applying lidocaine patch to Resident 6's right hip. LVN 2 further stated the practice violated Residents 6' privacy and was a dignity issue when privacy curtain was not drawn during treatment or medication application to a resident'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.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 12), was transferred from Geri chair ([or geriatric chairs] are large, padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) to a bed using a two-person assist with mechanical lift. This deficient practice had the potential to result in falls or injuries to Resident 12 and/or the Certified Nursing Assistant (CNA 3) who transferred Resident 12 from the Geri chair to bed solely. Findings: During an observation with concurrent interview on 11/22/21 at 03:39 PM, Resident 12 was observed transferred from Geri chair by CNA 3 alone using a Mechanical lift (device used to transfer) to a clean bed. CNA 3 stated she should have had another person to assist her in the use of lift for safety. A review of Resident 12's Face Sheet(admission record), indicated an original admission date of 05/23/2016 with a latest return date of 06/07/2021. The Face Sheet further indicated Resident 12 had diagnoses not limited to: adult failure to thrive (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 the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for Resident 25 and 327 according to the residents' needs and professional standard of care. This deficient practice placed the residents at risk of poor wound healing of the current pressure ulcer and had a potential to develop new pressure sores/wounds. Findings: 1. A review of Resident 25's admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 25's diagnoses included, but were not limited to, Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]), contracture of muscle on multiple sites and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 25's Minimum Data Set (MDS - a comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 gastrostomy tube site (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) was cleansed daily and as needed with dressing care as ordered for one of eight sampled resident (Resident 14) who were fed by enteral means. This deficient practice had the potential to result in developing an infection due inadequate GT site and dressing care. Findings: A review of Resident 14's admission Record indicated the resident was originally admitted to the facility on [DATE]. Resident 14's diagnoses included, but were not limited to, dysphagia (difficulty swallowing - taking more time and effort to move food or liquid from your mouth to your stomach), anorexia (eating disorder causing people to obsess about weight and what they eat), and muscle weakness. A review of Resident 14's Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 8/20/2021, indicated Resident 14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 The facility failed to implement its policies and procedures which addressed action and documentation by the facility staff and/or the prescriber in providing the rationale for disagreeing on pharmacy recommendations from the pharmacist medication regimen review (MRR) for two of 42 sampled residents (Resident 37 and 56). This deficient practice increased the risk for adverse medication outcome from possibly unnecessary medication use, leading to negative impact on residents' health and well-being. Findings: a. A review of the face sheet (admission record) indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including, but not limited to sepsis (a life-threatening complication of an infection), syndrome of inappropriate secretion of antidiuretic hormone (a condition where high levels of hormone cause the body to retain water), paranoid schizophrenia (a mental disorder where people interpret reality abnormally), major depressive disorder (a mental disorder characterized by persistently…

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

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 28 total opportunities contributed to an overall medication error rate of 7.14% affecting two of four residents observed for medication administration (Residents 24 and 34.) The deficient practices of failing to administer medications with good technique or in accordance with the attending physician's orders increased the risk that Residents 24 and 34 may have experienced health complications related to incorrect medication administration which could have negatively impacted their health and well-being. Findings: During an observation on 11/22/21 at 9:10 AM in Nursing Unit 2, Resident 34 was observed lying in bed with the head of the bed elevated to approximately a 45 degree angle. During an observation on 11/22/21 at 9:13 AM in Nursing Unit 2, the Director of Staff Development (DSD) was observed administering Combigan eye drops (a medication used to treat eye problems) to Resident 34 without lowering the head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 36 resident rooms met the square footage requirement of 80 square feet (sq. ft.) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: On 11/24/2021, the facility administrator (ADM) provided a copy of the Client Accommodation Analysis and a facility letter requesting for a room waiver. A review of the Client Accommodation Analysis indicated one of 31 rooms did not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis indicated the following: Room # Beds Sq.Ft. Sq.Ft per resident 31 2 155.24 77.62 The minimum requirement for a 2-bedroom should be at least 160 sq. ft. During the resident council meeting on 11/23/2021 at 2:04 p.m., the attendees did not voice any issues or concerns regarding the room size. During multiple observations from 11/22/2021 through 11/25/2021, both…

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