Lighthouse Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the residents prior to treatment with psychotropic (medications that affect brain activities associated with mental processed and behavior) medications for two of six sampled residents (Residents 77 and 86) by failing to: 1. Obtain informed consent from Resident 77, for the use Chlorpromazine (an antipsychotic medication [a medication that effects the mind, emotion, and behavior]). 2. Ensure Resident 86's informed consent for Risperidone (an antipsychotic medication), and Seroquel (an antipsychotic medication) was renewed every six months. The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications could have prevented Residents 77 from exercising the right to decline treatment with psychotropic medications. This increased…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was kept within reach for two of 25 sampled residents (Resident 23 and Resident 34). This deficient practice removed Resident 23's and Resident 34's ability to exercise their right to request assistance from staff and created the potential for accidents and/or delays in care. Findings: a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 23's admitting diagnoses included generalized muscle weakness, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (when blood flow to the brain is interrupted, leading to a lack of oxygen and nutrients to brain tissue) affecting left non-dominant side, symptoms and signs involving the musculoskeletal system, and dementia (progressive state of decline in mental abilities). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, a resident assessment tool) for three of 25 sampled residents (Residents 72, 76, and 83) accurately reflected the care and services they received. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for Residents 72, 76, and 83 to not receive the interventions needed monitor the effectiveness of the care received. Findings: 1. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 76's admitting diagnoses included dementia (a progressive state of decline in mental abilities) and epilepsy (a condition causing recurring seizures [sudden, uncontrolled electrical disturbances in the brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for five of 25 sampled residents (Resident 94, 101, 121, 83 and 77) by failing to: 1. Develop a care plan to address Resident 94's use of valproic acid (an anticonvulsant medication, a medication used to prevent or treat seizures and can be used to treat behavioral disorders). 2. Develop a care plan for Resident 101's wearable external heart defibrillator (a device that provides an electric shock to the heart to allow it to treat a potentially fatal abnormal heart rhythm). 3. Develop a care plan for the refusal for Restorative Nurse Aid services (nursing interventions that promote a person's ability to adapt and adjust to living as independently and safely as possible) for Resident 121, a resident diagnosed with an extremely painful bone disorder that severely affected his mobility. 4. Develop a care plan for Resident 83's missing natural teeth. 5. Develop a care plan to address Resident 77's use of chlorpromazine (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise one of five sampled resident's (Resident 5) care plan and interventions after Resident 5 had an unwitnessed fall on 11/24/2025. This deficient practice had the potential to result in Resident 5 sustaining a major injury after another fall. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment tool), dated 5/25/2025, the MDS indicated Resident 5's cognitive skills (ability to think and reason) for daily decision making was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 76) had floor mats (cushioned floor pads designed to help prevent injury should a person fall) placed appropriately to prevent injury related to potential falls. This deficient practice placed Resident 76 at risk of experiencing injuries related to falls, such as bruises and/or broken bones. Findings: During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 76's admitting diagnoses included epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and dementia (a progressive state of decline in mental abilities). During a review of Resident 76's Minimum Data Saet (MDS, a resident assessment tool), dated 5/13/2025, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to change the nasal cannula (device used to deliver supplemental [extra] oxygen placed directly on a resident's nostrils) and humidifier (water used to increase the moisture while providing oxygen therapy) weekly and store an oxygen mask (mask placed over the nose and mouth and connected to a supply of oxygen) inside a plastic bag in accordance to the facility's policy and procedure for one of three sampled residents (Resident 29). This deficient practice had the potential to result in an increased the risk for Resident 29 to acquire a respiratory infection. Findings: During a review of Resident 29's admission Record (Face Sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), generalized muscle weakness (lack of strength in many muscles throughout the body), and neuromuscular dysfunction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Registered Nurse (RN) 1, RN 2, and Licensed Vocational Nurse (LVN) 4 practiced the necessary competencies when providing care and services when the following occurred: 1. RN 1 did not correctly interpret or carry out Resident 115's physician order to change the resident's urinary catheter (thin tube inserted into the bladder) drainage bag (a medical device used to collect urine that is drained from the bladder). 2. RN 2 and LVN 4 did not know the facility policy and procedure (P&P) for replacing a resident's humidifier bottle (a device that adds moisture to the oxygen being delivered). These deficient practices placed the residents at risk for infection and illness. Findings: 1. During a review of Resident 115's admission Record, the admission Record indicated Resident 115 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 115's admitting diagnoses included urinary retention (the inability to fully…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and routine medications for two of six sampled residents (Resident 23 and Resident 60). Resident 23 and Resident 60 did not receive medications per Physician's Order, nor did the pharmacy have the medication available for Resident 23. These deficient practices had the potential to cause adverse outcomes to the residents such as low blood pressure and cerebral hypoperfusion (inadequate blood flow to the brain) for Resident 23, and gastric upset for Resident 60. Findings: a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was re-admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (an interruption in blood flow to the brain), dementia (a progressive state of decline in mental abilities),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of one sampled resident (Resident 5) with weighted utensils (eating tools designed to be heavier, providing added weight to help stabilize shaking hands and reduce hand tremors) in accordance with the physician's order. This deficient practice had the potential for Resident 5 to become discouraged in self-feeding due to difficulty handling regularly weighted utensils. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's Minimum Data Set ([MDS], a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, infection control measures were not maintained for two of 25 sampled residents (Resident 13 and Resident 78) when Certified Nursing Assistant (CNA) 5 failed to implement enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high-contact resident care activities that are associated with a high risk of MDRO colonization, such as presence of a gastrostomy tube) and failed to perform hand hygiene (hand washing with soap or using alcohol-based hand rubs) while providing direct patient care. These deficient practices placed the residents at risk for infection and illness. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 13's admitting diagnoses included generalized muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure one of 25 sampled residents (Resident 6) had a functioning call light. This deficient practice resulted in Resident 6's inability to call for staff assistnace or express his needs, and placed him at risk for delayed care and/or accidents. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 6's admitting diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting his left side, generalized muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 6 had severely impaired cognition (ability to think and reason). The MDS indicated Resident 6 was dependent on staff for personal hygiene, and required substantial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was offered and provided showers and baths, who required assistance with Activities of Daily Living (ADLs). This failure had the potential to cause skin irritation, infections and negatively affect the residents' psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cellulitis (a skin infection that causes swelling and redness). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 1 had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five residents (Resident 1) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 1's Primary Care Provider (PCP) was notified of the resident's refusals of showers/baths and wound care treatment. This failure had the potential to place Resident 1 at risk for worsening skin conditions and complications from wound care noncompliance such as sepsis (a life-threatening blood infection), hospitalization and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cellulitis (a skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 weekly skin checks were documented timely for one out of five sampled residents (Resident 1). This failure had the potential to result in inaccurate information communicated between healthcare providers and a delay in the provision of care or interventions for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cellulitis (a skin infection that causes swelling and redness). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 1 had no cognitive (the ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transfer to a medical appointment for one resident of three sampled residents (Resident 1) by failing to:1. Ensure a transportation vehicle was parked in a designated parking space to transport Resident 1 to a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) appointment. The medical transportation van was double parked (parked beside a row of vehicles already parked parallel to the curb) in the middle of a street.2. Ensure staff was in-serviced on safe resident transportation to medical appointments.3. Follow its policy and procedure (P&P) titled Accidents and Incidents, which indicated the facility will comply with current rules and regulations to prevent accidents.4. Follow its P&P titled and Safety Committee-Composition and Duties, which indicated the facility will develop a reporting system for staff to identify potential safety risks, hazardous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents was free from physical abuse for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 being hit with a wet floor sign cone ([12 inch wide and 36-inch height 36 between 5-10 pounds] a safety measure used to notify of a slippery surface) by Resident 2, and left Resident 1 feeling threatened (the sense that something bad might happen) and scared for his life. Findings: During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that can affect thoughts, mood, and behavior), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents ' environment remained free of accident hazards by keeping housekeeping cones (wet floor signs) unattended in residents ' rooms. This deficient practice resulted in Resident 1 being hit by Resident 2 with a wet floor sign-cone ([12 inch wide and 36-inch height 36, and between 5-10 pounds] a safety measure used to notify of a slippery surface) and had the potential to cause physical harm to other residents in the facility. Findings: During an observation on 10/22/2024 at 1:40 p.m., 2:00 p.m., and 2:40 p.m., in the facility ' s hallway, a wet floor sign cone and housekeeping cart was observed unattended and placed in front of a residents ' room. During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (DM-a disorder characterized 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 interview and record review, the facility staff failed to ensure one out of two sampled residents (Resident 1) was informed about her medical coverage during her stay at the facility by: 1. Not informing Resident 1 that she did not have a secondary coverage (insurance that pays after primary coverage, it will cover the remaining costs that the primary insurance did not cover) for the length of her stay at the facility. 2. Not assisting Resident 1 with the process of applying for a secondary coverage. These deficient practices resulted in Resident 1 to live at the facility without being informed she had no medical coverage and Resident 1 received a medical bill for the uncovered amount. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including depression (a common and serious medical illness that negatively affects how a person feels, thinks, and acts) and anxiety disorder (intense, excessive, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, one of three residents (Resident 1), received treatment and care in accordance with professional standards of practice by failing to ensure: 1. The license nurse notified the attending physician (MD) for Resident 1's blood sugar (BS) level of 55 milligrams/ deciliter ([mg/dl] unit of measurement, normal BS level 70 to 99 mg/dL) on 1/24/2024 at 11:30 a.m. 2. Administer Glucagon 1 mg. Intramuscular ([IM] injection of medicine into the muscles) on 1/24/2024 at 11:30 a.m. when Resident 1 had a blood sugar level of 55 mg/dl as indicated in Resident 1's physician order to administer Glucagon 1 mg. IM, if BS was less than 60 mg/dl. 3. Resident 1, who was diabetic and on multiple medications to lower blood sugar levels, was assessed when Resident 1 became nonverbally responsive on 1/24/2024 at 11:41 p.m. 4. Notify the MD promptly on 1/24/2024 at 11:41 p.m. when Resident 1 was nonresponsive. 5. Implement its Nursing Manual – Dietary & Dining titled,…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention Control Program, completed ten hours of continuing education training on an annual basis. This deficient practice had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control. Findings: During an interview on 6/13/2024 at 7:40 a.m., with the Infection Preventionist (IP), the IP stated he was unable to find documentation that he completed ten hours of continuing education for the year of 2023. The IP stated he completed continuing education hours when he renewed his nursing license, however, those hours were not completed in the year of 2023. The IP stated he was responsible for completing ten hours of continuing education annually to ensure he was aware of any new guidelines or studies that were released and to be up to date with current infection prevention and control practices. During an interview on 6/13/2024 at 10 a.m., with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents and/or responsible party were informed in advance, of the risks and benefits of the use of physical restraints (manual method or device used to restrict freedom of movement or normal access to one's body) for five of 12 sampled residents (Resident 66, Resident 71, Resident 15, Resident 88, and Resident 16). These deficient practices resulted in the violation of Resident 66, 71, 15, 88, and 16's and/or responsible party's right to make an informed decision regarding the use of physical restraints. Findings: a. A review of Resident 66's admission Record indicated Resident 66 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 66's admitting diagnoses included unspecified abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and anxiety disorder (mental health disorder characterized by feelings of worry, 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 5. During an observation on 6/10/2024 at 10:36 a.m., in Resident 93's room, Resident 93 was observed lying in bed. Resident 93's bed was observed against the wall, and bilateral siderails upper position. A review of Resident 93's admission Record, indicated Resident 93 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 93's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease that causes obstructed airflow from the lungs) and chronic kidney disease (loss of kidney function). A review of Resident 93's MDS, dated [DATE], the MDS indicated Resident 93's cognitive skills for daily decision making was intact. The MDS indicated Resident 93 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene. 6. During an observation on 6/10/2024 at 10:47 a.m., in Resident 40's room, Resident 40 was observed lying in bed watching television. Resident 40's bed was observed against the wall,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop, implement, and update the comprehensive care plan for 15 out of 25 residents (Resident 88, 10, 13, 66, 109, 11, 71, 15, 16, 17, 93, 40, 13, 36, and 112) by failing to: 1. Develop a comprehensive care plan for Resident 88's use of Buspirone (a medication used to treat mental illness) and to address the problematic behavior of auditory hallucinations (hearing voices to harm self or others), and Resident 17's use of Ativan (a medication used to treat anxiety [feeling of unease, excessive worry]). 2. Develop a comprehensive care plan for Resident 10's behavior of wandering into Resident 13's room. 3. Develop a comprehensive care plan for Resident 66's use of dentures. 4. Develop a comprehensive care plan for Resident 109's diagnosis of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly), and Resident 11's diagnoses of paranoid schizophrenia, major depressive disorder (a mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for four of 14 residents (Resident 13, Resident 16, Resident 47, and Resident 98) by failing to: 1. Check Resident 98's soiled diaper in a timely manner per facility policy and professional standards. 2. Keep Residents 13, 16, and 47's nails clean and neat. These deficient practices had the potential to result in a negative impact on Resident's 98, 13, 16, and 47's quality of life and self-esteem, and had the potential for the development of infection. Findings: a. A review of Resident 98's admission Record indicated Resident 98 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 98's admitting diagnoses included hemiplegia (paralysis on one side) and hemiparesis (weakness or the inability to move on one side) following a cerebral vascular infarction (brain tissue death resulting from disrupted blood flow to the brain)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the medical need, obtain a physician order, and informed consent for the use of bed side rails for nine of nine sampled residents (Resident 93, Resident 40, Resident 13, Resident 36, Resident 112, Resident 66, Resident 71, Resident 88, and Resident 16). These deficient practices had the potential to place Residents 93, 40, 13, 36, 112, 66, 71, 88, and 16 at risk for accidents, injury, and hazards such as entrapment and falls. Findings: a. During an observation on 6/10/2024 at 10:36 a.m., in Resident 93's room Resident 93's bed was observed with the bilateral (pertaining to both sides) siderails up. A review of Resident 93's admission Record indicated Resident 93 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 93's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease that causes obstructed airflow from the lungs) and chronic kidney disease (loss of kidney…

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

Based on observation, interview, and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch service when: 1. Fortified diets (diet enriched to increase caloric content) were not prepared and served to 10 residents who were receiving a fortified diet. 2. 17 residents who were prescribed a pureed diet (foods that do not require chewing and are easily swallowed in which all foods should be smooth and pureed to the consistency of pudding) received pureed vegetables (carrots and green beans) that were lumpy, not smooth, and had chunks which required chewing before swallowing. 3. [NAME] 1 used a small scoop size to serve meatloaf for residents receiving a mechanical soft and finally chopped diet (includes moist foods in bit sized pieces for residents who have chewing and or swallowing difficulty). 29 residents prescribed a mechanical soft diet and four residents prescribed a finally chopped diet received 1/3 cup of meat loaf instead of 1/2 cup per the menu. These deficient practices…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. One package of ready to eat ham was stored in the walk-in refrigerator with no thaw date. One large tray of breaded fish, two large packages of diced pork and six logs of ground beef were thawing in the walk-in refrigerator with no pulled out of the freezer or thaw date. One plastic storage bag with a breaded food item stored in the reach in freezer had no label or date. 2. The ice machine was not maintained in a clean manner and the inside compartment of the ice machine was observed with black residue. 3. Dietary Aide 1 did not follow cleaning and sanitizing procedures when there was raw ground beef in the food preparation sink, and when [NAME] 1 used the same sink to drain ready to eat cooked vegetables. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 108 out of 114 residents who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessment entries on the Minimum Data Set (MDS, a standardized resident assessment care screening tool) were accurate for two of seven sampled residents (Resident 17 and 88) when the facility failed to: 1. Include the presence of hallucinations (an experience involving the apparent perception of something not present) for Resident 17. 2. Include a diagnosis of anxiety disorder per information in the medical record for Resident 88. Theses deficient practices had the potential to negatively affect Resident 17 and Resident 88's plan of care and delivery of necessary care and services. Findings: a. A review of Resident 17's admission Record (Face Sheet), indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 17's diagnoses included chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), schizophrenia (a severe mental illness 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 ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) assessments were accurate, and that determination for the necessity of potential necessary services was completed for two of 25 sampled residents (Resident 109 and Resident 25). This deficient practice had the potential for Resident 109 and Resident 25 to not receive the required services and care needed for their diagnosed mental disorders. Findings: 1. A review of Resident 109's admission Record indicated the facility admitted Resident 109 on 1/19/2024. Resident 109's admitting diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent the development of a pressure ulcer (a wound that develops from prolonged pressure depriving the tissue from receiving oxygen) for one out of three residents (Resident 58). The deficient practice had the potential to cause serious infection, tissue injury, and extreme discomfort to Resident 58. Findings: A review of Resident 58's admission Record indicated the facility originally admitted Resident 58 on 2/11/2021, and most recently re-admitted Resident 58 on 4/12/2024. Resident 58's admitting diagnoses included carcinoma (cancer) of the anus (the opening at the far end of the digestive tract through which stool leaves the body) and anal canal (a channel connecting the rectum to the anus), chronic ulcerative proctitis (an inflammatory disease involving only the rectum), and adult failure to thrive (a weight syndrome with decreased appetite, poor nutrition, and inactivity). A review of Resident 58's History and Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep the environment free from hazardous maintenance tools and nails in the room for two out of eight residents (Resident 10 and Resident 51). The deficient practice had the potential to cause injury to Resident 10 and 51 by coming into direct contact with sharp objects. Findings: a. A review of Resident 10's admission Record indicated the facility originally admitted Resident 10 on 7/22/2016, and most recently re-admitted Resident 10 on 12/21/2022. Resident 10's admitting diagnoses included dementia (a brain disease that effects memory and cognitive function, interfering with daily life), schizophrenia (a mental disorder characterized by disorganized and delusional thinking, and auditory or visual hallucinations), and bipolar disorder (a mood disorder with manic and depressive episodes). A review of Resident 10's History and Physical (H&P), dated 12/19/2022, indicated Resident 10 did not have the capacity to understand and make…

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

Based on observation, interview, and record review, the facility failed to implement the Registered Dietician's (RD, a health professional who has special training in diet and nutrition) recommendations for one of 25 sampled residents (Resident 66), when staff were unaware of recommendations for Resident 66 to be initiated on a Restorative Nursing Aid (RNA, a certified nursing assistant primarily assigned to perform therapeutic exercises and activities to maintain or re- establish a resident's optimum physical function and abilities) feeding program (a medical and nutritional treatment regimen to aid those with nutritional concerns). This deficient practice increased the risk for Resident 66 to sustain further weight loss and not meet his nutritional needs. Findings: A review of Resident 66's admission Record indicated the facility originally admitted Resident 66 on 7/9/2021, and most recently re-admitted the Resident 66 on 1/27/2023. Resident 66's admitting diagnoses included generalized muscle weakness and dysphagia (difficulty swallowing). A review of Resident 66's History 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 follow its policy and procedure (P&P) titled Behavior - Management, which indicated when a resident displayed new behavioral symptoms, staff would use effective verbal and non-verbal communication techniques to manage the behavior problems, prior to initiating psychotropic medications (medications used to treat anxiety) for one of one sampled residents (Resident 107), who was deaf and visually impaired. The facility failed to ensure: 1. Resident 107's behavior was assessed using a communication board, writing pad, or American Sign Language (ASL, a language expressed by movements of the hands and face), to meet the resident's needs, prior to diagnosing Resident 107 with anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and administering lorazepam ([Ativan], a drug used to treat anxiety) to Resident 107 on 4/20/2024, 4/25/2024, and 5/3/2024. This deficient practice placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bottle of Gabapentin (a medication used to treat nerve pain) 250 milligrams (mg - a unit of measure for mass) per 5 milliliters (ml - a unit of measure for volume) was stored in the refrigerator in one of three inspected medication carts (Station 2 Medication Cart 2) for Resident 62. The deficient practice of failing to store medications per the manufacturers' requirements increased the risk that Resident 62 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications. Findings: During a concurrent observation and interview on [DATE] at 1:45 p.m. of Station 2 Medication Cart 2, with Licensed Vocational Nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One bottle 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 food that accommodated residents' preferences and offer meal substitutes of the same nutritive values for one of six sampled residents (Resident 112). These deficient practices had the potential to alter Resident 112's nutritional status. Findings: During a concurrent observation and interview on 6/10/2024 at 12:58 p.m., with Resident 112, in Resident 112's room, Resident 112's lunch meal tray was observed on top of the resident's bedside table. Resident 112's lunch meal tray included meatloaf, steamed vegetables, mashed potatoes, corn bread, and milk. Resident 112 was observed eating ice cream, and stated she was not going to eat her lunch because she did not like beef. Resident 112 stated that she was still being served beef even though she told the dietary staff that she did not like beef. A review Resident 112's meal tray ticket on 6/10/2024 at 1:05 p.m., indicated Resident 112 was receiving a regular, mechanical soft diet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately obtain blood pressure readings to determine if two of four sampled residents (Resident 1 and Resident 2) have orthostatic hypotension (a form of low blood pressure that happens when standing after lying down or sitting). This deficient practice had the potential for Resident 1 and Resident 2 to experience delayed medical interventions, falls, and injuries due to not having their orthostatic blood pressures (taken while lying, sitting, and standing to determine orthostatic hypotension) taken appropriately to determine orthostatic hypotension. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscles weakness, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), epilepsy (seizures, burst of uncontrolled electrical activity between brain cells), cerebral infarction (disrupted blood flow 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 interview and record review, the facility failed to implement the care plan by providing a two staff assist when turning and repositioning one of 4 sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to be at risk for a fall or injury. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included muscle weakness and unspecified abnormalities of gait (walking pattern) and mobility. A review of Resident 2's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated 2/8/2024, indicated the resident was moderately impaired in decision making (ability to reason, understand, remember, judge, and learn). The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) rolling left and right, and was dependent on staff for chair/bed to chair transfer and tub/shower transfer. A review of Resident 2 ' s care plan, dated 3/28/23, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to notify the physician of behavior changes for one out of four sampled residents (Resident 2). This deficient practice had the potential to result in harm for Resident 1 by not informing the physician of Resident 2's mental health decline. Findings: a. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included dementia (a disease of cognitive impairment that effects memory and the cognition required for daily living), anxiety (feeling of unease, exvessive worry), and paranoid schizophrenia (a mental disorder with hallucinations and delusions accompanied by being distrustful and suspicious of people). During a review of Resident 1's History and Physical (H&P), dated 12/14/2023, the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SA) within 2 hours after the allegation occurred for one of four sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for elder abuse. Findings: a. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included dementia (a disease of cognitive impairment that effects memory and the cognition required for daily living), anxiety (feeling of unease, excessive worry), and paranoid schizophrenia (a mental disorder with hallucinations and delusions accompanied by being distrustful and suspicious of people). During a review of Resident 1's History and Physical (H&P), dated 12/14/2023, the H&P indicated Resident 1 did not have the capacity to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an incident of a resident-to-resident altercation between two of two sampled residents (Resident 1 and Resident 2) within two hours from the time the altercation occurred. The above failure had the potential to cause a delay in the notification of necessary agencies and the timeliness of their investigations, and the potential for additional altercations between Resident 2 and other facility residents and staff. Findings: During a review of Resident 1 ' s admission Record, the record indicated the facility admitted Resident 1 on 8/10/2018 and re-admitted Resident 1 on 8/9/2021. Resident 1 ' s admitting diagnoses included unspecified abnormalities of gait (way of walking) and mobility, generalized weakness. During a review of Resident 1 ' s History and Physical (H&P), dated 2/12/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Physician Orders for Life-Sustaining Treatment ([POLST] a written medical order that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of three sampled residents (Resident 1) was honored. The deficient practice resulted in Resident 1's end of life care wishes, not being followed, and had violated her preference and residents' rights. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including spondylosis without myelopathy (a condition where wear and tear accumulate in your neck, without putting pressure on the spinal cord), type 2 diabetes mellitus (a disease that occurs when your blood glucose is too high), and quadriplegia (paralysis of the arms and legs caused by neurological damage). During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control measures and the prevention of COVID-19 (a highly contagious infection that easily spreads from person to person) when: 1. Resident 1, who was COVID-19 positive (confirmed infected or sick), was not isolated from other residents (Resident 2 and Resident 3) from 12/5/2023 to 12/12/2023, while other rooms were empty. 2. Resident 2 and Resident 3, who were exposed to COVID-19 (close contacts) but negative (not confirmed infected or sick), were kept in the same room of a COVID-19 positive resident from 12/5/2023 to 12/12/2023, while other rooms were empty. 3. Resident 2 and Resident 3 were not wearing a face mask before or after eating in the room. 4. Resident 2 left her room without a mask. 5. Resident 2 and Resident 3 were not tested for COVID-19 using a more sensitive test called Polymerase chain reaction (PCR) test within or after five days of exposure. 6. Certified Nurse Assistant (CNA) 3 did not wear proper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an observation, interview, and record review, the facility failed to label three (3) insulin (a medication used to regulate blood sugar levels) pens with an open date in accordance with the facility's policy in two (2) of three (3) inspected medication carts for Resident 4, 20, and 100. This deficient practice increased the risk for Resident 4, 20, and 100 to potentially receive medication that may have become ineffective or toxic due to the failure of not labeling medication with an open date which may have potentially resulted in harmful side effects, hospitalization, and death. Findings: During a review of admission record (Facesheet), the Facesheet indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing problems) and type 2 diabetes mellitus (a long-term condition that affects the way the body processes blood sugar; the body…

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

Based on observation, interview, and record review, the facility's kitchen staff failed to demonstrate the correct calibration technique (process of validating the thermometer was working properly) for a food thermometer. This deficiency had the potential to result in food being held at unsafe temperatures, thus potentially compromising food safety and contaminating foods that facility residents consume. Findings: During an observation and interview with the [NAME] (CK) on 4/26/2022 at 11:50 a.m., the facility's cook demonstrated the process of calibrating a digital thermometer using a hot water method. Using water from the hot water dispenser, the CK measured the temperature using the digital thermometer. The Ck stated, the thermometer reading indicated the hot water was at 185 degrees Fahrenheit. According to the CK the thermometer was safe for use. Per CK the calibration method using ice water was only used with the analog thermometers. During an interview with the Dietary Manager (DM) on 4/26/2022 at 11:58 a.m., the DM confirmed they typically use the ice water method to…

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

Based on observations, interviews and record reviews, the facility's staff failed to store and prepare food under sanitary conditions in the kitchen, by failing to: a. Ensure the ice machine was clean. b. Remove the rubber object in the bottom shelf of the walk-in refrigerator. c. Monitor the temperature in the dry storage area and date the bags of hamburger buns and loaves of bread. These deficient practices had the potential to result in the transmission of infectious agents that can lead to food born illness. Findings: a. During the initial kitchen tour observation and interview with the Dietary Manager (DM) on 4/25/2022 at 8:30 a.m., the DM confirmed seeing dark greenish unidentified substances approximately three (3) inches in length on the metal surface in the upper inner left corner of the interior of the ice machine. This finding was photographed and shared with the DM. According to the DM, that should not be there. During a follow up interview with the Maintenance Director (MD) on 4/25/2022 at 1:56 p.m., the MD confirmed that the ice machine cleaning was due for the month…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for two of 45 sampled residents (Resident 17 and 62) when the facility did not: a. Use a dignity bag (blue nonwoven material that conceals fluid in the drainage bag to improve resident dignity) for Resident 62's Foley catheter drainage bag (device that holds the urine that drains from the resident's body). b. Serve Resident 17's meal at the same time with the roommates. These deficient practices had the potential to negatively affect Resident 17 and 62's 's self-esteem and self-worth and to cause psychosocial harm or decline to the residents and violates residents' right to be treated with dignity. Findings: a. During a record review of the Resident 62's admission record (face sheet), the face sheet indicated Resident 62 was readmitted to the facility on [DATE]. Resident 62's diagnoses included dehydration (a harmful reduction in the amount of water in…

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

Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation clarifying if a resident had an advance directive (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) or not for one (1) out of the 23 sampled residents (Resident 95). This deficient practice had the potential to result in confusion in the care and services for Resident 95 and placed the resident at risk of receiving unwanted treatment and not receiving appropriate care based on her wishes. Findings: During a review of Resident 95's admission Record, dated 1/09/2022, the record indicated, Resident 95 was admitted to the facility, with diagnoses of but not limited to, acute respiratory failure with hypoxia (not enough oxygen in the blood stream), encephalopathy (a disease that affect the function and structure of the brain), paranoid schizophrenia (a mental disorder characterized by abnormalities in the perception or expression of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of two residents (Resident 105 and 100) were free from physical restraints (any manual method adjacent to the resident's body, that cannot be removed easily by the resident, and restricts the resident's freedom of movement) by failing to: a. Identify position change alarms (alerting devices emit an audible signal when the resident moves in certain ways) as physical restraints. b. Assess the residents (Resident 100 and 105) prior to use of position change alarm. c. Ensure documentation of a medical symptom that warrant the use of position change alarm. d. Ensure the alarms were not used for staff convenience. e. Ensure individualized care planning by the Interdisciplinary team (IDT) that addressed: 1) Direct monitoring and supervision provided during use of the alarm, 2) Ongoing re-evaluation for the need of the alarm and its efficacy in treating the medical symptom, and 3) The development and implementation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the minimum data set ([MDS] a comprehensive standardized assessment and screening tool) assessment accurately reflected resident's medical status for three of three sampled Residents (Residents 81,100 and 94). This deficient practice had the potential to negatively affect Residents 81,100 and 94's plan of care and cause delay of necessary care and services. Findings: a. During a review of the admission record, the record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of left femur (partial or complete break in the bone), muscle weakness, chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 81's MDS, dated [DATE], indicated Resident 81 had unclear speech, able to make himself usually understood and was usually able to understand others. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered care plan to meet the preferences and goals, and address the residents' medical, physical, mental, and psychosocial needs for three of three sampled residents (Resident 1, 81, and 90 ). This deficient practice may potentially result in the facility not providing the residents' individual needs, services, and care to attain or maintain his or her highest practicable quality of life. Findings: a. During a review of Resident 90 admission record, the record indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that included but not limited to metabolic encephalopathy (changes to the structure and function of the brain caused by an underlying condition), type 2 diabetes mellitus (irregular blood sugar), and depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of resident 90's quarterly Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of seven sampled residents (Resident 22, 105, 94, 81, and 67) received treatment and necessary care in accordance with professional standards and in accordance with the plan of care (provides direction for type of nursing care to be rendered) by failing to: a. Comprehensively assess and report 126 bowel movements with a consistency of diarrhea/loose to the physician and manage Resident 67's diarrhea/loose bowel movements. As a result of this deficient practice Resident 67 experienced 126 diarrhea/loose bowel movements which led to Resident 67's suffered the discomfort of constantly having loose/diarrhea and needing to be changed frequently. Resident 67 was isolated to his room and did not want to go outside due to fear of having stool leak out of his adult brief. Resident 67 also endured feeling frustrated that his bowel condition was left untreated from 12/6/2021-4/26/2022. b. Follow up with Resident 22 after she had refused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manage and re-assess two of two sampled residents' (Resident 105 and 81) pain after the residents fell and sustained major injuries. a. Resident 105 fell and complained of pain six out of 10 ([moderate pain] 6/10) on a pain scale, the resident was medicated with no pain relief noted. There was no documented evidence the resident's pain was re-assessed after the pain medication was given. b. Resident 81 fell in the bathroom and complained of pain 5/10 on a pain scale to the left hip, the resident was given Tylenol 650 milligrams ([mg] unit of measurement). There was no documented evidence the resident's pain was re-assessed. This deficient practice resulted in Resident 105 and 81 experiencing necessary pain and lack of proper management of pain. Findings: a. During a review of the Resident 105's admission record (face sheet), the face sheet indicated the facility originally admitted Resident 105 on 1/7/2013. Resident 105 was most recently readmitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility's staff failed to ensure the spreadsheet menu for a regular diet on 4/26/2022 was followed. This deficiency had the potential to result in residents receiving the wrong protein and caloric intake prescribed when not following the menu, which could result in undernutrition and further compromise the resident's medical status. Findings: During tray line observation and interview with the [NAME] (CK) on 4/26/2022 at 12:05 p.m., it was observed that the CK confirmed the regular diet had 1 scoop of corned beef casserole, 1 scoop of carrots, beet salad, hash, and low-fat milk. During an interview with the Dietary Manager (DM) and a record review of the facility's daily menu for spring 2022 spreadsheet for week 4 on 4/27/2022 at 2:15 p.m., the DM confirmed the regular diet lunch meal included corned beef casserole, tangy beet salad, parslied noodles, zesty carrots, low fat milk and [NAME] hash. According to the DM, there was no parslied noodles served…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: a. Ensure two of three residents (Residents 35 and 13) unvaccinated residents or partially vaccinated (received only one dose and needed another dose of the COVID-19 [a highly contagious viral infection] vaccine ) residents did not attend indoor communal dining during the COVID-19 outbreak (presence of least one confirmed COVID-19 resident) in the facility. b. Ensure Licensed Vocational Nurse (LVN) 2 wore personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) per recommended guidelines. These deficient practices had the potential to expedite the transmission of Covid-19 to the residents and staff of the facility; and thereby the community. Findings: a. During a review of the Resident 35's admission record (face sheet), the face sheet indicated the facility admitted Resident 35 to the facility on 2/1/2019. Resident 35's diagnoses included covid 19, chronic obstructive pulmonary disease ([COPD]group of lung diseases that block…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 105) had the right to be informed of, and participate in their care by not: 1. Obtaining informed consent (process in which residents were given important information, including possible risks and benefits, about a medical procedure or treatment) for Resident 105 prior to administering her with Remeron (medication used to treat depression [mental health disorder characterized by persistent sadness or loss of interest in daily life]) on 3/26/2022. 2. Updating and implementing the facility policy for treating residents without a decision-making capacity and without a representative to include the following, as per all facilities letter (AFL 20-83.1): i. Defined process for verbal and written notice ii. Process for identification, selection, and participation of a resident representative not affiliated with the facility on the interdisciplinary team ([IDT] group of different disciplines working together…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide personal privacy for one of three residents (Resident 71) by not closing the privacy curtain or door while cleaning the private area of the resident. This deficient practice violated the resident's right to personal privacy. Findings: During a review of the admission record, the record indicated Resident 71 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include COVID-19 (a highly infectious disease caused by a virus), generalized muscle weakness, type 2 diabetes mellitus (irregular blood sugar), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 2/12/2022, MDS indicated Resident 71 required total assistance from staff members…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up with the status of the Pre-admission Screening and Resident Review ([PASRR] a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level II (a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has a Mental Disorder (MD), Intellectual Disability (ID) or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) required evaluation and integrate the level of care into a plan of care for one (1) of one (1) sample resident (Resident 61). This deficient practice led to not incorporating the results of the Level II mental health evaluation into Resident 61's plan of care. This deficient practice may have potentially resulted in the facility not providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent the range of motion ([ROM] movement of the joints) decline of one (1) of three (3) sampled residents (Resident 22) when: a. The facility failed to provide RNA services for Resident 22 upon return to the facility on 1/3/2022. b. The Rehabilitation (services help people return to daily life and live in a normal or near-normal way) department did not re-attempt to reassess Resident 22 after she refused the initial attempt to screen for needed services upon re-admission to the facility on 1/3/2022. c. The Director of Rehabilitation (DOR) did not notify nursing services or the interdisciplinary team (IDT) team that Resident 22 refused the joint mobility assessment (JMA) on 1/4/2022. d. The IDT failed to identify that Resident 22 needed to resume Restorative Nursing Assistant (RNA) services she was receiving prior to being hospitalized on [DATE]. e. The facility failed to develop and implement a comprehensive care plan that addressed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify, evaluate, and implement accident risks and hazard interventions for one of two sampled residents (Resident 94), who was identified as a high risk for falls and assessed on the Minimum Data Set ([MDS] resident assessment and care-screening tool) as having moderate visual impairment and requiring supervision, by failing to: 1. Provide supervision to prevent Resident 94 from having three fall incidents on 12/17/2021, 1/20/2022, and on 2/8/2022. 2. Comprehensively assess and follow up after each of Resident 94's fall incidents. 3. Ensure Resident 94's room was free from trip hazards. These deficient practices resulted in Resident 94 tripping and falling three times on 12/17/2021, 1/20/2022, and 2/8/2022. During the third fall, Resident 94 tripped over his bedside table, hitting the back of his head sustaining swelling to the crown of his head measuring 2 centimeters ([cm] unit of measurement) by 2 cm. Findings: During a review of Resident 94's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility's staff failed to ensure a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue) for a psychotropic (acting on the mind) medication was done after no more than three months, after starting on a psychotropic medication, unless clinically contraindicated for one of one sampled residents (Resident 100). This deficient practice had the potential to result in Resident 100 receiving unnecessary medications. Findings: During a review of Resident 100's admission record, the admission Record indicated the resident was originally admitted to the skilled nursing facility on [DATE] and was readmitted on [DATE]. Resident 100's diagnoses included type two diabetes mellitus (high blood sugar), muscle weakness 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 Resident 100'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's staff failed to properly dispose of one of three sampled residents (Resident 56) tube feeding bag which was labeled with the resident's medical information. This failure had the potential outcome of residents' personal medical information being released to the public without the resident's knowledge or consent. Findings: During a review of Resident 56's admission record indicated, the resident was initially admitted to the skilled nursing facility on [DATE] and was readmitted on [DATE]. Resident 56's diagnoses include, schizoaffective disorder (a mental health condition, including schizophrenia and mood disorder symptoms) of schizophrenia bipolar type (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments) and dysphagia (difficulty swallowing foods or liquids,…

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